BPPV

Benign Positional VertigoTaleb Mohammed MansoorKhaleil Ebrahem Al-Matroushi

The Ear

The Inner Ear

Benign Paroxysmal Positional Vertigo (BPPV) Inner ear problem that results in short lasting, but severe, room-spinning vertigo. Benign: not a very serious or progressive conditionParoxysmal: sudden and unpredictable in onset Positional: comes with a change in head positionVertigo: causing a sense of dizziness.

Canalolithiasis TheoryThe most widely accepted theory of the pathophysiology of BPV Otoliths (calcium carbonate particles) are normally attached to a membrane inside the utricle and sacculeThe utricle is connected to the semicircular ducts These otoliths may become displaced from the utricle to enter the posterior semicircular duct since this is the most dependent of the 3 ducts Changing head position relative to gravity causes the free otoliths to gravitate longitudinally through the canal. The concurrent flow of endolymph stimulates the hair cells of the affected semicircular canal, causing vertigo.

Canalolithiasis Theory

CausesIdiopathicInfection (viral neuronitis)Head traumaDegeneration of the peripheral end organSurgical damage to the labyrinth

SymptomsStarts suddenly first noticed in bed, when waking from sleep. Any turn of the head bring on dizziness. Patients often describe the occurrence of vertigo with tilting of the head, looking up or down (top-shelf vertigo) rolling over in bed. nausea and vomiting. There is no new hearing loss or tinnitus.

DiagnosisLab Studies: No pathognomonic laboratory test for BPV exists. Laboratory tests may be ordered to rule out other pathology.Imaging Studies: Head CT scan or MRI.Procedures: The Dix-Hallpike test, along with the patient's history, aids in the diagnosis of BPV.

The Dix-Hallpike test

TreatmentMedicationsThe Canalith Repositioning Procedure (CRP)Surgery

MedicationsAntiemeticAntihistaminicAnticholinergic

Canalith Repositioning Procedure ( CRP )The treatment of choice for BPPV. Also known as the Epley maneuver, The patient is positioned in a series of steps so as to slowly move the otoconia particles from the posterior semicircular canal back into the utricle. Takes approximately 5 minutes. The patient is instructed to wear a neck brace for 24 hours and to not bend down or lay flat for 24 hours after the procedure. One week after the CRP, the Dix-Hallpike test is repeated. If the patient does experience vertigo and nystagmus, then the CRP is repeated with a vibrator placed on the skull in order to better dislodge the otoconia.

The Epley Maneuver

Clinical TrialRuckenstein (2001) Therapeutic efficacy of the Epley canalith repositioning maneuver. Laryngoscope

Eighty-six patients 74% of cases that were treated with one or two canalith repositioning maneuvers had a resolution of vertigo as a direct result of the maneuver. A resolution attributable to the first intervention was obtained in 70% of cases within 48 hours of the maneuver. An additional 14% of cases that were treated had a resolution of vertigo.Only 4% of cases (three patients) manifested BPV that persisted after four treatments.

Brandt-Daroff Exercisesmethod of treating BPPV, usually used when the office treatment fails. These exercises should be performed for two weeks, three times per day for three weeks, twice per day. In each time, one performs the maneuver as shown five times. 1 repetition = maneuver done to each side in turn (takes 2 minutes)

Brandt-Daroff Exercises

Clinical TrialRadtke et al (1999) A modified Epley's procedure for self-treatment of benign paroxysmal positional vertigo. Neurology Compared the efficacy of a modified Epley's procedure (MEP) and Brandt-Daroff exercises (BDE) for self-treatment of (PC-BPPV)54 patients. PC-BPPV resolved within 1 week in 18 of 28 patients (64%) using the MEP 6 of 26 patients (23%) performing BDE The MEP is more suitable for self-treatment of PC-BPPV than conventional BDE

SurgerySingular neurectomyVestibular Nerve SectionPosterior Canal Plugging Procedure

Singular neurectomy Old procedure Section the nerve that transmits information from the posterior semicircular canal ampulla toward the brain.Can cause hearing loss in 7-17% of patients and fails in 8-12%.

Clinical TrialGacek (1995) Technique and results of singular neurectomy for the management of benign paroxysmal positional vertigo. Acta Otolaryngol One hundred thirty-seven patients 1972-1994. (94%) experienced complete relief of vertigo following SN. (2%) experienced partial relief of positional vertigo following SN and (4%) failed to have any improvement of symptoms following SN.(3%) had a partial sensorineural following SN.

Posterior Canal Plugging ProcedureRecently developed procedure Replaced the singular neurectomy. A mastoidectomy is performed through an incision made behind the ear. The balance center is then uncovered and The posterior semicircular canal is opened, exposing the delicate membranous channel in which the crystalline debris is floating. The canal is then gently, but firmly packed off with tissue so the debris can no longer move within the canal and strike against the nerve endings. The canal is then sealed and the incision closed.One-night hospital stay is advised. The patient returns in one week for suture removal. less than 20% hearing loss.

Clinical TrialWalsh (1999)Long-term results of posterior semicircular canal occlusion for intractable benign paroxysmal positional vertigo. Clin Otolaryngol 13 patients who All patients reported complete and immediate resolution of their positional vertigo, which has been maintained in the long term. All patients developed a transient mild conductive hearing loss secondary to a middle ear collection, which usually resolved within 4 weeks. Five patients developed a transient mild high frequency sensorineural hearing loss which resolved in all cases within 6 months. There were no reports of sensorineural hearing loss nor tinnitus in the long term.

Vestibular Nerve Sectiondone when the attacks of vertigo cannot be controlled with medication. An incision is made behind the ear and balance-hearing nerve is located. The balance part of the nerve is cut. The operation is done with a neurosurgeon and takes two hours. The success rate (no vertigo attacks) is over 90%. The hearing is usually not affected.

Vestibular Nerve Section

Clinical TrialThomsen et al, (2000) Vestibular neurectomy Auris Nasus Larynx

42 patients.The vertigo was controlled in 88% of the patientspostoperative imbalance occurred in 14 patients

SummaryBPPVCommon complainVertigo when changing head positionDiagnosed by Dix-hallpikeTreated by CRPSurgery if CRP fails