Posterior Canal Benign Paroxysmal Positional Vertigo

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Posterior Canal Benign Paroxysmal Positional Vertigo

Vertigo is a specific type of dizziness that is defined as a spinning sensation. Patients with vertigo report a feeling that they, or their surroundings, are spinning. There are 3 body systems that help to control balance. These are the visual, proprioceptive, and vestibular systems. Vertigo arises when there is a discrepancy between the information arising from the vestibular system and that arising from the visual and proprioceptive systems. A common cause of vertigo is Benign Paroxysmal Positional Vertigo (BPPV) which involves the semicircular canals of the vestibular apparatus. The vestibular apparatus is composed of the utricle, the saccule, and the three semicircular canals (the posterior, the anterior, and the horizontal). The semicircular canals are filled with a fluid called endolymph. The utricle contains numerous crystals of calcium carbonate called otoliths or otoconia.

BPPV is most commonly attributed to a condition known as canalithiasis. Canalithiasis arises when otoliths become dislodged from the utricle and settle into one of the semicircular canals. Vertigo is provoked by changes in head position, which cause the displaced otoliths to move within a semicircular canal, disturbing the normal flow of endolymph. This results in a spinning sensation for a brief period of time. The majority of BPPV cases occur with no known cause and are referred to as primary or idiopathic BPPV. On the other hand, secondary BPPV is associated with an underlying pathology such as head trauma, vestibular neuritis (or vestibular neuronitis), labyrinthitis, Ménière disease, migraine, ischemia, and iatrogenic causes. Risk factors include comorbidities such as diabetes, hypertension, hyperlipidemia, osteoporosis, and vitamin D deficiency. The peak incidence of primary BPPV is from 50 to 70 years of age. Whilst BPPV may occur in any age group, it is rarely observed in patients under the age of 35 without a history of head trauma. The majority of BPPV cases involve the posterior canal. Posterior canal BPPV usually responds well to a particle-repositioning maneuver (the Epley Maneuver), either performed during a consultation with the assistance of a practitioner or by the patient at home.

• Recurrent episodes of vertigo (spinning sensation) lasting less than one minute that result from changes in head position (e.g., tilting the head to look upwards, rolling over in bed, or sitting up from the supine position)
• Vertigo may be accompanied by nausea and vomiting

The following are examples of “red flags” for patients presenting with vertigo:

• History of a significant head trauma
• Prolonged (non-episodic) vertigo or nystagmus
• Concurrent hearing loss
• Concurrent neurological dysfunction
• Severe hypertension
• Fever

If any “red flags” are identified during history taking and clinical examination, referral for urgent medical evaluation and further investigation is warranted.

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