1. 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

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

3. Benign paroxysmal positional vertigo
History
Pathology
Management
P/E
Treatment

4. 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 .

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

6. Benign paroxysmal positional vertigo
History
Pathology
Management
P/E
Treatment

7. 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

8. 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%)

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

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

16. Benign paroxysmal positional vertigo
History
Pathology
Management
P/E
Treatment

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

18. 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.

19. Benign paroxysmal positional vertigo
History
Pathology
Management
P/E
Treatment

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

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

23. 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 =

24. 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

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

26. Benign paroxysmal positional vertigo
History
Pathology
P/E
Treatment

27. Treatment
Patient education
Medical
Exercise
Surgical

28. Patient education
Inner ear disease
Not CVA
Not Cancer
Recurrence

29. Medical
Relieve of nausea
Promethazine
Prochlorperazine

30. Epley Maneuver Dr. John M. Epley 1980 * Canalilith Repositioning
Canalith debris  vestibule
single treatment = 95% Remission
Otolaryngol Head Neck Surg 88:599–605, 1980.

31. Epley Maneuver
Reclined head hanging 45 degree turn

32. Epley Maneuver
Rotate 45 degrees contralateral

33. Epley Maneuver
Head and body rotated to 135 degrees from supine

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

37. Video

38. Sleep semi-recumbent for the next two nights

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

41. 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

42. Brandt-Daroff Exercises

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

44. Brandt and Daroff

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

46. 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

47. 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

48. 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

49. 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

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

51. 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)

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

54. Thank You

58. BPPV Results

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

67. 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

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

69. 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

71. BPV: Clinical Approach Examination

72. Dix-Hallpike Maneuver

73. 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.)

78. Brandt and Daroff