Benign paroxysmal positional vertigo in the elderly: current insights

Figures & data

Figure 1 Theories of posterior semicircular canal stimulation in BPPV.

Notes: (A) Cupulolithiasis: adherence of debris to the cupula making it gravity sensitive (1. Sensory epithelium. 2. Cupula. 3. Otoconia. 4. Ampulla). (B) Cupulolithiasis: cupula deflection after canal rotation. (C) Canalolithiasis: position of particles before canal rotation. (D) Canalolithiasis: movement of particles and cupula deflection after canal rotation.
Abbreviation: BPPV, benign paroxysmal positional vertigo.

Figure 2 The Dix-Hallpike test, for the left (L) ear on the left panel and for the right (R) ear on the right panel.

Notes: (A) Initial sitting position. (B) Head turn 45° toward the examined ear. (C) Head hanging 45° below the horizontal, with the examined ear undermost.

Table 1 Diagnosis of the involved semicircular canal and the side of involvement, according to the appropriate diagnostic maneuver

Involved SCC	Diagnostic maneuver	Positioning nystagmus
		Vertical	Torsional
Vertical SCC
p-canalolithiasis (moving debris)
p-BPPV R	Dix-Hallpike R (+)	Upbeating (transient)	R (counter-clockwise)
	Dix-Hallpike L (−)	No nystagmus
p-BPPV L	Dix-Hallpike R (−)	No nystagmus
	Dix-Hallpike L (+)	Upbeating (transient)	L (clockwise)
p-cupulolithiasis (heavy cupula)		Same with p-canalolithiasis but the nystagmus is persistent
p-BPPV R	Dix-Hallpike R (+)	Upbeating (persistent)	R (counter-clockwise)
	Dix-Hallpike L (−)	No nystagmus
p-BPPV L	Dix-Hallpike R (+)	No nystagmus
	Dix-Hallpike L (−)	Upbeating L (clockwise) (persistent)
a-BPPV R	Dix-Hallpike R (+)	Downbeating	R (counter-clockwise)
	Dix-Hallpike L (+)	Downbeating	R (counter-clockwise)
a-BPPV L	Dix-Hallpike R (+)	Downbeating	L (clockwise)
	Dix-Hallpike L (+)	Downbeating	L (clockwise)
	Diagnostic maneuver	Direction of nystagmus	Intensity of nystagmus
Horizontal SCC
h-canalolithiasis (moving debris)
h-BPPV R	Supine roll test R (+)	R (geotropic, transient)	More intense
	Supine roll test L (+)	L (geotropic, transient)	Less intense
h-BPPV L	Supine roll test R (+)	R (geotropic, transient)	Less intense
	Supine roll test L (+)	L (geotropic, transient)	More intense
h-light cupula same with h-canalolithiasis but the nystagmus is persistent
h-cupulolithiasis (heavy cupula) or canalolithiasis of the short arm of the horizontal SCC
h-BPPV R	Supine roll test R (+)	L (persistent, apogeotropic)	Less intense
	Supine roll test L (+)	R (persistent, apogeotropic)	More intense
h-BPPV L	Supine roll test R (+)	L (persistent, apogeotropic)	More intense
	Supine roll test L (+)	R (persistent, apogeotropic)	Less intense

Abbreviations: a, anterior; BPPV, benign paroxysmal positional vertigo; h, horizontal; L, left; p, posterior; R, right; SCC, semicircular canal.

Table 2 Diagnostic test, characteristics and treatment of BPPV types

Features of BPPV types	p-BPPV	h-BPPV	a-BPPV
Diagnostic test	Dix-Hallpike	Supine roll	Dix-Hallpike
Latency	1–5 seconds	Very short, 0–3 seconds	3–5 seconds
Duration	Limited <30 seconds	>30 seconds	<30 seconds
Fatigability	Yes	No, in most of the cases	Yes
Nystagmus type	Mixed torsional/upbeating	Horizontal	Mixed torsional/downbeating
Nystagmus direction	Geotropic	Mainly geotropic and occasionally apogeotropic	Either geotropic or apogeotropic
Nystagmus intensity	Crescendo and decrescendo	Intense persistent nystagmus	Crescendo and decrescendo
Reversal of nystagmus	Yes, in most of the cases (on returning to the upright position)	Yes, mainly on changing head position	Occasionally yes (on returning to upright position)
Treatment	• Epley’s maneuver	• Vannucchi’s forced prolonged position	• Epley’s maneuver
	• Semont’s liberatory maneuver	• Barbecue	• Yacovino-Hain
		Gufoni

Abbreviations: a, anterior canal; h, horizontal canal; p, posterior canal.

Figure 3 The Epley canalith repositioning procedure when the posterior semicircular canal of the left ear is affected.

Notes: (A) The patient is sitting with the head turned horizontally 45° to the affected (left) ear. (B) Left head-hanging position. (C) Rightward roll, right head-hanging position. (D) Further rightward roll. (E) Sitting up. The head is held still in all positions for 1–3 minutes.

Figure 4 The Semont maneuver when the posterior semicircular canal of the left ear is affected.

Notes: (A) The patient sits with the head turned horizontally 45° to the healthy (right) ear. (B) Moving to left side-lying position (nose up). (C) Moving to the right side-lying position (nose down). Then the patient returns to initial position (D). Again the head is held still in all positions for 1–3 minutes.