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BENIGN PAROXYSMAL POSITIONAL VERTIGO
(BPPV): CASE REPORT WITH EPLEY MANOEUVER
Ana Rita Silva1ABDEF, David Tome1BCD, Unn Siri Olsen2EF
1 Department of Audiology, Laboratory of Audiology, Superior School of Health,
Polytechnic Institute of Porto, Porto, Portugal
2 Department of Pharmacy, Faculty of Health, North University, Bodo, Norway
Corresponding author: David Tome, Department of Audiology, Laboratory of Audiology,
Superior School of Health, Polytechnic Institute of Porto, Porto, Portugal,
e-mail: dts@eu.ipp.pt
Abstract
Background: Benign paroxysmal positional vertigo (BPPV) is a peripheral vestibular dysfunction which represents about 70% of vestibular
pathology presented at ENT clinics. However, a variety of rst treatment approaches are reported among clinicians.
Case report: We present the case of a 39-year-old woman who presented vertigo which worsened with head movement to the le. e
patient reported dizziness and migraine over the previous three days. Audiological testing revealed normal hearing, but under postur-
al examination the Dix-Hallpike manoeuver was positive to BPPV of the le posterior canal. e patient was treated with a single Epley
manoeuver.
Conclusions: Aer the Epley manoeuver the patient had no further symptoms of vertigo or dizziness. e Dix-Hallpike manoeuver was eec-
tive as a dierential diagnosis. e Epley manoeuver was successful in a case in which canalithiasis was believed to be the cause of the vertigo.
Key words: dizziness • rehabilitation • semicircular canals • vestibular disease
EL VERTIGO POSTURAL PAROXÍSTICO BENIGNO (BPPV): ESTUDIO DEL CASO
DE LA MANIOBRA DE EPLEY
Resumen
Introducción: El vértigo postural paroxístico benigno (inglés: benign paroxysmal positional vertigo, BPPV) es una disfunción de la porción
periférica del sistema vestibular, la cual constituye un 70% de los trastornos vestibulares observados en clínicas otorrinolaringológicas. Los
clinicistas describen sin embargo varios enfoques distintos con respecto a su tratamiento temprano.
Estudio del caso: En el presente trabajo se presenta el caso de una mujer de 39 años con síntomas de vértigo que se intensificaban al mover
la cabeza hacia el lado izquierdo. La paciente se quejaba de una sensación subjetiva de mareo y migrañas durante tres días previos a la con-
sulta. Las pruebas audiológicas demostraron una audición normal, sin embargo el test de pruebas posturales demostró la maniobra de Dix-
Hallpike positiva, lo cual confirmó el vértigo postural benigno del canal semivestibular posterior del lado izquierdo. La paciente fue curada
con una maniobra única de Epley.
Conclusiones: Tras aplicar la maniobra de Epley, en la paciente no se observaban más síntomas de vértigo o sensaciones de mareo. La maniobra
de Dix-Hallpike proporciona un diagnóstico diferencial eficaz en casos donde como la causa del vértigo se indica el fenómeno de canalolithiasis.
Palabras clave: sensación subjetiva de mareo • rehabilitación • canales semicirculares • trastorno vestibular
ДОБРОКАЧЕСТВЕННОЕ ПАРОКСИЗМАЛЬНОЕ ПОЗИЦИОННОЕ
ГОЛОВОКРУЖЕНИЕ (ДППГ): ОПИСАНИЕ СЛУЧАЯ ПРИЕМА ЭПЛИ
Изложение
Введение: Доброкачественное пароксизмальное позиционное головокружение (англ. benign paroxysmal positional vertigo,
BPPV) является дисфункцией периферического отдела вестибулярной системы, к которым относится около 70% вестибуляр-
ных расстройств, наблюдаемых в отоларингологических клиниках. Однако клиницисты описывают множество различных
подходов к начальному лечению.
