Benign paroxysmal positional vertigo

 

BENIGN PAROXYSMAL POSITIONAL VERTIGO: NEW DIAGNOSTIC AND THERAPEUTIC RECOMMENDATIONS

The positional vertigo Benin Paroxysmal (BPPV) is an more frequent dizziness . The High Authority for Health (HAS) and the College of Masso-Kinesitherapy (CMK) have just published recommendations on diagnostic and therapeutic approaches to BPPV .
 
These recommendations insist on the fact that doctors and physiotherapists who have not received specific training on the subject must redirect any patient with BPPV to a trained professional, or even an ENT doctor specializing in otoneurology (diagnosis of vertigo). in some complicated cases.
 
In addition to a review of the various diagnostic tests andtherapeutic maneuvers that can be used according to the semicircular canals responsible for BPPV, these recommendations stress the importance of patient education , in particular those suffering from an aggravated risk of falls, due to age or to other ailments.

HAS publishes recommendations on the diagnosis and treatment of benign paroxysmal positional vertigo

The positional vertigo Benin paroxysmal, the most common of all dizziness
thepositional vertigo Benin paroxysmal(bppv) involves one or more channels semicircular.

Triggered bychanges in the position of the head, it isa rotatory dizziness (the impression that the room and the objects it contains suddenly start to turn around you) which persists for less than a minute. It is associated withnystagmusand, more rarely, withnauseaand evenvomiting.

BPPVrather begins between theages of50 and 70,with women being twice as affected as men. Its annual prevalence is 1.6% (lifetime prevalence: 2.4%).

In a third of patients, BPPV resolves spontaneously within a week . It is the most common of all dizziness. Most often, this vertigo is not linked to a pathology BPPV is most often idiopathic (without an identified cause) . Several risk factors  have nevertheless been reported: history of head trauma, Ménière's disease, vestibular neuronitis (or neuritis) , history of BPPV or severe systemic disease. Small crystals of calcium carbonate called otoconia, or otoliths Two theories exist to explain the symptoms: - 
 



 
the theory of cupulolithiasis proposes that fragments of otoconia ( small  crystals of calcium carbonate, also called  otoliths) detached from the utricle (central part of the inner ear) attach to the cup of the semicircular canals,
- the theory of canalolithiasis postulates that these otoliths float freely in the canal.

Treatment of BPPV is clinical and depends in particular on the semicircular canal involved.
 
New recommendations from HAS and CMK
In December 2017, the High Authority for Health (HAS) and the College of Masso-kinesitherapy (CMK) publishedrecommendations on diagnostic and therapeutic procedures in the face of benign paroxysmal positional vertigo .

These recommendations insist on the fact that doctors and physiotherapists who have not received specific training on the subject must redirect any patient with BPPV to a trained professional.

The new recommendations propose formulating the physiotherapy prescription as follows: “ Physiotherapy diagnostic assessment, therapeutic maneuvers for positional vertigo and control if necessary ” (grade C).
 
Systematic recourse to the neurologist in certain cases
In some cases, these professionals trained in the management of BPPV must nevertheless refer their patient to an ENT doctor trained in the diagnosis and management of vertigo ( otoneurology ):

• in the event of headache, diplopia, ataxia, tinnitus, earache, neck pain and / or any other neurological sign ;
• in case of spontaneous nystagmus :
  • spontaneous torsional and vertical nystagmus,
  • nystagmus reversing according to the gaze position,
  • spontaneously reversing nystagmus,
  • spontaneous nystagmus without dizziness;
• in case of appearance, immediately after the triggering maneuver, of a nystagmus which lasts a few minutes , of constant speed without paroxysm and not accompanied by a feeling of dizziness;
• in the event of an unexpected development .

 
When faced with a suspicion of BPPV, a precise examination is essential
The diagnosis of BPPV arises in front of a vertigo or a rotational positional sensationtriggered ongettingup, at bedtime or in bed, predominantly in the morning with a tendency to improve during the day, and associated with nystagmus.

Therecommendations of the HAS and the CMKinsist on the need toconduct an appropriate interrogationto identify vertigo that may be of peripheral origin and to specify the circumstances of triggering.

In order to highlight the origin of BPPV, idiopathic or secondary, it is suggested toidentify whether the dizziness appeared as a result of a traumatic event in the patient's history., such as trauma, viral disease, or cervical manipulation.
 
