1. B.P.P.V. & Vestibular neuronitis
Dr. Vishal Sharma

2. Benign Paroxysmal Positional Vertigo

3. Introduction
Most common cause of vertigo arising from peripheral labyrinthine dysfunction
20% of vertigo cases in all age groups
50% of vertigo cases in elderly pt
Average age of onset: years
Male : female = 2:1

4. Etiology Idiopathic (50% of all cases) Head injury (pt < 50 yrs)
Vestibular degeneration (pt > 50 yrs)
Viral labyrinthitis
Otitis media
Meniere’s disease
Following ear surgery
Prolonged bed rest

5. Pathogenesis
POSTR
S.C.C.
UTRICLE
MACULA
CUPULA

7. Pathogenesis
Otoconial debris (calcium carbonate) released from degenerating macula of adjacent utricle
 floats freely in endolymph
 settles on cupula of posterior semicircular
canal in a critical head position
 causes displacement of cupula & vertigo

8. Types of BPPV Posterior semicircular canal BPPV: 80 - 85 %
Lateral semicircular canal BPPV: %
Superior semicircular canal BPPV: < 5 %
Lateral & superior semicircular canal BPPV mostly
caused by faulty treatment maneuvers of posterior
semicircular canal BPPV

9. Symptoms 95% cases have unilateral BPPV
Vertigo in a certain head position
Inability to roll in bed or to look up high
Nausea & vomiting in severe conditions
There is no hearing loss
Absence of other neurologic symptoms

10. Nystagmus in B.P.P.V.  Duration: < 1 minute due to adaptation
 Asthenia (fatiguing): on repeating maneuver
 Latent period: of 2–20 sec before nystagmus
 Direction: fixed, rotatory, geotropic &
reverses on return to sitting position
 Associated symptoms: vertigo, vomiting,
excessive sweating

11. Management of B.P.P.V. Diagnosis: Dix-Hallpike positional maneuver
Treatment:
Epley’s canalith repositioning maneuver
Semont’s liberatory maneuver
Home exercises
Surgical treatment

12. Diagnosis
Dix-Hallpike test is diagnostic for posterior semicircular canal BPPV
Dix-Hallpike test done with Frenzel’s glasses & video display gives better accuracy
Electro-nystagmography does not record rotatory component of nystagmus
Other investigations not required for diagnosis

13. Frenzel glasses

14. Dix – Hallpike maneuver (Nylen – Barany maneuver)

15. Step 1 (for Right ear) 3

16. Step 2

17. Step 3

18. Step 4

19. Steps 1 to 3

20. Step 3 to 4

21. Dix-Hallpike Maneuver
1. Pt in sitting position on a couch looking ahead
2. Pt’s head turned 45° towards diseased ear
3. Pt moved rapidly into supine position with
head hanging 30° below couch. Pt’s eyes
observed for nystagmus for 1 minute
4. Pt moved rapidly back into sitting position
5. Maneuver repeated for opposite ear

22. Epley’s particle repositioning maneuver for right ear

23. Step 1 3

24. Step 2

25. Step 3

26. Step 4

27. Step 5

28. Step 6

29. Step 5 to 6

30. Step 7

32. Epley’s Maneuver for Rt ear
1. Pt in sitting position on a couch looking ahead
2. Pt’s head turned 45° towards diseased ear
3. Pt moved rapidly into supine position with
head hanging 30° below couch
4. Pt’s head rotated by 90° to opposite side
5. Further 90° head + trunk rotation

33. Epley’s Maneuver for Rt ear
6. Pt moved rapidly back into sitting position & pt’s head brought in midline
7. Slight flexion of pt’s head
Cervical collar given to pt for 48 hours
Pt must have nystagmus at every step of Epley’s manoeuvre if it is done properly
80% pt get cured by a single maneuver

34. Advice after maneuver  Do not drive yourself home
 Wait for 30 minutes before going home
 Do not drive yourself home

35. Home advice
 Avoid violent head jerks & head positions that trigger positional vertigo for at least 1 week  Sleep in 45o head end elevation for 48 hr.  1 week after tx, carefully put yourself in position that usually makes you dizzy. Let your doctor know how you felt.

36. If Epley’s maneuver fails
Repeat Epley’s maneuver after 1 month
Try Semont’s maneuver
Advice home exercises
If all maneuvers & exercises fail, diagnosis is clear & symptoms are intolerable: Surgical Therapy

37. Semont’s maneuver for Rt posterior canal BPPV

38. 1. Sit upright with head turned 45° toward left
2. Drop quickly to right by 900. Debris moves towards apex of posterior SCC. Wait for 30 sec after nystagmus stops.
3. Move head & trunk swiftly toward left by 1800
Debris moves towards exit of posterior SCC. Wait again for 30 sec after nystagmus stops.
4. Sit upright again. Debris falls into utricle.
5. Performed 3 times a day for 2 weeks

39. Home Exercises 1. Brandt-Daroff Exercise 2. Home Epley’s Maneuver
Indications:
Diagnosis is clear & patient well-trained
Absence of other causes of vertigo
Pt must report immediately if neurological symptoms appear during exercise due to vertebral artery compression

40. Home Epley’s maneuver

41. Brandt-Daroff Exercise

42. 1. Sit upright.
2. Drop quickly to right by 900, with head angled upward by 450. Stay for 30 seconds.
3. Sit upright again. Stay for 30 seconds.
4. Drop quickly to left by 900, with head angled upward by 450. Stay for 30 seconds.
5. Sit upright again.
Perform 5 sets, thrice / day for 2 weeks.

