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Bppv 16 06-2015
Benign paroxysmal positional vertigo (BPPV) is a common inner ear condition characterized by brief episodes of vertigo triggered by changes in head position. It is caused by debris in the semicircular canals leading to abnormal signals in the vestibular system. BPPV involving the posterior semicircular canal accounts for about 94% of cases. Diagnosis is made through provocative positional tests like the Dix-Hallpike maneuver. Treatment involves repositioning maneuvers like Epley's maneuver to move the debris out of the affected canal. BPPV typically resolves spontaneously within weeks to months, but recurrence is possible in about 15-45% of cases within a year without treatment.
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Bppv 16 06-2015
- 1. Benign Paroxysmal Positional Vertigo Dr.Deepa Shivnani
- 2. BPPV • Dix andHallpike 1952 – specific characteristics • Vertigo • Rotatory nystagmus • Precipitated by head movement • Latency of 1 - 5 seconds • Accompanying nausea • Fatigable in 15-30 seconds • Adaptable Dix MR, Hallpike CS. Pathology, symptoms and diagnosis of certain disorders of the vestibular system. Proc R Soc Med.1952;45:341-354 C.S Hallpike
- 3. Definition • Benign paroxysmalpositional vertigo (BPPV) is a disorder of the inner ear characterized by episodes of vertigo triggered by changes in head position. • BPPV is thought to be caused by the presence of endo lymphatic debris in one or more semi- circular canals
- 4. • BPPV istermed “benign” because it is a naturally resolving condition • The average time to resolution of vertigo has been observed to be 13 days, and maximum time was about 35 days • Despite its favorable prognosis, BPPV is not an entirely benign condition, especially in the elderly, in whom it is often unrecognized and can lead to falls
- 5. • The posteriorsemicircular canal is involved in approximately 94% of cases • The lateral canal BPPV is next common Was first described by Cipparrone and McClure Two distinct subtypes Geotropic Apogeotropic Cipparrone L et al.Nistagmografia e pathologica vestibulare periferica. Milano, Italie: V Giornata Italiana di Nistagmografia Clinica;1985:6-53 McMclure JA.Horizontal canal BPPV. J Otolaryngol 1985; 14:30-35 Anterior canal BPPV is very rare
- 6. Risk Factors • 18-39:yoga,runningon pavement,working underneath objects such as cars,ceiling painters,aerobic exercises,jogging,running on treadmill and swimming • >40;head trauma,ear disorders(vestibular neuritis or labyrinthitis) • Certain positions are more likely to provoke vertigo;lying back in bed,arising quickly,looking up,reclining for dental or hair treatments
- 7. pathophysiology • Caused byotoconia that falls in to the PSC or LSC after detaching from the utricle • Reason for detachment:increased age/trauma and infections • Schuknecht :basophillic deposits on the cupula of the PSC causes BPPV • Dix and hallpike :1952/head manuover to produce the ipsidirectional torsional nystagmus used to identify BPPV
- 8. Pathophysiology Cupulolithiasis • Schuknecht firstdescribed cupulolithiasis • Could not explain Adaptability Fatiguability Schuknecht HF. Cupulolithiasis. Arch Otolaryngol 1969;90:765-778
- 9. Canalolithiasis • McClure andParnes described canalolithiasis McClure JA et al. The mechanics of benign paroxysmal vertigo. J Otolaryngol 1979;8:151-158 Parnes LS et al. Particle repositioning maneuver for benign paroxymal postional vertigo. Ann Otol Rhinol Laryngol 1993;102:325-331
- 10. • Self LimitingDisorder • Resolves by itself within a few weeks to few months in most cases • BPPV of PSC typically characterised by torsional nystagmus which has a duration of less than one minute • Always peripheral in origin
