bppv 16 06-2015
TRANSCRIPT
Benign Paroxysmal Positional Vertigo
Dr. Deepa Shivnani
BPPV• Dix and Hallpike 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
Definition
• Benign paroxysmal positional 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
• BPPV is termed “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
• The posterior semicircular canal is involved in approximately 94% of cases
• The lateral canal BPPV is next commonWas first described by Cipparrone and McClureTwo distinct subtypes
Geotropic Apogeotropic
Cipparrone L et al.Nistagmografia e pathologica vestibulare periferica. Milano, Italie: V Giornata Italiana di Nistagmografia Clinica;1985:6-53McMclure JA.Horizontal canal BPPV. J Otolaryngol 1985; 14:30-35
Anterior canal BPPV is very rare
Risk Factors
• 18-39:yoga,running on 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
pathophysiology
• Caused by otoconia 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
Pathophysiology
Cupulolithiasis• Schuknecht first described
cupulolithiasis
• Could not explain Adaptability Fatiguability
Schuknecht HF. Cupulolithiasis. Arch Otolaryngol 1969;90:765-778
Canalolithiasis• McClure and Parnes
described canalolithiasis
McClure JA et al. The mechanics of benign paroxysmal vertigo. J Otolaryngol 1979;8:151-158Parnes LS et al. Particle repositioning maneuver for benign paroxymal postional vertigo. Ann Otol Rhinol Laryngol 1993;102:325-331
• Self Limiting Disorder• 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
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
Movement of Otolith
Flow of Endolymph
Deflection of cupula in the
PSC
Excitation of Vestibular
Nerve
Stimulation of Maculo spinal
reflex
Maculo-Ocular Reflex
Vertigo
Nystagmus
Positional TestS/N Patient Sitting 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
Positioning tests
• Identify the canal involvedDix-Hallpike testLateral position
Geotropic Apogeotropic
BPPV Manoeuvres
S/N BPPV Variant Management
1 Posterior Canalolithiasis 1. Epley's manoeuvre
2 Posterior Cupololithiasis1. Semont's Liberatory manoeuvre2. Brand daroff’s Exercise
3Horizontal Canalolithiasis(Geotropic)
1. 360 Deg barbecue roll2. Gufoni’s manoeuvre
4Horizontal Cupololithiasis (Apogeotropic)
1. Modified Gufoni ‘s manoeuvre
2. Modified Brand daroff’s Exercise
5 Anterior Canal Cupololithiasis
1. Reverse Epley's manoeuvre2. Reverse Semont's (Liberatory) manoeuvre3. Crevitz manoeuvre
BPPV Variant
Test Direction of nystagmus
Duration of nystagmus
Treatment of choice
Posterior canalolithiasis
Dix-Hallpike test
Upbeat torsional-towards affected side
5-45 sec Epley’s maneuver
Dix-Hallpike Test
Epley’s Maneuver
BPPV Variant Test Direction of nystagmus
Duration of nystagmus
Treatment of choice
Posterior cupulolithiasis
Dix-Hallpike test
Upbeat torsional -towards affected side
Persistant >1min
Semont liberatory maneuver;
Brandt Daroff exercises
Semont’s Maneuver
Brandt-Daroff Exercises
BPPV Variant Test Direction 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
Roll Test
Barbecue Maneuver
Gufoni Maneuver
BPPV Variant Test Direction 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
Modified Gufoni Maneuver
Modified Brandt-Daroff Exercises
BPPV Variant
Test Direction of nystagmus
Duration of nystagmus
Treatment of choice
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
Dix Hallpike test
Head Hanging Test
Crevitz Maneuver
Treatment efficacy
• Patient has relief OR• Dix-Hallpike test negative• Spontaneous remission in 6-12 months• Recurrence in 15-45% in one year
Role of post-maneuver restrictions
• 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.
Summary • BPPV :most common 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
cont……….• Management:different manuever for different
types of BPPV• MEDICAL MANAGEMENT :not useful• Surgical management :singular neurectomy
/plugging of PSC• Usually resolves by its own.
THANK YOU……
ANY QUESTION?????