Identify the semicircular canals involved
In terms of frequency, BPPV of the posterior semicircular canal accounts for 80 to 90% of cases , that of horizontal (lateral) semicircular canals for 10 to 20% of cases , and only 1-2% of cases for involvement of the anterior (superior) semicircular canal .

Special cases exist:

• BPPV with multichannel or bilateral forms,
• BPPV felt but without visible nystagmus,
• channel conversion.

According to the recommendations of the HAS and the CMK, the execution of the Dix-Hallpike test and the rotatory positional lying test makes it possible to identify the offending semicircular canals ( triggering of a typical positional nystagmus depending on the canal involved ) .
 

 

Diagnosis of BPPV of the posterior semicircular canal, the most common
According to the recommendations of the HAS and CMK , concerning the diagnosis of BPPV of the posterior semicircular canal :

• the Dix-Hallpike test is the first reference test for its diagnosis (grade A);
• the diagnosis is made when this test causes vertigo associated with a geotropic, upper vertical, exhaustible and paroxysmal torsional nystagmus, appearing after a latency period (grade B).

 
Treatment of Posterior Semicircular Canal
BPPVTo treat posterior semicircular canalBPPV, it is recommended to use:

• the maneuver of repositioning the Epley canaliths (grade A);
• or the liberating maneuver of Sémont et al. (grade B);
• in case of persistence and typicality of symptoms after execution of a first maneuver ( evaluated by repeating the Dix-Hallpike test ), it is recommended to repeat the maneuver several times during the same session, if the physical conditions and the feeling of the patient patient allow it . (grade C).

The maneuvers of Epley and Sémont et al. have been adapted to allow the patient to self-administer them. Nevertheless, there is not enough evidence to recommend or refute these self-treatments (grade C).
 

 

Diagnosis of BPPV of horizontal semicircular canal
Regarding BPPV ofhorizontal semicircular canal:

• it is diagnosed when the vertigo associated with horizontal nystagmus is caused by the rotary positional test lying down with a slight flexion of the head and when the direction of the nystagmus is reversed during the change of rotation of the head (grade C);
• it is recommended to position the head in anteflexion of 30 degrees to determine the affected side in the horizontal canals (expert agreement).

 
Treatment of BPPV of the Horizontal Semicircular Canal
To treat BPPV ofthe horizontal semicircular canal, HAS and CMK recommend the use of:

• the maneuver of Lempert and Tiel-Wilck (called Barbecue or Bar-b-que) or the maneuver of Gufoni et al. (grade A);
• the state of knowledge does not allow to recommend or refute the use of the Vannucchi-Asprella maneuver for this form of BPPV (grade C);
• it is recommended to use the maneuver of Gufoni et al . to convert an ageotropic form of BPPV from the horizontal semicircular canal to a geotropic form (grade A).

 

 

Treatment of BPPV of the anterior semicircular canal, the rarest
To treat BPPV of the anterior semicircular canal, HAS and CMK offer three maneuvers:

• the maneuver of Yacovino et al.  ;
• the Epley maneuver  ;
• the modified Epley maneuver .

The state of knowledge is insufficient to recommend or refute the various maneuvers proposed, but those of Yacovino et al. and Epley seem to be the most commonly used (grade C).
 

 

 
Follow-up and education of BPPV patients
Clinicians may re-evaluate patients with BPPVwithin one month after an initial period of observation or treatmentto confirm resolution of symptoms and refer to a specialist physician in case of unexpected development (grade C).

According to experts from HAS and CMK,patients should be informed about the mechanisms and benignity of BPPV, but also about the increased risk of falls, especially for the elderly, frail, and presenting specific risk factors.

Patients should also be informed aboutatypical symptoms(subjective hearing loss, walking disorders, non-positional dizziness, nausea, vomiting, etc.), as well as their  possible persistence and the risk of recurrence after resolution of the main symptoms.

Finally, patients should know that there is no medicine to treat BPPV: maneuvers are the only treatment. 
 
To go further
 
The recommendations of the HAS and the CMK
“  Benign paroxysmal positional vertigo: diagnostic and therapeutic maneuvers  ”, Recommendations of the HAS and the CMK, December 2017.
 
The tests and maneuvers used in BPPV (videos)

• The test Dix-Hallpike (English)
• The test lying positional rotation (in English)
• The canalithes repositioning maneuver of Epley (English)
• The maneuver modified Epley (English)
• The liberating maneuver of Sémont et al.
• The Lempert and Tiel-Wilck maneuver (Barcecue )
• The maneuver of Gufoni et al. (in English)
• The maneuver of Yacovino et al. (in English)

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