Patient Profile

• Most common form of vertigo (19%)
• 90% posterior canal, 10% horizontal canal
• 1 in 3 affected before 7th decade
• 2/3 female
• Yearly incidence 10-20:100.000

Pathophysiology

Trigger

Otolith particles break off of the macula utriculi and accumulate in the posterior (90%) and horizontal (10%) canal. They accumulate at the lowest point of the canal. Movement of otolith particles during e.g. head rotation cause vertigo and nystagmus

Etiology

• Head trauma (~20%)
• Neurolabyrinthitis (10- 15%)
• Migraine
• Prolonged bedridden period
• Genetic predisposition

Course

Very good prognosis. ~90% symptom free after one maneuver. If strategy is executed properly, success rate of ~100%. If maneuver was done successfully, discomfort subsides within a week. Relapse rate 2-5%

History

Head trauma, migraines, bedridden for extended period, inner ear pathology

• Possibly associated neck pain
• Real vertigo:
  • Illusionary sensation of movement (own body, surroundings)
  • Tilt of visual surroundings
  • Rotational
• Nystagmus with rotation
• Lateropulsion
• Feeling of falling or lifting
• No neurological symptom character
• Associated reactions:
  • Vertigo
  • Vomiting
  • Fainting
  • Ataxia
  • Hearing problems/Tinnitus

Physical Examination

Active Examination
Neck movement is avoided and leads to AROM limitation

Functional Assessment
Change of head position triggers nystagmus and vertigo

Special Testing

Differential Diagnosis

1. Infection
2. Intoxication
3. Tumor
4. Idiopathic
5. Psychogenic
6. Metabolic
7. Phobia

Strategy

Maneuvers are very effective. Patient education and instructions on behavior at home are incorporated

Interventions

IMPORTANT

• Maneuver is only then positive if dizziness occurs. Therefore, hold the position.
• After symptoms subside, patients should remain in the end position for ~4min to prevent particles from returning back
• Beware of sudden retropulsion
• In case maneuver fails, wait at least 10 min before trying again
• Max. 3 consecutive tries

Home instructions

• Patients may experience discomfort within the next 24h (normal reaction of CNS)
• No sudden head movements
• Avoid lying on affected side
• In supine, use a pillow under neck to avoid hyper extension
• Lying prone and on unaffected side is permitted
• Adapted Epley maneuver as self-help tool

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