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Benign Paroxysmal Positional Vertigo
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  • Patient was watching TV lying down then suddenly felt dizzy when she sat up. Dizziness described as rotatory and feeling of loss of balance, lasted for about a minute and exacerbated by head movements. Patient decided to sleep it off but when she woke up she still had the same symptoms. Patient also complains of nausea but denies symptoms of hearing loss, tinnitus, loss of consciousness, headache, visual complaints, or diplopia. Patient did not take any medications nor sought consult. Persistence of symptoms prompted consult to this institution. Acute frequent rotatory vertigo exacerbated by head movementsNo hearing lossNo tinnitusNauseaNo traumaHypertensive, controlled; on Betablockers
  • "I feel as if I might faint," or "I feel giddy or light-headed." Some patients do faint or report that they have done so; others have never actually fainted (near-syncope). Pathophysiologically, both syndromes suggest several cardiovascular disorders that produce a generalized decrease in cerebral blood flow; there is no qualitative difference between syncope and near-syncope with respect to the differential diagnosis.Circulatory syndromes that should be considered in the differential include orthostatic hypotension, which may have a number of causes, most of them iatrogenic (e.g., antihypertensive agents and/or vasodilators). Cardiac arrhythmias are a very frequent cause of syncope and near-syncope. If the history suggests arrhythmic episodes, Holter monitoring may be required. Hypersensitive carotid sinus is relatively uncommon. Vasovagal attacks are otherwise known as the simple faint or the simple swoon. Neurocardiogenic syncope is probably due to over activity of the baroreceptor reflex such that brief periods of hypotension result in disproportionate bradycardia and hypotension resulting in decreased cerebral blood flow and consequent loss of consciousness.
  • "I feel as if I might fall.” This version of dizziness generally reflects one of two major categories of neurologic disease, apart from disorders of the vestibular system.146Cerebellar ataxia is due either to a primary disease of the cerebellum, e.g., cerebellum degeneration, or to a tumor in or near the cerebellum, e.g., in the cerebellopontine angle. Neurologic examination will ordinarily reveal such pathology.The multiple sensory deficits syndrome, reflects multiple abnormalities in the various sensory proprioceptive systems. When several of these systems fail in a given individual, the central nervous system receives conflicting proprioceptive input, with consequent dizziness. The typical patient is rather elderly, perhaps with some visual disorder due to cataracts, some auditory disorder due to presbyacusis, and peripheral neuropathy due to diabetes and/or chronic use of alcohol. Such a patient typically complains of dizziness at night, for instance, when the lights are out or dim and he or she has to go to the bathroom. On occasion, the patient may fall.The treatment of this extremely common syndrome is common sense: As many of the sensory abnormalities as can be corrected, should be. Cataracts and hearing disorders can be treated, and the progression of peripheral neuropathy can be prevented by abstinence from alcohol. You might also advise your patient to keep the lights on at night, which would help the visual system compensate for other sensory abnormalities. Such patients should not be treated with drugs that might sedate them, as antivertigo medications would do. Mistaking this syndrome for vertigo would, in fact, make matters worse.
  • There are patients who when asked, "What do you mean, dizzy?" respond, usually after a pause, "Dizzy." If the physician persists with "Do you mean you might faint?" or "Do you mean that you might fall?" or "Do you mean that the room spins?" the patient repeats, "No, I mean I'm dizzy." This disorder can only be called true dizziness, and it generally arises from various psychological disorders, most commonly anxiety (with or without hyperventilation) and/or depression.Affective disorders can often be recognized because of the effect that the patient has on the examiner. If you feel depressed or anxious yourself after spending time with a patient, it may well be because the patient is depressed or anxious. It is extremely important to recognize instances when dizziness represents a metaphor for depression, because treatment for vertigo is likely to exacerbate depression, whereas treatment for depression might dramatically relieve the dizziness.
  • The fourth and last category of disorder found in patients who complain of dizziness is true vertigo, or illusion of motion. Some patients insist that they themselves are moving, others- such as the one presented at the beginning of this chapter-that the environment is moving. In either case the patient says, "I feel as if I am tilting, rocking, or moving in some other way," or "I feel as if the room is spinning.”Vertigo indicates a disturbance in the vestibular system, which is responsible for keeping the central nervous system informed of the head's position in space, its relation to the pull ofgravity, and its acceleration in various planes.
