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3. Week Five Learning Objectives
During this module, we will discuss:
• Diagnosis of BPPV: How?
• Determine ear that is involved
• Forms of BPPV
• Treating BPPV
• Patient Restrictions
• Bilateral BPPV Treatment
• Precautions
• Outcomes
4. Suggested Readings
• Chapter 20 in the Herdman/Clendaniel test
– Vestibular Rehabilitation: Fourth Edition
• Pages 324-358
• Week five readings
– linked in the weekly assigned readings
• BPPV Clinical Practice Guide pages 16-30
• AAA Position Statement on the Audiologist's Role in
the Diagnosis & Treatment of Vestibular Disorders
5. Treatment of Benign Paroxysmal Positional
Vertigo (BPPV)
How do we diagnose BPPV?
1. Observation is the key
2. Provocative maneuvers
3. VNG or ENG
6. Causes of BPPV
• Result of concussive force
• In people over age 50
• Associated with migraine and ototoxicity
• Viruses affecting the ear
7. Forms of BPPV
• Canalithiasis
• Cupulolithiasis
• Vestibulolithiasis
9. Each canal produces a different vector of nystagmus
• Posterior canal – up-beating and twisting
towards earth (geotropic)
• Anterior canal -- downbeating, with variable
twisting (torsion)
• Lateral canal - side-beating, either always
downward (geotropic), or always upward
(ageotropic).
13. • Debris might be either attached or loose
– attached, the pattern is identical to cupulolithiasis
– loose, then pattern should be a mixture of
cupulolithiasis and canalithiasis
14. How to determine which ear is involved
• Direction of the fast phase
• Pathophysiology involved
• Symptoms of BPPV occur the down ear is generally involved
• Direction of the nystagmus
24. Anterior Canal BPPV
•
• Displaced otoconia can
migrate to any of the three
semicircular canals.
• When it goes to the top
canal, it is called "anterior
canal BPPV".
25. Deep head hanging treatment
for AC BPPV
• the head is not turned to
either side
• it is positioned so that it is
further back with respect
to horizontal
26. Home Treatment
• Brandt-Daroff Exercises
– Successful treatment in 95% of cases
– Take longer
– Performed in three sets per day for two weeks
– Multi-canal BPPV can be a consequence of using
these exercises
– Complete relief from symptoms is obtained after
30 sets, or about 10 days in most cases
28. • Begin in sitting position
• Turn their head towards left side
• Bend it at an angle of 45 degrees
• Lie down on the surface for at least 30
seconds.
• Back to sitting position
29. • Turn your head to the opposite side
• Bend it at an angle of 45 degrees
• Lie down on the surface toward the opposite
side of the head turn for at least 30 seconds.
• Back to sitting position
30. Patient Restrictions
• Restrict head movement, or not?
• If so, for how long?
• Gans has studied this and reports that patient restrictions
are not necessary.
31. Bilateral BPPV
• The toughest cases are bilateral BPPV cases
• Treat one ear at a time
• You need to carefully treat only one ear at a
time in those cases
33. Outcomes
• Treatments or BPPV are 95% successful
• 50% of BPPV patients do exhibit post treatment
vestibulopathy
34. Summary
• BPPV is self-limiting
• When to see the patient after treatment
• within the week
35. ARE BPPV MANEUVRES
CONSIDERED VRT ?
• a "specialized" form of VRT treatment, not VRT
exercises themselves
• depend on which canal is involved
• why you need to use different maneuvers
HOW DO WE DIAGNOSE BPPV?
WE DETERMINE IF THERE IS BPPV WITH HX AND OBSERVATION OF EYE MOVEMENTS DURING PROVOCATIVE MANEIVERS
THE HALLPIKE IS JUST ONE OF THE MANEUVERS THAT MAY INDUCE BPPV SYMPTMOS
OBSERVATION BEING THE KEY
SYMPTOMS OF BPPV BEING DELAYED ONSET TORSIONAL NYSTAGMUS THAT FATIGUES
BPPV is presently generally accepted to be due to dislodged particles from the utricle.
There are several possible sites within the inner ear where particles can accumulate.
Canalithiasis
This is thought to be the cause of most BPPV. Debris is loose within the fluid filled pathways of the inner ear. When the head is repositioned with respect to gravity, the particles move to the new lowest portion of the inner ear.
