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%
– Menier’s 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
 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
 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
 THANK YOU …