  • The question is whether the vertigo is due to a disorder in the peripheral nervous system (the end organ or the peripheral nerve) or in the central nervous system (the brainstem or its projections to parts of the cerebral cortex, particularly the temporal lobe). Each lesion has its own differential diagnosis and treatment.
  • Vertigo of central origin results from lesions of the central vestibular apparatus (including the brainstem vestibular nuclei and their central connections).Of the central causes, vertebrobasilar insufficiency closely ressembles BPPV.Vertigo of peripheral origin includes conditions affecting the peripheral vestibular apparatus (including the internal ear labyrinth and the vestibular portion of the acoustic nerve)or the proprioceptive sense organs of the cervical spine.Peripheral Rapid-phase nystagmus away from lesionSlow-phase nystagmus toward lesionEnvironment spinning away from lesionRomberg’s sign toward lesion
  • Peripheral Rapid-phase nystagmus away from lesionSlow-phase nystagmus toward lesionEnvironment spinning away from lesionRomberg’s sign toward lesion
  • Vestibular neuronitis, or acute vestibulopathy, is thought to be pathogenetically identical to labyrinthitis but without any hearing symptomatology. If the patient has vertigo unaccompanied by a hearing abnormality, it is strictly speaking impossible to be sure whether the disease is cochlear or retrocochlear. However, its natural history is also benign, and it clears up completely in three to six weeks, which makes a retrocochlear illness very unlikely.Ménière’s disease is caused by a cryptogenic hydrops of the endolymph such that there is intermittent swelling of the semicircular ducts, with damage to the hair cells. An attack of Ménièr’s syndrome is classically characterized by a dull ache in the region of the mastoid process or around the ear associated with severe tinnitus, a cochlear kind of sensory neural hearing loss, and a classic peripheral type of vestibular syndrome with severe spinning vertigo. It is identical in almost every respect with an acute attack of labyrinthitis. However, it does not clear up completely in three to six weeks, and patients are left with residual hearing loss. Several months or years later a similar attack may occur, leaving the patient with even more severe hearing loss. Tinnitus, a nonspecific sign of auditory system disorder, is a major problem for these patients, who can be terribly disabled for weeks at a time by the vertigo that accompanies acute attacks.
  • Ménière’s disease is caused by a cryptogenic hydrops of the endolymph such that there is intermittent swelling of the semicircular ducts, with damage to the hair cells. An attack of Ménièr’s syndrome is classically characterized by a dull ache in the region of the mastoid process or around the ear associated with severe tinnitus, a cochlear kind of sensory neural hearing loss, and a classic peripheral type of vestibular syndrome with severe spinning vertigo. It is identical in almost every respect with an acute attack of labyrinthitis. However, it does not clear up completely in three to six weeks, and patients are left with residual hearing loss. Several months or years later a similar attack may occur, leaving the patient with even more severe hearing loss. Tinnitus, a nonspecific sign of auditory system disorder, is a major problem for these patients, who can be terribly disabled for weeks at a time by the vertigo that accompanies acute attacks.
  • is thought to be a result of viral infection of the endolymph and perilymphaffecting both the vestibular and cochlear components of the system. The usual history is viral illness followed by acute onset of severe spinning vertigo and sensory neural deafness with tinnitus. Despite its severe onset, labyrinthitis is a benign illness, which resolves completely in three to six weeks. Patients regain normal hearing and vestibular function.Vestibular neuronitis, or acute vestibulopathy, is thought to be pathogenetically identical to labyrinthitis but without any hearing symptomatology. If the patient has vertigo unaccompanied by a hearing abnormality, it is strictly speaking impossible to be sure whether the disease is cochlear or retrocochlear. However, its natural history is also benign, and it clears up completely in three to six weeks, which makes a retrocochlear illness very unlikely.
  • The specific clinical characteristics of BPPV include:1)acute onset of vertigo and nystagmus induced by provocative positioning of the head with the affected ear down,2)Vertigo and nystagmus having a brief latent onset period(1-30seconds),3)Vertigo and nystagmus of limited duration (15-30 seconds),4) characteristic rotary nystgamus in head hanging position,5)Reversal of nystagmus on upright siting position of shorter duration, and6) Fatiguability of the response to the Dix-Hallpike (Barany- Nylan) manoeuvre with repeated positioning.