This causes a "nystagmus", or jumping of the eyes with the following features: Here we are discussing debris in the posterior canal.
A latency between 5-30 seconds. Particles move out of the ampulla (dilated part of inner ear at bottom of picture above).
While they are moving, there is no nystagmus. After the particles finish moving, the nystagmus begins.
A "burst" of nystagmus, typically lasting 10 seconds.
The direction of the burst is about the axis of the canal containing the debris (i.e. upbeating and torsional for the posterior canal).
A reversal of nystagmus on sitting
Fatigability (i.e. less nystagmus when the maneuver is repeated, within a short period of time).
There might be canalithiasis involving any of the semicircular canals (or several at once). Each canal produces a different vector of nystagmus
Posterior canal -- upbeating and twisting towards earth
Anterior canal -- downbeating, with variable twisting (torsion)
Lateral canal - -side-beating, either always downward (geotropic), or always upward (ageotropic).
Cupulolithiasis
This is thought to be unusual (less than 5%). Here, debris is attached to the cupula of one of the canals. When the cupula is horizontal, there is no nystagmus or dizziness.
When the cupula is non-horizontal (most of the time), there is a constant input from the inner ear and dizziness.
The typical nystagmus of cupulolithiasis is thought to have the following features:
No latency
Permanent nystagmus, that persists as long as the head is positioned so that the canal being stimulated is not horizontal
Weak nystagmus (about 5 deg/sec), directed about the axis of the canal being stimulated.
Cupulolithiasis might occur in any canal -- horizontal, anterior or vertical, each of which might have it's own pattern of positional nystagmus.
For the lateral canal, the nystagmus is "ageotropic", meaning that it beats upward with respect to the head position.
Reversibility when the head is positioned such that canal is 180 degrees.
This is called "direction changing", and is most commonly observed in persons in whom lateral canal BPPV is diagnosed.
If cupulolithiasis is suspected, it seems logical to treat with either the Epley with vibration, or alternatively, use the Semont maneuver.
There are no studies of cupulolithiasis to indicate which strategy is the most effective.
Injuries to the cupula such as due to infection or poor circulation can also, in theory, cause cupulolithiasis.
Vestibulolithiasis
The prevalence of this condition is unknown. The conjecture is that debris is on the "vestibule" side of the labyrinth, rather than within or on the canal side. Debris might be either attached or loose. If attached, the pattern is identical to cupulolithiasis.
There is deterioration of the otoconia, near but unattached to cupula of the later channel, possibly in the lobby or the short arm of the semicircular channel.
Pathologic studies of BPPV have found roughly equal amounts of fixed debris on either side of the cupula suggesting that loose debris might also be found on either side.
If loose, then there should be a mixture of cupulolithiasis and canalithiasis.
For the mechanism of the vestibulolithiasis, when the head moves, the stones or the other ruin could change of lobby position ampulla, or within ampulla, affecting cupula.
HOW DO WE TELL WHICH EAR IS INVOLVED?
Direction of THE FAST PHASE OF nystagmus
Usually the down ear but also look at the direction of the nystagmus
Depends not only on direction but on whether the pathophysiology is cupulolithiasis v. canalithiasis
WHEN YOU PLACE THE HEAD IN THE OFFENDING POSITION NYSTAGMUS WILL ROTATE TOWARDS THE BAD EAR,
IF THE LEFT EAR IS UNDERMOST AND THE NYSTAGMUS BEATES TOWARD THE LEFT EAR, WHICH EAR IS INVOLVED?
