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Similar to Benign paroxysmal positional vertigo
Benign paroxysmal positional vertigo
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- 3. BPPV Barany 1921 Dix-Hallpike 1952– important features of nystagmus Abnormal sensation of motion elicited by certain critical positions Provocative position nystagmus At least 20% of vertigo Underestimated
- 4. BPPV … Subclassification :scc post/lat/ant/bilat Pathophysiology : – Canalithiasis – cupulolithiasis
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- 6. Pathophysiology (cont.) Cupulolithiasis : –Harold Schuknecht 1962 – Densities (otocania) adherent to cupula of crista ampullaris – Basophilic particles -1969
- 7. Canalithiasis : – JohnEpley – 1980 – Densities free floating in canal portion – Parnes , McClure – 1991 found particles in post SCC
- 8. BPPV ... Frequency :10-64/100000 Sex : 64% women Age : older population ( 51-57) younger than 35 – head trauma. History : – sudden – days-weeks – occassionally months -years – episodes.
- 9. Physical : – neurologicalexamination – normal – except – Dix-Hallpike pathognomonic
- 10. BPPV … Nystagmus :characterization and types – RT / LT , vertical / horizontal , changing – Tortional = Rotational – clockwise / counterclockwise – Geotropic- toward the earth – Ageotropic – opposite
- 11. BPPV … Classic postSCC – geotropic rotatory nystagmus Horizontal SCC – purely horizontal nystagmus Non-fatiguing nystagmus – cupulolithiasis > canalithiasis
- 12. Classic BPPV Involved thePOST 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. Lat. SCC PPV Mostcommon atypical BPPV 3-9% of cases Consequence of Epley maneuver Horizontal purely nystagmus Cupulolithiasis rather than canalithiasis Modified Epley / lampert maneuver …
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- 15. Ant. SCC PPV Rare– 2% Down-beating /torsional NG for the opposite ear on Dix-Hallpike maneuver
- 16. BPPV - Causes Predisposingfactors : – Inactivity – Acute alcoholism – Major surgery – CNS disease
- 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. Causes ( cont.) Trauma – 21% CNS diseases – 11% Acustic neuroma – 2% Cervical vertigo – 2%
- 19. BPPV - D.D Menier’sdisease Inner ear concussion Alcohol intoxication Labyrinthitis Vascular loop syndrome Post. Fossa lesions : acustic neuroma , meningioma Central origion : stroke , MS , cerebellar degeneration Vertibral artery insuffeciency Cervical vertigo
- 20. BPPV - Treatment Watchfulwaiting Vestibular suppressant medications Vestibular rehabilitation Canalith repositioning Surgery care – Labyrinthectomy – Post. Canal occlusion – Singula neurectomy – Transtympanic aminpglycoside application
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- 22. General Labeled benign paroxysmalpositional vertigo is not always benign Evaluation of the effectiveness of canalith reepositioning procedurs – CRP Several studies …
- 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 group John Li (1995) :
- 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. 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. 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. Elderly population andBPPV 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. CRP Meta-Analysis B. Woodworth - 2004 CRP - 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. Meta - Analysis 9randomized-controlled trials Symptoms resolution and elimination of positive Dix-Hallpike test CRP more effective than control ( x5 ) Untreated patients - symptoms improvements with time but positive DH So Resolution of vertigo – avoidance of provocative positions
- 30. CRP – Epleymaneuver
- 31. CRP – Semontmaneuver
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- 34. Lampert maneuver- Lat.SCC BPPV
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- 36. Complications of CRP Failure– 25% (12%-56) Recurrence – 13% in 6 months Side effects – Nausea – Vomiting – Fainting – Sweating Worse vertigo – LAT SCC PPV
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