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VIDEO – Post-Traumatic BPPV May be Complex

According to the NIH, each year, 1.7. Million Americans experience a concussion also called mild Traumatic Brain Injury (m-TBI). Researchers have reported a wide variability of the condition in individuals with head-impact induced BPPV than those with otologic or idiopathic onset. The nature of the mTBI may be sports related, motor vehicle accidents (MVA), military blast, or head trauma from a fall.

At the AIB, BPPV post head trauma with or without a diagnosis of mTBI is seen on a daily basis for both children and adults. Whether it occurs in children from a collision on the playing field or an elderly patient falling on a hard tile floor, we know that the BPPV pattern will not be straightforward. We see increased incidence of bilateral cases, multiple canals, and recurrence rates.

 

 

VIDEO – CASE STUDY

79 year-old female who had a significant fall backwards onto a concrete floor, hitting her head one month prior to presentation at AIB. She was unconscious, transported to the ER, admitted to the hospital. There was not a diagnosis of concussion, but she did require sutures to close the wound. Since discharge from hospital she has had acute onset positional vertigo with two subsequent falls, but none as serious or requiring transport to hospital.

As can be seen in the video, there is an initial burst of nystagmus and vertigo which stops, but is then followed seconds later by a more intense and long-lived nystagmus and vertigo. This too stops and is followed a few seconds later by a short-lived and transient vertigo. Note the nystagmus in the patient’s contralateral eye is viewed (See Gans Blog Nov. 19, 2013) most easily. A side lying m-Hallpike is utilized for patient comfort and serves as the first treatment position of the Gans Repositioning Maneuver (See Gans Blog, Oct. 23, 2013). This is a very typical example that BPPV is rarely “typical” in patients post head trauma.

PEARLS

1.  Post head trauma BPPV may not behave as a “classical” BPPV response as it relates to latencies, duration or overall patterns.
2.  Expect a higher incidence of bilateral and/or multiple canal involvement.
3.  If the patient has intense motion intolerance, he or she may need sedation from the referring physician or practitioner for the vertigo and an anti-emetic to allow for full treatment without emesis.
4.  Although the AIB reports a 97% successful treatment outcome after one-treatment visit (this includes a treatment-recheck and retreat protocol), the bilateral, multi-canal patient will no doubt require additional treatments in addition to the issues of a higher recurrence rate.

References:
1.  Liu,M. Presentation and outcome of post-traumatic benign paroxysmal positional vertigo. Acta otolaryngol. 2012 Aug: 132(8):803-6
2.  Motin, M. et al., Benign paroxysmal positional vertigo as the cause of dizziness in patients after severe traumatic brain injury: diagnosis and treatment. Brain Inj. 2005 Aug 20:19 (9): 693-7.
3.  Ernst A, Basta D, Seidl RO, Todt I, Scherer H, Clarke A. Management of posttraumatic vertigo.Otolaryngol Head Neck Surg. Apr 2005;132(4):554-8.
4.  Hoffer ME, Gottshall KR, Moore R, Balough BJ, Wester D. Characterizing and treating dizziness after mild head trauma. Otol Neurotol. Mar 2004;25(2):135-8.
5.  Dispenza F, De Stefano A, Mathur N, Croce A, Gallina S. Benign paroxysmal positional vertigo following whiplash injury: a myth or a reality?. Am J Otolaryngol. Sep-Oct 2011;32(5):376-80.