THE NYSTAGMUS ROTATE, DOWN TOWARD THE LEFT
IF THERE IS A SLIGHT “UPWARD JUMP“ DURING THE DOWNWARD ROTATION
THE POSTERIOR CANAL THAT IS INVOLVED
IF THERE IS A "JUMP" DOWNWARD THE ANTERIOR CANAL IS INVOLVED
THE REASON THAT THIS IS HAS TO DO WITH THE PLANE OF EYE MOVEMENT THAT EACH CANAL CONTROLS
THE POSTERIOR CANAL CONTROLS MOVEMENT IN THE UPWARD PLANE
THE SLIGHT UPWARD MOVEMENT OR SLIGHT DOWNWARD MOVEMENT IS NOT OFTEN EASY TO SEE
THE HORIZONTAL VARIANT WILL PRODUCE A HORIZONTAL NYSTAGMUS
YOU TELL WHICH SIDE IS INVOLVED IN THE HORIZONTAL VARIANT BY
ASSUMING THAT THE AFFECTED SIDE IS THE ONE THAT PRODUCES THE
STRONGER SYMPTOMS
IN HORIZONTAL, WHEN YOU TURN THE HEAD TO THE LEFT, YOU WILL GET A
LEFT BEAT AND WHEN YOU TURN THE HEAD TO THE RIGHT, YOU GET A RIGHT BEAT
LET’S TALK ABOUT HORIZONTAL CANAL BPPV
IF THE INTENSITY OF THE NYSTAGMUS IS STRONGER ON the LEFT SIDE AND THE NYSTAGMUS IS AGEOTRIPIC (AWAY FROM THE GROUND), YOU MORE THAN LIKE LIKELLY HAVE A RIGHT CANAL CUPULOLITHIASIS
IN THE SAME CASE IF THE NYSTAGMUS IS GEOTROPIC YOU MORE THAN LIKELY HAVE A LEFT CANALITHIASIS
IF ON THE OTHER HAND YOU HAVE A NSYTAGMUS STRONGER ON THE RIGHT SIDE AND THE NYSTAGMUS IS
APGEITROPIC YOU WOULD HAVE A LEFT CUPULOLITHIASIS
IF THE NYSTAGMUS WAS GEOTROPIC YOU WOULD HAVE A RIGHT CANALITHIASIS
There are two treatments of BPPV that are usually performed in the doctor's office. Both treatments are very effective, with roughly an 80% cure rate.
The maneuvers, named after their inventors, are both intended to move debris or "ear rocks" out of the sensitive part of the ear (posterior canal) to a less sensitive location. Each maneuver takes about 15 minutes to complete.
The Semont maneuver (also called the "liberatory" maneuver) involves a procedure whereby the patient is rapidly moved from lying on one side to lying on the other. It is a brisk maneuver that is not currently favored in the United States, but it is 90% effective after 4 treatment sessions. In our opinion, it is equivalent to the Epley maneuver as the head orientation with respect to gravity is very similar, omitting only 'C' from the figure to the right.
The Epley maneuver is also called the particle repositioning or canalith repositioning procedure. It involves sequential movement of the head into four positions, staying in each position for roughly 30 seconds.
The recurrence rate for BPPV after these maneuvers is about 30 percent at one year, and in some instances a second treatment may be necessary.
Lateral canal BPPV is the most common atypical variant, accounting for about 3-12 percent of cases. Most cases are seen as a consequence of an Epley maneuver, but others find that spontaneous occurrence is more common.
It is diagnosed by seeing a horizontal nystagmus that changes direction depending on the down ear. The best position to see this nystagmus is not the Dix-Hallpike maneuver. Rather one starts with the body supine, head inclined forward 30 degrees, and then turns the head to either side.
The nystagmus can be either always towards the ground ("geotropic") or always towards the sky ("ageotropic", or "ageotropic")
Lateral canal BPPV can cause a very strong and prolonged vertigo.
People with lateral canal BPPV are also generally more disturbed by ordinary sideways rotational head-movements than people with posterior canal BPPV.
Lateral canal BPPV may occur commonly but may also be self treated as people roll back and forth at night naturally during sleep.
When lateral canal BPPV follows a treatment maneuver for posterior canal BPPV, the "bad" ear is considered to be the same one with the posterior canal BPPV.
Treatment of lateral canal BPPV has not been as well established as in typical BPPV. lateral canal BPPV after an Epley maneuver nearly always resolves without any treatment after a week.
The "log roll" exercises, are a procedure where an individual is rolled in steps of 90 deg, starting supine/affected ear down, to supine, to affected ear up, to nose-down, and then to sitting at intervals of 30 seconds or one minute.
There is a report of 75% efficacy (15/20) of a variant procedure called the "iterative full-contralateral roll", going from supine nose up, a full 360 degrees in 90 degree increments, rotating towards the good ear.
