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BENIGN PAROXYSMAL

POSITIONAL VERTIGO






WASEEM WATAD
Basic Anatomy

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

BPPV
Subclassification : scc post/lat/ant/bilat
Pathophysiology :
Canalithiasis
cupulolithiasis
Pathophysiology
Pathophysiology (cont.)
Cupulolithiasis :
Harold Schuknecht 1962
Densities (otocania) adherent to cupula of
crista ampullaris
Basophilic particles -1969
Canalithiasis :
John Epley 1980
Densities free floating in canal portion
Parnes , McClure 1991 found particles in
post SCC

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.






Physical :
neurological examination normal
except Dix-Hallpike pathognomonic

BPPV
Nystagmus : characterization and types
RT / LT , vertical / horizontal , changing
Tortional = Rotational clockwise /
counterclockwise
Geotropic- toward the earth
Ageotropic opposite

BPPV
Classic post SCC geotropic rotatory
nystagmus
Horizontal SCC purely horizontal
nystagmus
Non-fatiguing nystagmus
cupulolithiasis > canalithiasis
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

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

Lat. SCC PPV

Ant. SCC PPV
Rare 2%
Down-beating /torsional NG for the
opposite ear on Dix-Hallpike maneuver


BPPV - Causes
Predisposing factors :
Inactivity
Acute alcoholism
Major surgery
CNS disease

Causes ( cont. )
Idiopathic 39%
Ear disease 29%
OM 9%
Vestibular neuritis 7%
Meniers dis 7%
Otosclerosis 4%
Sudden SNHL 2%
Trauma 21%


Causes ( cont. )
Trauma 21%
CNS diseases 11%
Acustic neuroma 2%
Cervical vertigo 2%

BPPV - D.D
Meniers 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

BPPV - Treatment
Watchful waiting
Vestibular suppressant medications
Vestibular rehabilitation
Canalith repositioning
Surgery care
Labyrinthectomy
Post. Canal occlusion
Singula neurectomy
Transtympanic aminpglycoside application
Trials about BPPV
General
Labeled benign paroxysmal positional
vertigo is not always benign
Evaluation of the effectiveness of
canalith reepositioning procedurs CRP
Several studies
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) :


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
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

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
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

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

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

CRP Epley maneuver

CRP Semont maneuver

Mastoid oscillator

Brandt-Daroff Exsercise
Lampert maneuver- Lat. SCC
BPPV

Vestibular rehabilitaions
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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