Описание случая: В настоящей работе представлен случай 39-летней женщины с симптомами головокружения, которые усили-
вались при наклоне головы в левую сторону. Пациентка сообщала о субъективных ощущениях вращения предметов и мигрени
49
© J Hear Sci, 2017; 7(1): 49–51
DOI : 10.17430/90 4560
Contributions:
A Study design/planning
B Data collection/entry
C Data analysis/statistics
D Data interpretation
E Preparation of manuscript
F Literature analysis/search
G Funds collection
Background
Benign paroxysmal positional vertigo (BPPV) is a pe-
ripheral vestibular dysfunction, rst described by Bara-
ny in 1921 [1].
e physiopathology of this dysfunction is characterized
by migration of otoconia in the semicircular canals, most
commonly the posterior semicircular canal. ere are two
theories that try to explain this migration and its impact:
cupulolithiasis and canalithiasis. Cupulolithiasis was de-
scribed by Schuknecht in 1969 [2]; here otoconia are said
to be deposited in the cupula of the aected semicircular
canal, and gravity initiates a stimulus which the nervous
system interprets as head rotation and therefore as move-
ment. Canalithiasis was the explanation given by Hall in
1979, and is the more commonly accepted explanation [3,4];
here otoconia are said to be released from the utricular mac-
ula, suspended in the endolymph, and erroneously stim-
ulate the ampulla of the pathologic semicircular canal [5].
BPPV patients report symptoms such as rotational verti-
go of short duration and high intensity, and rotatory nys-
tagmus in the plane of the aected semicircular canal,
with the rapid phase directed to the pathologic side [5].
e symptoms have their origin in fast head movements.
In the orthostatic position, sudden movements can cause
vertigo. e results are rotational, horizontal, or vertical
nystagmus at the same time as vertigo. In 60% of patients
vestibular exams give normal results [6]. Caloric tests of
the pathologic hear reveal vestibular unilateral hyporeex-
ia. Posturography reveals an increased instability which is
aggravated by a visual aerent decrease.
In diagnosing BVVP, the most eective test is the Dix-
Hallpike manoeuver, which tries to reproduce the vertigo
в течение трех дней, предшествовавших консультации. Аудиологические исследования показали отсутс твие нарушений слух а,
однако исследование позиционных тестов показало положительную пробу Проба Дикса-Холлпайка, подтвердив ДППГ задне-
го полукружного канала с левой стороны. Пациентка была вылечена с помощью однократного использования приема Эпли.
Выводы: После применения приема Эпли у пациентки не наблюдались дальнейшие симптомы головокружений или ощуще-
ние вращения предметов. Проба Дикса-Холлпайка обеспечила эффективную дифференциальную диагностику в том случае,
когда причиной головокружений считалось явление каналолитиаза.
Ключевые слова: субъективное ощущение вращения предметов • реабилитация • полукружные каналы • вестибулярные
расстройства
ŁAGODNE POŁOŻENIOWE ZAWROTY GŁOWY (BPPV): OPIS PRZYPADKU
MANEWRU EPLEYA
Streszczenie
Wstęp: Łagodne położeniowe zawroty głowy (ang. benign paroxysmal positional vertigo, BPPV) jest dysfunkcją części obwodowej układu
przedsionkowego, która stanowi około 70% zaburzeń przedsionkowych, obserwowanych wklinikach otorynolaryngologicznych. Wśród kli-
nicystów jednak opisywanych jest wiele różnych podejść do początkowego leczenia.
Opis przypadku: Wniniejszej pracy zaprezentowano przypadek 39-letniej kobiety zobjawami zawrotów głowy, które wzmagały się przy po-
ruszaniu głową wlewą stronę. Pacjentka zgłaszała subiektywne odczucie wirowania imigrenę wciągu trzech dni poprzedzających konsulta-
cję. Badania audiologiczne wykazały słuch prawidłowy, jednak badanie prób posturalnych pokazało pozytywny manewr Dix-Hallpike’a, po-
twierdzając BPPV kanału półkolistego tylnego po lewej stronie. Pacjentkę wyleczono jednorazowym manewrem Epleya.
Wnioski: Po zastosowaniu manewru Epleya upacjenta nie stwierdzono dalszych objawów zawrotów głowy lub uczucia wirowania. Manewr
Dix-Hallpike’azapewnił efektywną diagnostykę różnicową wprzypadku, gdy za przyczynę zawrotów głowy uznawano zjawisko canalolithiasis.
Słowa kluczowe: subiektywne odczucie wirowania • rehabilitacja • kanały półkoliste • zaburzenie przedsionkowe
sensation [7]. e Dix-Hallpike manoeuver induces verti-
go and dizziness in patients with BPPV, and provides dif-
ferential diagnosis [7,8].
