Benign paroxysmal positional vertigo

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Benign paroxysmal positional vertigo

  1. 1. BENIGN PAROXYSMALPOSITIONAL VERTIGO
  2. 2. Basic Anatomy
  3. 3. BPPVBarany 1921Dix-Hallpike 1952 – important featuresof nystagmusAbnormal sensation of motion elicitedby certain critical positionsProvocative position  nystagmusAt least 20% of vertigoUnderestimated
  4. 4. BPPV …Subclassification : scc post/lat/ant/bilatPathophysiology :– Canalithiasis– cupulolithiasis
  5. 5. Pathophysiology
  6. 6. Pathophysiology (cont.)Cupulolithiasis :– Harold Schuknecht 1962– Densities (otocania) adherent to cupula of crista ampullaris– Basophilic particles -1969
  7. 7. Canalithiasis :– John Epley – 1980– Densities free floating in canal portion– Parnes , McClure – 1991 found particles in post SCC
  8. 8. BPPV ...Frequency : 10-64/100000Sex : 64% womenAge : older population ( 51-57) younger than 35 – head trauma.History :– sudden– days-weeks– occassionally months -years– episodes.
  9. 9. Physical :– neurological examination – normal– except – Dix-Hallpike  pathognomonic
  10. 10. BPPV …Nystagmus : characterization and types– RT / LT , vertical / horizontal , changing– Tortional = Rotational – clockwise / counterclockwise– Geotropic- toward the earth– Ageotropic – opposite
  11. 11. BPPV …Classic post SCC – geotropic rotatorynystagmusHorizontal SCC – purely horizontalnystagmusNon-fatiguing nystagmus –cupulolithiasis > canalithiasis
  12. 12. Classic BPPVInvolved the POST SCC– Geotropic NG with affected ear down– Rotatory , fast phase toward the undermost ear– Latency – few seconds– Duration – limited < 20 seconds– Reversal upon return upright position– Response decline upon repetitive provocation
  13. 13. Lat. SCC PPVMost common atypical BPPV3-9% of casesConsequence of Epley maneuverHorizontal purely nystagmusCupulolithiasis rather than canalithiasisModified Epley / lampert maneuver …
  14. 14. Lat. SCC PPV
  15. 15. Ant. SCC PPVRare – 2%Down-beating /torsional NG for theopposite ear on Dix-Hallpike maneuver
  16. 16. BPPV - CausesPredisposing factors :– Inactivity– Acute alcoholism– Major surgery– CNS disease
  17. 17. Causes ( cont. )Idiopathic – 39%Ear disease – 29%– OM – 9%– Vestibular neuritis – 7%– Menier’s dis – 7%– Otosclerosis – 4%– Sudden SNHL – 2%Trauma – 21%
  18. 18. Causes ( cont. )Trauma – 21%CNS diseases – 11%Acustic neuroma – 2%Cervical vertigo – 2%
  19. 19. BPPV - D.DMenier’s diseaseInner ear concussionAlcohol intoxicationLabyrinthitisVascular loop syndromePost. Fossa lesions : acustic neuroma ,meningiomaCentral origion : stroke , MS , cerebellardegenerationVertibral artery insuffeciencyCervical vertigo
  20. 20. BPPV - TreatmentWatchful waitingVestibular suppressant medicationsVestibular rehabilitationCanalith repositioningSurgery care– Labyrinthectomy– Post. Canal occlusion– Singula neurectomy– Transtympanic aminpglycoside application
  21. 21. Trials about BPPV
  22. 22. GeneralLabeled benign paroxysmal positionalvertigo is not always benignEvaluation of the effectiveness ofcanalith reepositioning procedurs –CRPSeveral studies …
  23. 23. Trials …Blakely – 1994 :– 50% improvement in the control and CRP group !! ( 2-3 months)Lynn – 1995 :– Randomized-controlled : 89% negative DH in CRP group , 27% in the control groupJohn Li (1995) :
  24. 24. Trials…John Li (1995) :– Comparison CRP / CRP + mastoid oscillation and control– Modified Epley maneuver– Use of colar and head elevation after CRP– No spontaneous resolution within aweek– 60% symptoms improvement in CRP group– 92% symptoms improvement in CRP +mastoid oscilation and 70% negative DH
  25. 25. Trials…R. steenerson –1996 :– Comparison of CRP and vestibular habituation training– Tow approaches are effective in symptomatic relief ( 3 months)– CRP faster relief and fewer treatments
  26. 26. Trials …K. Yimatae (2003)– Randomized-controoled– Modified Epley maneuver, no mastoid oscillator and no instructions after the maneuver– Subjective and objective weekly follow-up– CRP group – 76% negative DH, 48% control group– CRP group – 96% symptoms improvement , 90% control group– Non-cured patients need > 6 procedures in 2 weeks , should considering liberatory maneuver
  27. 27. Elderly population and BPPV S. Angeli – 2003 : – Effectiveness of CRP and VR – Modified Epley : Elderly comorbidities : degenerative osteoarthritis disease , CVA , peripheral neuropathy, cognitive and autonomic dysfunctions S/E of CRP – neck torsion and extension result in vertibrobasilar artery insufficiency, strain on the spine column, dislodged carotid a. emboli Avoid liberatory maneuver – 64% CRP group – negative DH after a month – Overall 77% with CRP and VR
  28. 28. CRP Meta-Analysis B. Woodworth - 2004CRP - First line of treatment– Non-invasive– Easy to perform in the office– No need to expensive instrumentations– Repeat maneuver if needed– Potential to provide rapid relief of vertigo
  29. 29. Meta - Analysis9 randomized-controlled trialsSymptoms resolution and elimination ofpositive Dix-Hallpike testCRP more effective than control ( x5 )Untreated patients - symptomsimprovements with time but positive DHSo Resolution of vertigo – avoidance ofprovocative positions
  30. 30. CRP – Epley maneuver
  31. 31. CRP – Semont maneuver
  32. 32. Mastoid oscillator
  33. 33. Brandt-Daroff Exsercise
  34. 34. Lampert maneuver- Lat. SCC BPPV
  35. 35. Vestibular rehabilitaions
  36. 36. Complications of CRPFailure – 25% (12%-56)Recurrence – 13% in 6 monthsSide effects– Nausea– Vomiting– Fainting– SweatingWorse vertigo – LAT SCC PPV
  37. 37. THANK YOU …

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