Benign Paroxysmal Positional Vertigo B.P.P.V. Dr. Abdulrahman Hagr MBBS FRCS(c) Assistant Professor King Saud University Otolaryngology Consultant Otologist, Neurotologist & Skull Base Surgeon King Abdulaziz Hospital

The most scary thing in ent clinic is dizzy patient at the end of the day

Benign paroxysmal positional vertigo History Pathology Management P/E Treatment

Benign Paroxysmal Positional Vertigo 1921 first described in by Bárány 1952, Dix and Hallpike reported this entity in a large group of patients. described the Dix-Hallpike maneuver recognized features of the nystagmus Latency directional characteristics brief duration Reversibility fatigability .

BPPV Schuknecht 1969 (Cupulolithiasis ) McClure loose otoconia from the utricle PSCC McClure 1979 Canalithiasis mechanism

Benign paroxysmal positional vertigo History Pathology Management P/E Treatment

Incidence 30% of peripheral vestibular disease 15 per 100,000 in Japan 64 per 100,000 in Minnesota. Twice Ménière's mean age fifth decades Increases with age. Women:men 1.6:1

Etiology Primary or idiopathic (50%–70%) Secondary (30%–50%) Viral labyrinthitis (15%) Head trauma (10%) Ménière’s disease (5%) Migraines (< 5%) Inner ear surgery (< 1%)

BPPV: Pathophysiology Degenerative debris from utricle (otoconia) Canalithiasis Theory floating freely in the endolymph Cupulolithiasis Theory Adhering to the cupula

? PSCC PSCC Hangs down like the water trap in a drain pipe Allowing the crystals to settle in the bottom of the canal.

Benign paroxysmal positional vertigo History Pathology Management P/E Treatment

History Sudden Seconds Severe vertigo Bouts of vertigo remissions Chronic balance problems Worse in the morning

History Associated with change in head position. rolling over or getting into bed assuming a supine position. arising from a bending position looking up to take an object off a shelf tilting the head back to shave turning rapidly.

Benign paroxysmal positional vertigo History Pathology Management P/E Treatment

Dix-Hallpike Maneuver Hagr 6 D Delay seconds latency Downward (Geotropic) Duration <1 minute Directional change Dizziness (Subjective) Disappear fatigable

Benign paroxysmal positional vertigo History Pathology Management P/E Diagnosis Treatment

Test Results ENG limitation Do not record the torsion Low frequency(0.003 Hz)* Lateral SCC LOC Rotational-chair & posturography have no role Imaging with CT scanning or MRI is unnecessary = PTA @125Hz

D/D Postural hypotension Drugs Cupula sensitive to gravity Fistula anti-hypertensive drugs CV problems Drugs Cupula sensitive to gravity PAN-1 PAN-2 Heavy water Fistula

D/D History is virtually pathognomonic Only type of vertigo Multiple times per day brief episodes NO auditory complaints No neurological

Benign paroxysmal positional vertigo History Pathology P/E Treatment

Treatment Patient education Medical Exercise Surgical

Patient education Inner ear disease Not CVA Not Cancer Recurrence

Medical Relieve of nausea Promethazine Prochlorperazine

Epley Maneuver Dr. John M. Epley 1980 * Canalilith Repositioning Canalith debris  vestibule single treatment = 95% Remission Otolaryngol Head Neck Surg 88:599–605, 1980. http://www.earinfosite.org/about.htm

Epley Maneuver Reclined head hanging 45 degree turn

Epley Maneuver Rotate 45 degrees contralateral

Epley Maneuver Head and body rotated to 135 degrees from supine

Epley Maneuver Keep head turn and to sitting Turn forward chin down 20 degrees

Video

Sleep semi-recumbent for the next two nights

Semont Liberatory maneuver 1st rapid single treatment 83.96% one maneuver 92.68% two 4.22% recurrence Others less success, too violent

Brandt and Daroff exercises Seated eyes closed Tilted laterally to precipitating position Lateral occiput resting Vertigo subsides Sit up for 30 sec Opposite head down position 30 sec Vertigo opposite (bilateral) maintain until resolves Every 3 hrs while awake, until 2 days free