  • The specific clinical characteristics of BPPV include:1)acute onset of vertigo and nystagmus induced by provocative positioning of the head with the affected ear down,2)Vertigo and nystagmus having a brief latent onset period(1-30seconds),3)Vertigo and nystagmus of limited duration (15-30 seconds),4) characteristic rotary nystgamus in head hanging position,5)Reversal of nystagmus on upright siting position of shorter duration, and6) Fatiguability of the response to the Dix-Hallpike (Barany- Nylan) manoeuvre with repeated positioning.
  • Each inner ear contains 3 SCCs oriented in 3 perpendicular planes;
  • The post SCC is directed along the axis of the petrous bone (app 45 to the sagittal and coronal plane) and is roughly vertical. The lateral (horizaontal SCC is tilted approximately 30 upward from the horizontal plane at its anterior end when the head is inanorma upright pisition. When caloric testing is done in the supine position, the head is elevated by about 30 so that the lateral canal lies vertically.
  • Each SCC has a dilation at its utricular end called the ampulla
  • The ampulla contains the sensory cell system of the associated SCC, consiting of crista and cupula (a sail-like tower, the cupula, that detects the flow of fluid within the SCC). Due to inertial lag of the endolymph, angular acceleration of the head causes a deflection of the cupula that displaces the sensory cilia within it. The cupular motion is a bowing rather than a swinging door type of movement and it is this delection that stimulates the vestibular sensory cells
  • A rotational stimulus is amplified in the vestibular nuclei by a “push-pull mechanism” resulting from the mirror-image arrangement of the right and left semicircular canal systems. The inhibition of neural discharges in the semicircular canals on one side (“push”) is accompanied by an increase discharge rate on the opposite side (“pull”) (Probst, 2006The vestibular system is active even when you’re not moving. Signals are sent all the time. There is therefore a resting firing rate.There is no such thing as a positive or negative firing rate but you can make it go faster or slower than the resting rate.It is because of the fact that you have a resting firing rate and they’re both active at the same time which will cause vertigo when one has a problem. Because one is still active and the other is not it will make the eyes move in a certain direction
  • The vestibular apparatus contains two additional sensory regions called the static maculae. The hair-cell cilia in these regions are embedded in a gelatinous material called the otolithic membrane. This membrane is studded with otoliths, which are calcium carbonate crystals. The otolithic organs are sensitive to linear acceleration. These forces cause the relatively inert otolithic membrane to shift in relation to the layer of sensory cells. The otolithic apparatus senses the position of the head in space
  • CupulolithiasisTwo major theories have been proposed to explain benign vertigo. The theory of cupulolithiasis maintains that bits of calcium break off from the otolithic apparatus in the ear, perhaps as a consequence of aging or minor head trauma. If these bits of calcium are floating in the endolymph, they can, in certain positions, put pressure on the end organ, which initiates an impulse arising from that ear. Since the calcium tends to fall into the most dependent of the three semicircular ducts, the cupulolithiasis tends to affect the posterior vertical semicircular duct resulting in rotatory nystagmus maximum when the affected ear is down.
  • Within thelabyrinth of the inner ear lie collections of calcium crystals known as otoconia. In patients with BPPV, the otoconia are dislodged from their usual position within the utricle and they migrate over time into one of the semicircular canals (the posterior canal is most commonly affected due to its anatomical position). When the head is reoriented relative to gravity, the gravity-dependent movement of the heavier otoconial debris (colloquially "ear rocks") within the affected semicircular canal causes abnormal (pathological) fluid endolymph displacement and a resultant sensation of vertigo. This more common condition is known as canalithiasis.
