BPPV ppt

BENIGN PAROXYSMAL POSITIONAL VERTIGO

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Basic Anatomy

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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

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BPPV …

• Subclassification : scc post/lat/ant/bilat• Pathophysiology :– Canalithiasis– cupulolithiasis

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Pathophysiology

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Pathophysiology (cont.)

• Cupulolithiasis :– Harold Schuknecht 1962 – Densities (otocania) adherent to cupula of crista

ampullaris– Basophilic particles -1969

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• Canalithiasis :– John Epley – 1980– Densities free floating in canal portion– Parnes , McClure – 1991 found particles in post

SCC

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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.

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• Physical : – neurological examination – normal– except – Dix-Hallpike pathognomonic

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BPPV …

• Nystagmus : characterization and types – RT / LT , vertical / horizontal , changing– Tortional = Rotational – clockwise /

counterclockwise– Geotropic- toward the earth– Ageotropic – opposite

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BPPV …

• Classic post SCC – geotropic rotatory nystagmus

• Horizontal SCC – purely horizontal nystagmus• Non-fatiguing nystagmus – cupulolithiasis >

canalithiasis

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Classic BPPV

• Involved 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

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Lat. SCC PPV

• Most common 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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Lat. SCC PPV

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Ant. SCC PPV

• Rare – 2%• Down-beating /torsional NG for the opposite

ear on Dix-Hallpike maneuver

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BPPV - Causes

• Predisposing factors :– Inactivity – Acute alcoholism– Major surgery– CNS disease

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Causes ( cont. )

• Idiopathic – 39% • Ear disease – 29%– OM – 9%– Vestibular neuritis – 7%– Menier’s dis – 7%– Otosclerosis – 4%– Sudden SNHL – 2%

• Trauma – 21%

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Causes ( cont. )

• Trauma – 21%• CNS diseases – 11%• Acustic neuroma – 2%• Cervical vertigo – 2%

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BPPV - D.D

• Menier’s disease• 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

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BPPV - Treatment

• Watchful waiting• Vestibular suppressant medications• Vestibular rehabilitation• Canalith repositioning• Surgery care– Labyrinthectomy– Post. Canal occlusion– Singula neurectomy – Transtympanic aminpglycoside application

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Trials about BPPV

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General

• Labeled benign paroxysmal positional vertigo is not always benign

• Evaluation of the effectiveness of canalith reepositioning procedurs – CRP

• Several studies …

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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) :

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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

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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

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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

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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

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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

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Meta - Analysis

• 9 randomized-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

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CRP – Epley maneuver

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CRP – Semont maneuver

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Mastoid oscillator

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Brandt-Daroff Exsercise

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Lampert maneuver- Lat. SCC BPPV

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Vestibular rehabilitaions

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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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