A positive result indicates pathology of the posterior ca-
nal. During the manoeuver, we can verify the presence of
a geotropic horizontal-rotational nystagmus of short du-
ration, which is subject to habituation and accompanied
by dizziness and vertigo [5].
Treatment for BPPV is vestibular rehabilitation by apply-
ing repositioning manoeuvers or vestibular habituation
manoeuvers (such as the Brandt and Daro manoeuver)
[9]. e main goal is to reposition otoconia back to their
point of origin, the utricular macula. Manoeuvers specif-
ic to the posterior canal are the Harvey, Semont, Toupet,
Epley, and Herdman manoeuvers; there are also the ves-
tibular habituation exercises of Norré and the vestibular
exercises of Fujini et al. [5,8,10].
e Epley manoeuver is used in BPPV cases in order to
induce the otoconia to reposition to the maculas. In this
procedure, the patient is advised to take their vertigo med-
ication on the day before the rehabilitation session. Dur-
ing the exam, ultrasound or a bone vibrator is used to pro-
mote otoconia migration [8,10,11].
At the end of the treatment we have to verify whether the
rehabilitation has been eective or whether the vertigo
and dizziness remain.
Case report
At the rst appointment the patient (female, 39 years)
complained of vertigo over the previous 3 days, with se-
vere aggravation with head movements to the le. Vertigo
Case Reports • 49–51
50 © Journal of Hearing Science® · 2017 Vol. 7 · No. 1
DOI: 10.17430/904560
lasted 1 minute and provoked migraine. e patient did
not complain of hearing uctuation or tinnitus. Otoscopy
and tympanometry were normal. In acumetry, a 256 Hz
Rinne was positive bilaterally; there was no lateralization
in the Weber test.
Pure tone audiometry revealed normal hearing [12].
Speech audiometry revealed a SRT of 10 dB HL with 100%
discrimination in both ears.
e Romberg and Unterberger tests revealed positivity of
peripheral vestibulopathy for the le side. During the pos-
tural examination the Dix-Hallpike manoeuver was exe-
cuted. e patient mentioned dizziness and nausea, and
there was a geotropic horizontal-rotational nystagmus. is
exam revealed BPPV of the le posterior canal.
One single Epley manoeuver was applied, and further po-
sitional exercises at home were recommended.
At the second appointment one month later, the patient
reported no vertigo or dizziness. e patient reported
intermittent tinnitus. Pure-tone and speech audiometry
were normal, as before. e Dix-Hallpike manoeuver was
negative to BPPV. We recommended a re-evaluation one
month later.
Discussion
BPPV is one of the main causes of vertigo. e manoeu-
ver that is most eective in diagnosing the condition is the
Dix–Hallpike manoeuver [6,7]. When a positive response
is elicited, there are several manoeuvers that can help re-
habilitate the patient.
We veried that one Epley manoeuver was enough for
the patient to start feeling better, suppressing dizziness
and vertigo symptoms [13,14]. As a number of studies re-
port, one Epley manoeuver is eective in 47% of cases [9].
us, an Epley manoeuver should always be the rst re-
positioning manoeuver performed, particularly because
it is comfortable for the patient. On the other hand, if the
manoeuver is not eective we recommend a more com-
plete evaluation, using exams such as the caloric test and
the video head impulse test (vHIT). Alternatively, any
posturography protocol can be used as a complementary
exam in order to provide a prognosis [15].
In this reported case, the origin of the BPPV was taken
to be abnormal stimulation of the ampulla cupulas caused
by otoconia suspended in the endolymph of the le pos-
terior canal. A successful way of rehabilitating the patient
was with an Epley manoeuver involving head movement.
Canalithiasis explains the BPPV symptoms and their char-
acteristics (such as short duration and latency and fatiga-
bility). Patients whose BPPV is due to this condition have
good results with the Epley’s treatment, with rehabilitation
rates between 87 and 100% [11,16–19].
Conclusions
is case study shows that a simple Epley maneuver was
sucient to treat posterior canal BPPV, and other pos-
terior canal repositioning maneuvers were not required.
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Silva et al. – Benign Paroxysmal Positional Vertigo (BPPV)…
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DOI: 10.17430/904560