  • (observed best under Frenzel's glasses or electronystagmography (ENG))
  • Dix-HallpikePlacing patient’s head over the end of the table typically evokes a rotary nystagmus to one side after a latnent period of about 10 sec. The nystagmus increases for about 30 sec, then diminishes (crescendo-decrescendo nystagmus). When the patient is brought back to an upright position, a smiliarnystagmus occurs in the opposite direction. This positional nystagmus is fatigable and disappears after several repetitions of the maneuver
  • Dix-Hallpike maneuver to elicit benign positional vertigo (originating in the right ear). The maneuver begins with the patient seated and the headturnedtoonesideat45degrees(A),whichalignstherightposteriorsemicircularcanalwiththesagittalplaneofthehead.Thepatientisthenhelped toreclinerapidlysothattheheadhangsovertheedgeofthetable
  • Still turned 45 degrees from themidline. Within several seconds, this elicits vertigo and nystagmus that is right beating with a rotary (counterclockwisecomponent. An important feature of this type of “peripheral” vertigo is a change in the direction of nystagmus when the patient sits up again with his head still rotated. If no nystagmus is elicited, the maneuver is repeated after a pause of 30 s, with the head turned to the left
  • A home exercise program (Brandt-Daroff exercises, see Patient information sheet later on) will often provide relief after several days but it must be emphasised to patients that the symptoms will need to be provoked during these exercises for subsequent improvement to occur. These exercises probably work by flushing out the otoconial deposits, which are either reabsorbed or displaced to other parts of the labyrinth.Alternatively, single treatment manoeuvres (Epley and Semont) can be used and have similar success rates. These techniques take some practice to master. The interested reader is referred to a discussion and step by step instruction of these techniques. These manoeuvres and the Brandt-Daroff exercises are curative in more than 90% of cases. Surgery is rarely required.
  • The patient begins in an upright sitting posture, with the legs fully extended and the head turned 45 degrees towards the affected side.The patient then quickly lies down backwards with the head held approximately in a 30 degree neck extension (Dix-Hallpike position) where the affected ear faces the ground.Remain in this position for approximately 30 seconds.The head is then turned 90 degrees to the opposite direction so that the unaffected ear faces the ground, all while maintaining the 30 degree neck extension.Remain in this position for approximately 30 seconds.Keeping the head and neck in a fixed position, the individual rolls onto their shoulder, in the direction that they are facing.Remain in this position for approximately 30 seconds.Finally, the individual is slowly brought up to an upright sitting posture, while maintaining the 45 degree rotation of the head.Hold sitting position for up to 30 seconds.
  • Brandt-Daroff ExercisesStep 1. Sit on edge of bed, turn head slightly to left side (approximately 45 degrees).Step 2. Lie down quickly on right side (so that the back of the head rather than the front is resting on the bed). Wait for 20-30 seconds or for any dizziness to resolve.Step 3. Sit up straight, again waiting for 20-30 seconds or for any dizziness to resolve. Step 4. Turn head slightly to right side and repeat sequence in opposite direction. Continue as above for 10 minutes (five or more repetitions to each side).
  • Antiserotonin- And Antihistamine-TypeThere are three categories of drugs for treating true vertigo. Antiserotonin- and antihistamine-type drugs include dimenhydrinate, diphenhydramine, meclizine, and cyclizine. All of these drugs are effective if the dosage is adequate—about 50 mg every six hours (see Table 2). They produce major sedation as their side effect, but this is usually of no concern: Patients who have been dizzy and vomiting for hours tend to be more than happy to go to sleep.The Phenothiazines: PromethazinePromethazine is the only phenothiazine that works against the nausea associated with vestibular imbalance and vertigo. Other phenothiazines, useful for chemical nausea, are of no help whatsoever in this setting. Promethazine may be effective primarily because it is an anticholinergic, not because it is a phenothiazine; it is useful also because it can be given together with the antihistamines or the antiserotonin drugs. A combination of promethazine and antihistamine is particularly effective for acute vertigo.BeladonnaAlkaloidsA belladonna alkaloid, usually scopolamine, is used only for severe recurrent vertigo (e.g., in difficult cases of Ménière's disease) because it is a dangerous drug with many cardiovascular and psychiatric side effects. Transdermally absorbed scopolamine, although helpful for motion sickness, is of inadequate dosage for use in treating an acute vestibular syndrome.
  • Antiserotonin- And Antihistamine-TypeThere are three categories of drugs for treating true vertigo. Antiserotonin- and antihistamine-type drugs include dimenhydrinate, diphenhydramine, meclizine, and cyclizine. All of these drugs are effective if the dosage is adequate—about 50 mg every six hours (see Table 2). They produce major sedation as their side effect, but this is usually of no concern: Patients who have been dizzy and vomiting for hours tend to be more than happy to go to sleep.Cinnarizine – antihistamineBetahistine - phenethylamine and histamine.The Phenothiazines: PromethazinePromethazine is the only phenothiazine that works against the nausea associated with vestibular imbalance and vertigo. Other phenothiazines, useful for chemical nausea, are of no help whatsoever in this setting. Promethazine may be effective primarily because it is an anticholinergic, not because it is a phenothiazine; it is useful also because it can be given together with the antihistamines or the antiserotonin drugs. A combination of promethazine and antihistamine is particularly effective for acute vertigo.BeladonnaAlkaloidsA belladonna alkaloid, usually scopolamine, is used only for severe recurrent vertigo (e.g., in difficult cases of Ménière's disease) because it is a dangerous drug with many cardiovascular and psychiatric side effects. Transdermally absorbed scopolamine, although helpful for motion sickness, is of inadequate dosage for use in treating an acute vestibular syndrome.