This procedure is performed once or twice in the clinic and repeated at home for 7 days. It seems to us that the difficulty of establishing which is the "bad" ear is an obvious drawback of this procedure and in some situations, we do the log roll to one side for a week, and follow with the log roll to the other side for another week.
it is preferable to begin with the bad-ear down rather than supine, for situations where there is debris close to the ampulla.
Currently it is generally felt that this is a poor prognosis variant of lateral canal BPPV. Because debris is stuck to the cupula, it may not be easily treated by physical maneuvers aimed at dislodging it. Debris could be stuck to either side of the cupula, leading to some uncertainty about which is the best way to treat it.
Photo on the right: In position 'b', the head is turned 45 degrees towards the symptomatic side.
Displaced otoconia can migrate to any of the three semicircular canals. When it goes to the top canal, it is called "anterior canal BPPV".
Debris can not only migrate into the long arms of the canals, but might also become adherent to the cupulae.
It is diagnosed by a positional nystagmus with components of downbeating and (sometimes) torsional movement on taking up the Dix-Hallpike position.
In AC BPPV, symptoms may be even stronger with the head straight back (head hanging)
An unsolved puzzle right now has to do with the torsional vector of AC nystagmus. From basic vestibular physiology, one would expect that it would beat towards the "up" side, but in our experience, it more often beats towards the down side, or just doesn't have any torsion at all.
Anterior canal BPPV is probably rare because the anterior canal is normally the highest part of the ear. Debris would naturally tend to fall out of the posterior half of the anterior canal, and getting debris into the anterior canal would not be easy.
Treatment for AC BPPV : In position 'b', the head is turned 45 degrees towards the symptomatic side.
Deep head hanging treatment for AC BPPV. This treatment differs in that the head is not turned to either side, and it is positioned so that it is further back with respect to horizontal in position 2.
The idea is to invert the anterior canal, to all debris to fall to the ow "top" of the canal, and then, on sitting, to allow it to further migrate into the common crus and then vestibule.
HOW ABOUT PATIENT RESTRICTIONS AFTER TREATMENT?
I DO USE SOME RESTRICTION
I ORIGINALLY HAD THE PATIENT RESTRICT MOVEMENTS FOR 48 HOURS WITH A CERVICAL COLLAR AND SLEEP AT A 45 DEG ANGLE FOR 2 NIGHTS
NOW I HAVE THEM SLEEP AT AN ANGLE 1 NIGHT AND HAVE THEM WEAR THE COLLAR FOR 1 DAY
THAT IS GANS FEELING
THE TOUGHEST CASES ARE BILATERAL BPPV CASES
YOU NEED TO CAREFULLY TREAT ONLY ONE EAR AT A TIME IN THOSE CASES
IN TREATING BPPV YOU WILL BE MOVING FLUID IN BOTH VESTIBUALR SYSTEMS BUT THE GOOD EAR" WILL NOT BE AFFECTED
YOU TURN THE HEAD TOWARD THE AFFECTED EAR, 3-4 MINUTES
THEN TURN THE HEAD TOWARD THE UNAFFECTED EAR, 3-4 MINUTES
THEN TURN THE HEAD DOWNWARD TOWARD THE FLOOR
YOU THEN SIT THE PATIENT UP
AS I SAID EARLIER THE TRICK IS THE BILAT BPPV CASES
PRECAUTIONS
FIRST PRECAUTION: CERVICAL INJURY
SECOND IS LOWER BACK INJURY
LASTLY VERTEBRAL BASILAR INSUFFICIENCY
YOU DONT WANT THE PATIENT TO PASS OUT DURING TREATMENT
THESE TREATMENTS ARE 95 % SUCCESSFUL IN TREATING BPPV
ALTHOUGH 50 % PRESENT WITH POST TREATMENT VESTIBULOPATHY
see the patient within the week after they have treated
How long after they have seen the physician that you see them is important because BPPV is fatigable.
That means if you see the patient two days after, you may still get a negative response on the Hallpike.
Wait about 7 days after a physician exam before you see the patient
in about 15 % of the cases, the Hallpike will also treat the BPPV and remove the offending otolith.
If they still have some symptoms and they are not related to BPPV then VR referral or procedures are warranted.