43. Surgical treatment Considered when Epley maneuver, Semont
maneuver + Brandt-Daroff exercises have
failed and diagnosis of BPPV is clear
1. Posterior semicircular canal plugging (Parnes)
2. Singular neurectomy (Gacek)

44. Posterior SCC plugging

45. Gacek’s singular neurectomy

46. Atypical BPPV Lateral Canal BPPV: debris in lateral SCC
Superior Canal BPPV: debris in superior SCC
Cupulo-lithiasis: Debris stuck to canal side of semicircular canal cupula
Vestibulo-lithiasis: Loose debris present on vestibule-side of semicircular canal cupula
Multi-canal BPPV: debris in multiple SCC

47. Etiology of atypical BPPV

48. Nystagmus (fast component)

49. Semicircular canal stimulated Nystagmus Direction
Right Lateral
Right horizontal
Left Lateral
Left horizontal
Right Superior
Down beating, counter-clockwise
Left Superior
Down beating, clockwise
Right Posterior
Up beating, counter-clockwise
Left Posterior
Up beating, clockwise

50. Diagnosis:
Lateral canal BPPV: Roll test  horizontal nystagmus towards lower ear
Superior canal BPPV: Dix Hallpike test  torsional ageotropic nystagmus
Treatment:
Lateral canal BPPV: 3600 contralateral Roll test, canal plugging in failure cases
Superior canal BPPV: Epley’s maneuver of opposite side, canal plugging

51. Up-beating, torsional nystagmus Down-beating, torsional nystagmus
Posterior SCC BPPV
Superior SCC BPPV
Up-beating, torsional nystagmus
Down-beating, torsional nystagmus
Geotropic (superior pole moves towards lower ear) during Dix-Hallpike maneuver
Ageotropic (superior pole moves towards upper ear) during Dix-Hallpike maneuver ***
*** during Dix Hallpike maneuver, opposite (upper) superior SCC gets stimulated & its clock wise movement becomes ageotropic nystagmus

52. Roll Test for lateral canal BPPV

53. 1 2 3 4 5

54. Roll test for lateral canal BPPV
1. Patient lies supine with nose pointing up 2. Head turned 900 right rapidly & kept for 30 sec 3. Head turned back to supine position for 30 sec 4. Head turned 900 left rapidly & kept for 30 sec 5. Head turned back to supine position for 30 sec Watch for nystagmus after each step

55. 3600 contra-lateral Roll over maneuver for left lateral canal BPPV

56. 1 2 3 4 5

57. 1. Patient lies supine with nose pointing up
2. Head turned 900 into Rt lateral decubitus
3. Head turned further 900 into prone position
4. Head turned further 900 into Lt lateral decubitus
5. Head turned further 900 into supine position
Each position kept for 30 sec & watch for nystagmus

58. Vestibular neuronitis

59. Clinical presentation
Occurs most commonly in middle-aged adults
Acute, sustained peripheral vestibular dysfunction with nausea, vomiting, severe vertigo & imbalance
Preceded by upper respiratory tract infection
After 24 hours of onset, vertigo intensity decreases progressively & most patients recover from severe vertigo & imbalance within 1-3 weeks

60. Third most common cause of peripheral vertigo after BPPV & Meniere’s disease
Etiology:
Viral infection of vestibular nerve
Acute localized ischemia of vestibular nerve
Auto-immune injury of vestibular nerve
Recurrence of symptoms due to dormant Herpes virus in Scarpa’s vestibular ganglion

61. Presence of
Absence of
Spontaneous, unidirectional, horizontal, nystagmus beating towards healthy ear, suppressed by optic fixation
Direction changing nystagmus
Hearing loss
Other cranial nerve deficits
Brain-stem & Cerebellar signs
Rhomberg test: fall towards diseased side
Middle ear infection
High fever
Caloric test: I/L canal paresis
Neck rigidity

62. Treatment of Acute attack
 Reassurance  Bed rest + head support
 Inj. Prochlorperazine (Stemetil):
12.5 mg I.V., T.I.D. – Q.I.D.
 Inj. Promethazine (Phenergan):
25 mg I.V., T.I.D. – Q.I.D.
 Inj. Diazepam (Calmpose):
5 mg I.V. stat

63. Subsequent Treatment
Oral Cinnarizine: 25 mg TID to 75 mg BD for 7 days
Oral Betahistine: 16 mg TID for weeks
3-week course of methyl prednisolone tapered from 100 mg down to 10 mg daily may reduce long-term loss of vestibular function
Anti-viral drugs have no benefit

64. Thank You