  • Antiserotonin- And Antihistamine-TypeThere are three categories of drugs for treating true vertigo. Antiserotonin- and antihistamine-type drugs include dimenhydrinate, diphenhydramine, meclizine, and cyclizine. All of these drugs are effective if the dosage is adequate—about 50 mg every six hours (see Table 2). They produce major sedation as their side effect, but this is usually of no concern: Patients who have been dizzy and vomiting for hours tend to be more than happy to go to sleep.The Phenothiazines: PromethazinePromethazine is the only phenothiazine that works against the nausea associated with vestibular imbalance and vertigo. Other phenothiazines, useful for chemical nausea, are of no help whatsoever in this setting. Promethazine may be effective primarily because it is an anticholinergic, not because it is a phenothiazine; it is useful also because it can be given together with the antihistamines or the antiserotonin drugs. A combination of promethazine and antihistamine is particularly effective for acute vertigo.BeladonnaAlkaloidsA belladonna alkaloid, usually scopolamine, is used only for severe recurrent vertigo (e.g., in difficult cases of Ménière's disease) because it is a dangerous drug with many cardiovascular and psychiatric side effects. Transdermally absorbed scopolamine, although helpful for motion sickness, is of inadequate dosage for use in treating an acute vestibular syndrome.

Transcript

  • 1. “Mary, Go Round”
    “Mary, Go Round”
    ENT-HNS Case Presentation
    By: Cristal Ann Laquindanum
    ASMPH Intern
  • 2. “Nahihiloako”
    Mrs. MP, 46/F
  • 3. History of Present Illness
    CONSULT
    “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 4. Review of Systems
    No weight loss
    No cough and cold
    No rashes
    No changes in hair/nails
    No changes in color
    No nosebleeds
    No hemoptysis
    No chest pain
    No syncope
    No changes in bowel habits
    No history of trauma
  • 5. Past Medical History
    Asthma, last attack years ago. No maintenance medications
    Hypertensionfor 5 years, on Metoprolol (Betaloc) 50 mg twice a day (Usual BP 130/80; Highest BP 160/90)
    UTI, took Cefuroxime
    No history of trauma to the skull or cervical spine
    No history of neurologic diseases
  • 6. Family History
    No history of asthma, hypertension, diabetes, allergies, neurologic disorders
  • 7. Personal Social History
    College graduate
    Works as a secretary
    Non smoker
    Non alcoholic beverage drinker
    Does not use illicit drugs
  • 8. Physical Examination
    Awake, ambulatory but slow walking, not in cardiorespiratory distress
    BP: 130/70
    HR: 74
    RR: 19
    Temp: 36.1
    “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 9. HEENNT
    Anictericsclerae
    Pink conjunctivae
    No ptosis
    Pupils 3mm equal brisk reactive to light
    Intact tympanic membrane
    Midline septum, no nasal congestion
    No CLAD
    Neck veins not dilated
    Moist lips, moist buccalmucosa
    Nonhyperemic posterior pharyngeal wall
    No TPC
  • 10. Chest/Lungs
    Symmetrical chest expansion
    Resonant on percussion
    Equal tactile and vocal fremiti
    No retractions
    No rales
    No wheezes
    “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 11. Heart
    Adynamicprecordium
    No heaves or thrills
    Apex beat is at 5th ICS MCL
    Normal rate, regular rhythm
    No murmurs
    “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 12. Abdomen
    Flat, soft abdomen
    No tenderness
    No organomegaly
    No masses
    Normoactive bowel sounds
    “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 13. Extremities
    Full pulses
    No edema, no cyanosis
    Good turgor
    No rashes, no lesions
    Equally distributed hair
    No clubbing
    CRT <2sec
    “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 14. Neuro
    Awake, coherent, cooperative
    Motor: 5/5 on all extremities
    Sensory: 100% on all extremities
    Gait: normal, slow
    No meningeal signs
    GCS 15
    Cranial Nerves: intact
    (-) Romberg’s Test
    Can do Finger-to-nose-test
    Can do rapid alternating pronation-supination test
    (+) Nystagmus, fatigable
    “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 15. Salient Features
    “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 16. Salient Features
    “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 17. Initial Impression
    Benign Paroxysmal Positional Vertigo
    “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 18. Approach to Dizziness
    Dizziness and other sensations of imbalance are, along with headache, back pain, and fatigue, the most frequent complaints among medical outpatients
    “Dizziness”
    a feeling of rotation or whirling as well as non-rotatory swaying, weakness, faintness, light-headedness, or unsteadiness.
