Clinical Manifestations and Diagnosis of BPPV

Clinical Symptoms 

      BPPV occurs suddenly. Most patients are aware of the time they wake up, when to change position from lying to sitting. Patients feel dizzy spinning gradually diminished and disappeared. There is a lag between changes in head position with the onset of feeling dizzy spin. In general, feeling dizzy spinning arise very strong in the beginning and disappears after 30 seconds while its recurrent attacks become lighter. These symptoms are felt for days to months.

      In many cases, BPPV can be eased himself yet again at a later date. Along with feeling dizzy spinning, patients may experience nausea and vomiting. This sensation may arise again when the head is returned to its original position, but the direction of nystagmus resulting is the opposite.

How to make diagnosis of BPPV
       The diagnosis of BPPV in the posterior and anterior canal can be enforced in a way to provoke and observe the response of the abnormal nystagmus and vertigo response of the semicircular canals involved. Inspection can choose Dix-Hallpike or Sidelying maneuvers. Dix-Hallpike more commonly used in the maneuvers. Because the position of the head is perfect for canalith repositioning treatment. In patients with BPPV Parasat Dix-Hallpike will trigger vertigo (a feeling of spinning dizziness) and nystagmus.

1. Dix-Hallpike maneuvers
      Is a standard clinical examination for BPPV patients. Dix-Hallpike maneuver largely consists of two movements, namely:
a. Dix-Hallpike maneuvers right, the left anterior canal plane and the right posterior canal
b. Dix-Hallpike maneuvers left posterior left field.

To perform Dix-Hallpike maneuvers right, the patient sits upright on the examination table with the head turned to the right 45⁰. Quickly patients lay with her head still tilted 45⁰ to the right until the patient's head hanging on the end of the 20-300 exam table, wait 40 seconds until an abnormal response arises. Assessment of the response of the monitor made ​​for ± 1 minute or until the response disappeared. After examination of the actions can be directly followed by canalith repositioning treatment (CRT). If no response is abnormal or if the maneuvers are not followed by CRT, patients gradually reinstated. Continue checking the Dix-Hallpike maneuvers left exposed 45⁰ patients with head to the left, wait a maximum of 40 seconds to an abnormal response disappeared. If found any abnormal response, can be followed by CRT. if not found an abnormal response, or if it is not followed by action CRT, patients gradually reinstated.

 Dix and Hallpike describe the signs and symptoms of BPPV as follows: 

1) there is the position of the head that sparked attacks, 

2) the typical nystagmus; 

3) the latency period, 

4) duration of the attack is limited; 

5) nystagmus changed direction when the head is returned to the starting position ,

 6) the phenomenon of exhaustion / fatigue nystagmus when the stimulus was repeated

2.  Sidelying maneuver
       Consists of two movements, namely the right sidelying maneuvers that put the head in a position where the canal left anterior / right posterior canal on the plane perpendicular to the horizontal line of the posterior canal at the lowest position, and left sidelying maneuvers that put the head in a position where the right anterior canal and left posterior canal in the plane perpendicular to the horizontal line of the posterior canal on the bottom.
       The patient sits on the examination table with legs hanging on the edge of the table, the head is made to the right side, wait 40 seconds till arising abnormal response. The patient returned to the sitting position to the left sidelying to do maneuvers, the patient quickly dropped to the left side with the head to the right turn around 45⁰. Wait 40 seconds to emerge abnormal response.

ABNORMAL RESPONSE
       In normal people, nystagmus can occur when the provocation of motion back, but when the movement is complete no longer see nystagmus. In patients with BPPV after provocation was found arising nystagmus slow, ± 40 seconds, and nystagmus disappeared less than 1 minute if the cause canalithiasis, cupololithiasis nystagmus can occur in more than 1 minute, and severe vertigo attacks usually occur together with nystagmus.
     Examiner can identify the type of channel involved by noting the direction of the fast phase nystagmus patients abnormal eye looking straight ahead.
• Rapid phase up, turned to the right shows BPPV in the right posterior canal

• Rapid Phase  upward, rotating to the left shows BPPV in the left posterior canal

• Rapid phase down, turned to the right shows BPPV in the right anterior canal  .
• Rapid phase down, rotate to the left shows BPPV in the left anterior canal  Abnormal response provoked by the Dix-Hallpike maneuvers / sidelying in the appropriate field with premium involved.

       Examination electronystagmography (ENG) can not show nystagmus rotatoar types that can be found in patients with BPPV. ENG is useful in the detection of the onset of nystagmus and time on other types of nystagmus. Caloric test will show normal results. BPPV can be found on the ears show no response to caloric testing. This is due to test caloric test the horizontal semicircular canal. Horizontal semicircular canal and posterior nerves and blood vessels that supply different. Thus BPPV arising in patients who do not respond to the caloric test caused by canalith the posterior or anterior semicircular canal.