Brandt-Daroff Exercises

Brandt and Daroff 98.5% relief 3-14 days Most 7-10 days 3% recurred Non-responder had perilymph fistula 66 of 67

Brandt and Daroff

Surgical ? Section of singular nerve Canal occlusion Vestibular nerve section Eliminate response from PSCC Candidates unrelenting symptoms from same ear, multiple recurrences

Singular Neurectomy Gacek* Anatomy Nerve exits lateral IAC singular canal Courses inf. and post. to PSCC ampula Inf-post to round window niche *Ann Otol Rhinol Laryngol 83:596–605, 1974

Singular Neurectomy Published success 90% Persistent symptoms if nerve not definitively found Complications Recurrent vertigo, SNHL Severe SNHL 5% Trauma, labyrinthitis Mild SNHL 20% Only attempted by experience surgeons

PSCC Occlusion Prevents flow of endolymph Animal studies no effect on remaining vestibular organs Procedure Cortical mastoidectomy Identify and blue-line canal Open with pick Occlude canal Laser partitioning optional Pack canal, bone wax, dust, fascia covering

PSCC Occlusion Transient SNHL Mild SNHL persists 20% Detected intraoperatively by ECog Recovers by 6-8 weeks Mild SNHL persists 20% Post-op dysequilibrium for a few days/weeks Average in-patient stay 4.5 days Recurrent vertigo rare, f/u limited PSCC occlusion vs. singular neurectomy

Horizontal canal BPPV 17% of cases Supine head lateral provocative Cupulolithiasis > canalithiasis From reposition of PSCC for BPPV toward (geotropic) away from (ageotropic)

Horizontal canal BPPV Latency < 3 sec < 1 min duration may beat toward or away from side of the cupula No fatigability 92% Side lying with the affected ear up for 12 h resolves much more quickly than PSCC-BPPV toward (geotropic) away from (ageotropic)

Superior canal BPPV Least common Dix-Hallpike positioning testing Rt PSCC = Lt SSCC vice versa

Thank You

BPPV Results

Bedside Evaluation Static Vestibular Balance – Nystagmus: Check direction Check for torsional component Check for gaze suppression

BPPV Cawthorne 1954 Semont 1st exercises for vestibular disorder Liberatory maneuver 1st rapid single treatment 83.96% one maneuver 92.68% two 4.22% recurrence Others less success, too violent

Benign Paroxysmal Positional Vertigo The most common peripheral vestibular disorder semicircular canal becomes sensitive to gravity

Dix-Hallpike Maneuver Hagr 6 D Delay seconds latency Downward ear beating superior poles of the eyes (Geotropic)-Up for the head down for the gravity Duration <1 minute Directional change Dizziness (Subjective) Disappear fatigable

BPV: Clinical Approach Examination

Dix-Hallpike Maneuver

Canalith repositioning maneuver for treatment of benign paroxysmal positional vertigo (BPPV) affecting the posterior canal. Panel 1 shows a patient with right posterior canal BPPV. The patient's head is turned to the right at the beginning of the canalith repositioning maneuver. The inset shows the location of the debris near the ampulla of the posterior canal. The diagram of the head in each inset shows the orientation from which the labyrinth is viewed. In panel 2, the patient is brought into the supine position with the head extended below the level of the gurney. The debris falls toward the common crus as the head is moved backward. In panel 3, the head is moved approximately 180 degrees to the left while keeping the neck extended with the head below the level of the gurney. Debris enters the common crus as the head is turned toward the contralateral side. In panel 4, the patient's head is further rotated to the left by rolling onto the left side until the patient's head faces down. Debris begins to enter the vestibule. In panel 5, the patient is brought back to the upright position. Debris collects in the vestibule. Illustration by David Rini. (From Hullar TE and Minor LB: Vestibular physiology and disorders of the labyrinth. In Glasscock ME and Gulya AJ, editors: Surgery of the Ear, ed 5, 2003, Hamilton, Chapter 4.)

Brandt and Daroff