  • 19. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 20. “The room is
    spinning”
    “I might faint”
    “I’m light-headed”
    “I might fall”
    “I’m just dizzy”
    “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 21. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 22. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 23. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 24. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 25. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 26. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 27. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 28. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 29. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 30. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 31. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 32. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 33. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
    Clinical Characteristics of BPPV
    acute onset of vertigo and nystagmus induced by provocative positioning of the head with the affected ear down,
    brief latent onset period(1-30seconds),
    limited duration (15-30 seconds),
    characteristic rotary nystgamus in head hanging position,
    Reversal of nystagmus on upright siting position of shorter duration, and
    Fatigability of the response to the Dix-Hallpike (Barany- Nylan) manoeuvre with repeated positioning.
  • 34. Anatomy
  • 35. Anatomy
  • 36. Anatomy
  • 37. Anatomy
  • 38. Anatomy
  • 39. Push-pull mechanism
  • 40. Anatomy
    The otholiths and the gelatinous otholitic membrane together form a mass of greater density than the endolymph. It is responsive to gravity, therefore, and transmits this motion to the cilia of the sensory cells.
  • 41. Etiology
    Cupulolithiasis
    bits of calcium break off from the otolithic apparatus in the ear floating in the endolymph which can put pressure on the end organ, initiating an impulse from that ear
    Alter the specific gravity of the cupula making it sensitive to gravitational changes
    Posterior vertical semicircular duct
  • 42. Etiology
    Canalithiasis
    Otoconia are dislodged from their usual position within the utricle, migrate over time into one of the semicircular canals
    When there’s head movement, the gravity-dependent movement of the “ear rocks” or otoconial debris causes pathological fluid endolymph displacement and a resultant sensation of vertigo.
  • 43. Diagnostics
    Clinical diagnosis is dependent on an accurate history and a functional evaluation which includes the demonstration of a paroxysmal positioning nystagmus (observed best under Frenzel's glasses or electronystagmography (ENG)), accompanied by vertigo of short duration occuring after a brief latent period(1-5seconds),with the Dix-Hallpikemaneuver.
  • 44. Dix-Hallpike Maneuver
    “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 45. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 46. “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 47. Treatment
    Initial treatment: therapeutic exercises – brisk positioning maneuvers or a defined sequence of head position designed to displace and reposition the canaliths.
    Epley
    Semont
    Brandt-Daroff
  • 48. Epley’s Maneuver
    “MARY, GO ROUND”
    ENT-HNS Case Presentation
    By Cristal Ann Laquindanum
  • 49. Brand-Daroff Exercise
  • 50. Treatment
    Pharmacotherapeutics
    Antiserotonin- And Antihistamine-Type
    dimenhydrinate, diphenhydramine, meclizine, and cyclizine
    Cinnarizine, betahistine
    Side effect: major sedation
  • 51. Treatment
    Pharmatherapeutics
    Antiserotonin- And Antihistamine-Type
  • 52. Treatment
    Pharmacotherapeutics
    The Phenothiazines: Promethazine
    Promethazine is the only phenothiazine that works against the nausea associated with vestibular imbalance and vertigo.
    Anticholinergic; can be given together with the antihistamines or the antiserotonin drugs
    BeladonnaAlkaloids
    Scopolamine – severe recurrent vertigo
  • 53. Treatment
    Surgery
    Remains an option for the rare patient with disabling persistent disease
    Singular neurectomy to treat refractory BPPV was proposed by Gacek
    Generally effective, but technically difficult and the risk of hearing loss from the procedure may be as high as 41%
  • 54. “Mary, Go Round”
    “Mary, Go Round”
    ENT-HNS Case Presentation
    By: Cristal Ann Laquindanum
    ASMPH Intern