- 11. Nystagmus • Latency –5s to 20s • Accompanied by sense of vertigo • Gradual decrease in intensity (15s to 40s) • Beats towards the undermost ear and is direction-fixed • Fatigable on repetition
- 12. Movement of Otolith Flow of Endolymph Deflectionof cupula in the PSC Excitation of Vestibular Nerve Stimulation of Maculo spinal reflex Maculo-Ocular Reflex Vertigo Nystagmus
- 13. Positional Test S/N PatientSitting up S/N Patient Lying Down 1 Head Straight Ahead 1 Head Straight 2 Head Extended 2 Head Hanging 3 Head right side down 3 Head right side down 4 Head left side down 4 Head left side down 5 Head Flexed 5 Head 50 Deg below horizontal & 45 Deg turned to the left 6 Head 30 Deg below horizontal & 45 Deg turned to the right
- 14. Positioning tests • Identifythe canal involved Dix-Hallpike test Lateral position Geotropic Apogeotropic
- 15. BPPV Manoeuvres S/N BPPVVariant Management 1 Posterior Canalolithiasis 1. Epley's manoeuvre 2 Posterior Cupololithiasis 1. Semont's Liberatory manoeuvre 2. Brand daroff’s Exercise 3 Horizontal Canalolithiasis(Geotropic) 1. 360 Deg barbecue roll 2. Gufoni’s manoeuvre 4 Horizontal Cupololithiasis (Apogeotropic) 1. Modified Gufoni ‘s manoeuvre 2. Modified Brand daroff’s Exercise 5 Anterior Canal Cupololithiasis 1. Reverse Epley's manoeuvre 2. Reverse Semont's (Liberatory) manoeuvre 3. Crevitz manoeuvre
- 16. BPPV Variant Test Direction of nystagmus Duration of nystagmus Treatmentof choice Posterior canalolithias is Dix- Hallpike test Upbeat torsional- towards affected side 5-45 sec Epley’s maneuver
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- 19. BPPV Variant TestDirection of nystagmus Duration of nystagmus Treatment of choice Posterior cupulolithiasi s Dix- Hallpike test Upbeat torsional - towards affected side Persistant >1min Semont liberatory maneuver; Brandt Daroff exercises
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- 22. BPPV Variant TestDirection of nystagmus Duration of nystagmus Treatment of choice Horizontal canalolithiasis ( geotropic) Roll test Horizontal towards the ground Sec to min 360 deg barbecue roll Gufoni Maneuver
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- 26. BPPV Variant TestDirection of nystagmus Duration of nystagmus Treatment of choice Horizontal cupulolithiasis (apogeotropic) Roll test Horizontal away from the ground, more severe on the opposite side Sec to min Modified Gufoni’s maneuver Modified Brandt- Daroff exercises
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- 29. BPPV Variant Test Direction of nystagmus Duration of nystagmus Treatment ofchoice Anterior canal Cupulolithiasis Dix Hallpike test Head hanging Test Vertical downbeating nystagmus Sec to min Reverse Epley’s Maneuver Reverse Semont’s Maneuver Crevitz Maneuver
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- 33. Treatment efficacy • Patienthas relief OR • Dix-Hallpike test negative • Spontaneous remission in 6-12 months • Recurrence in 15-45% in one year
- 34. Role of post-maneuverrestrictions • Not to lie down flat.(45 degree head up) • Not to bend over, or look up or look down • Avoid lying down on the affected side for a week • Is it really necessary? Cakir et al(2006). Efficacy of postural restrictions in treating benign paroxysmal positional vertigo. Arch OHNS, 132,5, 501-505. No more postural restrictions in posterior canal benign paroxysmal positional vertigo. Otology & Neurotology, 2008;29:706-709.
- 35. Summary • BPPV :mostcommon type of peripheral vertigo • Aggrevates with head movements /positional changes • Associated with nause /vomitting and classical torsional (psc) or horizontal (lsc) nystagmus • Diagnosis is by history and positional /positioning testing
- 36. cont………. • Management:different manueverfor different types of BPPV • MEDICAL MANAGEMENT :not useful • Surgical management :singular neurectomy /plugging of PSC • Usually resolves by its own.
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