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  • 386.11 Benign paroxysmal positional vertigo

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  • H81.1 Benign paroxysmal (positional)
  • H81.10 unspecified
  • H81.11 right ear
  • H81.12 left ear
  • H81.13 bilateral

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Description

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  • Disorder of the inner ear
  • Vestibular part of inner ear has three semicircular canals and two otolith organs (utricle, saccule) that are interconnected and fluid-filled
  • Calcium carbonate crystals (otoconia, otoliths, ear stones) break free from utricular macula and float into one or more of the semicircular canals, making hair cells sensitive to gravity
  • Causes episodic feelings of rotary vertigo (illusion that the room or oneself is spinning) that occurs with head position changes and usually lasts less than one minute

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Essentials of Diagnosis

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  • Physical exam, including neurotologic exam, typically normal
  • Thorough and detailed history is essential to distinguish from other vestibular disorders and central pathology
  • Positive positioning tests: Dix-Hallpike maneuver, roll test, or side-lying test
  • Positioning maneuver results in particular pattern of nystagmus and simultaneous report of vertigo
  • Must rule out central nervous system pathology, which may mimic BPPV, especially if symptoms associated with head trauma

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General Considerations

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  • Patients feel like either they or the room is spinning
  • Typically triggered by tilting the head backward, rolling over in bed, or bending over
  • Can feel disoriented and off-balance between episodes of spinning

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Demographics

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  • More common in women than men (2:1 ratio)
  • Onset can range from 11 to 84 years of age; most common age of onset between 5th and 7th decades of life
  • Uncommon in children
  • Can run in families

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Signs and Symptoms

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  • Patient reports spinning sensation triggered by specific head positions or head position changes
  • Observe nystagmus and patient reports spinning during positioning test postures
  • Reports of dizziness (disorientation, wooziness, lightheadedness) between episodes of vertigo
  • Reports of loss of balance and falls
  • May also have nausea and vomiting when spinning sensation is provoked
  • No central signs (diplopia, dysarthria, dysphagia, dysmetria, numbness, or weakness)

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Functional Implications

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  • Difficulty performing normal head movements (bed mobility, looking up, bending over) because symptoms are provoked
  • Impedes balance and contributes to falls
  • Reduced or lost ability to perform tasks in home, at work, driving

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Possible Contributing Causes

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  • Primarily idiopathic
  • Secondary etiology most commonly head trauma
  • Other secondary causes are inner ear pathologies (Meniere’s, post-acute vestibulopathy, migraines)

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Differential Diagnosis

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  • Necessary when BPPV suspected, but want to rule out other diagnoses because patient does not have classic signs and symptoms or patient does not respond to treatment
  • Brainstem stroke or TIA
  • Vertebrobasilar insufficiency
  • Acoustic neuroma (vestibular schwannoma)
  • Migraine
  • Acute vestibulopathy (neuritis, labyrinthitis)
  • Ramsay ...

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