BENIGN PAROXYSMAL POSITIONAL VERTIGO WASEEM WATAD WASEEM WATAD

Basic Anatomy

BPPV n Barany 1921 n Dix-Hallpike 1952 – important features of nystagmus n Abnormal sensation of motion elicited by certain critical positions n Provocative position  nystagmus n At least 20% of vertigo n Underestimated

BPPV … n Subclassification : scc post/lat/ant/bilat n Pathophysiology : –Canalithiasis –cupulolithiasis

Pathophysiology

Pathophysiology (cont.) n Cupulolithiasis : – Harold Schuknecht 1962 –Densities (otocania) adherent to cupula of crista ampullaris –Basophilic particles -1969

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

BPPV... n Frequency : 10-64/ n Sex : 64% women n Age : older population ( 51-57) younger than 35 – head trauma. younger than 35 – head trauma. n History : –sudden –days-weeks –occassionally months -years – episodes.

n Physical : –neurological examination – normal – except – Dix-Hallpike  pathognomonic

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

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

Classic BPPV n 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 n Most common atypical BPPV n 3-9% of cases n Consequence of Epley maneuver n Horizontal purely nystagmus n Cupulolithiasis rather than canalithiasis n Modified Epley / lampert maneuver …

Lat. SCC PPV

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

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

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

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

BPPV - D.D n Menier’s disease n Inner ear concussion n Alcohol intoxication n Labyrinthitis n Vascular loop syndrome n Post. Fossa lesions : acustic neuroma, meningioma n Central origion : stroke, MS, cerebellar degeneration n Vertibral artery insuffeciency n Cervical vertigo

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

Trials about BPPV

General n Labeled benign paroxysmal positional vertigo is not always benign n Evaluation of the effectiveness of canalith reepositioning procedurs – CRP n Several studies …

Trials … n Blakely – 1994 : –50% improvement in the control and CRP group !! ( 2-3 months) n Lynn – 1995 : –Randomized-controlled : 89% negative DH in CRP group, 27% in the control group n John Li (1995) :

Trials… –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… n 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 … n 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 n S. Angeli – 2003 : –Effectiveness of CRP and VR –Modified Epley : n Elderly comorbidities : degenerative osteoarthritis disease, CVA, peripheral neuropathy, cognitive and autonomic dysfunctions n S/E of CRP – neck torsion and extension result in vertibrobasilar artery insufficiency, strain on the spine column, dislodged carotid a. emboli n Avoid liberatory maneuver –64% CRP group – negative DH after a month –Overall 77% with CRP and VR

CRP Meta-Analysis B. Woodworth n 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 n 9 randomized-controlled trials n Symptoms resolution and elimination of positive Dix-Hallpike test n CRP more effective than control ( x5 ) n Untreated patients - symptoms improvements with time but positive DH n 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 n Failure – 25% (12%-56) n Recurrence – 13% in 6 months n Side effects –Nausea –Vomiting –Fainting –Sweating n Worse vertigo – LAT SCC PPV

n THANK YOU …