BPPV

[Britney Ears]

I saw a patient today with a 12-year history of classic BPPV symptoms. His history also included two incapacitating episodes of vertigo lasting weeks (9-12 years ago), optokinetic sensitivity, and a rocking motion (possibly spontaneous and also when walking). He also has migraine since childhood.

Dix Hallpike was positive for canalithiasis bilaterally, unable to do calorics due to BP. No other significant findings. Although he may have an additional uncompensated peripheral lesion, does any one have much experience of patients with these kind of symptoms being completely resolved with Epley? I have heard of BPPV causing general lightheadedness and imbalance as well as the classic positioning vertigo.

[Guy]

Not unusual at all.
I presume you did an Epley on one side. Bilateral BPPV needs separate right & left Epleys on different occasions.
It is very common for BPPV patients to have continual light-headedness, especially following an Epley, but this usually resolves after a few weeks, especially if you can encourage them to move freely - and of course to avoid drugs like stemetil (if used long term, may require a gradual withdrawal).
I suspect the light-headedness is a result of the patient being "careful" and thus depriving their brain from exposure to normal vestibular, propreoceptive and visual stimuli.
Twelve years is a long time to have BPPV - but I can beat that - how about a 40-year history!
I even had a lovely old chap who didn't want me to treat him - he rather liked the feeling!

[Mr. Potato Head @]

I'm no expert but this is something that just came to mind... could there be a chance that some of these patients who are labelled as having "longstanding BPPV" could actually have CPV, but has just been misdiagnosed? I actually struggled to find some epidimological data for CPV- I think the best I could find was that it is thought to account for 5% of all positional vertigo...I dont know, I just think that a 12 year history of unresolved BPPV sounds like maybe there is something else going on that we could potentially be missing?

[Britney Ears]

would you not expect abnormal oculomotor results with CPV? We did, as Guy suggsted do a right Epley today and arranged another appt for the other side. It did vaguely cross my mind that it could even be migraine related - I read a case study of a patient with positive hallpike that did not respond to Epley but responded to migraine medication.

[Britney Ears]

Quick update, saw patient again today, and much better, symptoms have improved in general, and only slight BPPV on left today. Patient is happy he is able to go to the gym again

[Cochlear]

Bilateral BPPV needs separate right & left Epleys on different occasions.

How often do you see bilateral BPPV?
and please want to hear your explanation for doing Eply on different occasions.
and how long different occasions are separated? 7 days?

[Guy]

An Epley treats BPPV by using gravity to reposition otoconia and because of the mirror-image anatomy of the two labyrinths, the manoeuvre is appropriate for only one ear. If the patient has bilateral BPPV and both ears are treated in the same session there is a possibility (or the suspicion) that the act of doing the second Epley will "undo" the first. Separate visits are therefore appropriate. Yes, I usually do the second side a week later but I'm not aware of any study showing effectiveness versus delay.

[Julie]

Interesting... we tend to do bilateral Epley manoevures in the same appointment if the patient is compliant. Whilst anecdotally I think this is effective, we are currently auditing our BPPV patients so time may tell! (There is at least one patient so far for whom this was effective)
My thinking is that the 2nd Epley manoeuvre is not the same as a reverse-Epley so geometrically it shouldn't be problematic. I wonder what most centres do!?
(off to do a pubmed search next time I get a DNA.....!)

[Seb]

What has been the experience of people using DizzyFIX with patients for BPPV treatment?

[Julie]

We have 2 dizzyfix-es that we lend out to patients with particularly stubborn BPPV and they have been quite effective. These tend to be patients we have given home Epley exercises to do already, but I think the dizzyfix helps them to get the manoevure right more often! Hope this helps. J.