benign paroxysmal positional vertigo waseem watad waseem watad
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BENIGN PAROXYSMAL BENIGN PAROXYSMAL POSITIONAL VERTIGOPOSITIONAL VERTIGO
WASEEM WATADWASEEM WATAD
Basic AnatomyBasic Anatomy
BPPVBPPV
Barany 1921Barany 1921 Dix-Hallpike 1952 – important Dix-Hallpike 1952 – important
features of nystagmus features of nystagmus Abnormal sensation of motion Abnormal sensation of motion
elicited by certain critical positionselicited by certain critical positions Provocative position Provocative position nystagmus nystagmus At least 20% of vertigoAt least 20% of vertigo Underestimated Underestimated
BPPV …BPPV …
Subclassification : scc Subclassification : scc post/lat/ant/bilatpost/lat/ant/bilat
Pathophysiology :Pathophysiology :– CanalithiasisCanalithiasis– cupulolithiasiscupulolithiasis
PathophysiologyPathophysiology
Pathophysiology (cont.)Pathophysiology (cont.)
Cupulolithiasis :Cupulolithiasis :– Harold Schuknecht 1962 Harold Schuknecht 1962 – Densities (otocania) adherent to Densities (otocania) adherent to
cupula of crista ampullariscupula of crista ampullaris– Basophilic particles -1969Basophilic particles -1969
Canalithiasis :Canalithiasis :– John Epley – 1980John Epley – 1980– Densities free floating in canal portionDensities free floating in canal portion– Parnes , McClure – 1991 found Parnes , McClure – 1991 found
particles in post SCC particles in post SCC
BPPV ...BPPV ...
Frequency : 10-64/100000Frequency : 10-64/100000 Sex : 64% womenSex : 64% women Age : older population ( 51-57)Age : older population ( 51-57) younger than 35 – head trauma.younger than 35 – head trauma. History : History :
– sudden sudden – days-weeksdays-weeks– occassionally months -years occassionally months -years – episodes.episodes.
Physical : Physical : – neurological examination – normalneurological examination – normal– except – Dix-Hallpike except – Dix-Hallpike
pathognomonicpathognomonic
BPPV …BPPV …
Nystagmus : characterization and Nystagmus : characterization and types types – RT / LT , vertical / horizontal , RT / LT , vertical / horizontal ,
changingchanging– Tortional = Rotational – clockwise / Tortional = Rotational – clockwise /
counterclockwisecounterclockwise– Geotropic- toward the earthGeotropic- toward the earth– Ageotropic – oppositeAgeotropic – opposite
BPPV …BPPV …
Classic post SCC – geotropic Classic post SCC – geotropic rotatory nystagmusrotatory nystagmus
Horizontal SCC – purely horizontal Horizontal SCC – purely horizontal nystagmusnystagmus
Non-fatiguing nystagmus – Non-fatiguing nystagmus – cupulolithiasis > canalithiasiscupulolithiasis > canalithiasis
Classic BPPVClassic BPPV
Involved the POST SCC Involved the POST SCC – Geotropic NG with affected ear downGeotropic NG with affected ear down– Rotatory , fast phase toward the Rotatory , fast phase toward the
undermost earundermost ear– Latency – few secondsLatency – few seconds– Duration – limited < 20 secondsDuration – limited < 20 seconds– Reversal upon return upright positionReversal upon return upright position– Response decline upon repetitive Response decline upon repetitive
provocationprovocation
Lat. SCC PPVLat. SCC PPV
Most common atypical BPPVMost common atypical BPPV 3-9% of cases3-9% of cases Consequence of Epley maneuverConsequence of Epley maneuver Horizontal purely nystagmusHorizontal purely nystagmus Cupulolithiasis rather than Cupulolithiasis rather than
canalithiasiscanalithiasis Modified Epley / lampert maneuver Modified Epley / lampert maneuver
……
Lat. SCC PPVLat. SCC PPV
Ant. SCC PPVAnt. SCC PPV
Rare – 2%Rare – 2% Down-beating /torsional NG for the Down-beating /torsional NG for the
opposite ear on Dix-Hallpike opposite ear on Dix-Hallpike maneuvermaneuver
BPPV - CausesBPPV - Causes
Predisposing factors :Predisposing factors :– Inactivity Inactivity – Acute alcoholismAcute alcoholism– Major surgeryMajor surgery– CNS diseaseCNS disease
Causes ( cont. )Causes ( cont. )
Idiopathic – 39% Idiopathic – 39% Ear disease – 29%Ear disease – 29%
– OM – 9%OM – 9%– Vestibular neuritis – 7%Vestibular neuritis – 7%– Menier’s dis – 7%Menier’s dis – 7%– Otosclerosis – 4%Otosclerosis – 4%– Sudden SNHL – 2%Sudden SNHL – 2%
Trauma – 21%Trauma – 21%
Causes ( cont. )Causes ( cont. )
Trauma – 21%Trauma – 21% CNS diseases – 11%CNS diseases – 11% Acustic neuroma – 2%Acustic neuroma – 2% Cervical vertigo – 2%Cervical vertigo – 2%
BPPV - D.DBPPV - D.D
Menier’s diseaseMenier’s disease Inner ear concussionInner ear concussion Alcohol intoxicationAlcohol intoxication LabyrinthitisLabyrinthitis Vascular loop syndromeVascular loop syndrome Post. Fossa lesions : acustic neuroma , Post. Fossa lesions : acustic neuroma ,
meningiomameningioma Central origion : stroke , MS , cerebellar Central origion : stroke , MS , cerebellar
degenerationdegeneration Vertibral artery insuffeciencyVertibral artery insuffeciency Cervical vertigoCervical vertigo
BPPV - TreatmentBPPV - Treatment
Watchful waitingWatchful waiting Vestibular suppressant medicationsVestibular suppressant medications Vestibular rehabilitationVestibular rehabilitation Canalith repositioningCanalith repositioning Surgery careSurgery care
– LabyrinthectomyLabyrinthectomy– Post. Canal occlusionPost. Canal occlusion– Singula neurectomy Singula neurectomy – Transtympanic aminpglycoside applicationTranstympanic aminpglycoside application
Trials about BPPVTrials about BPPV
GeneralGeneral
Labeled benign paroxysmal Labeled benign paroxysmal positional vertigo is not always positional vertigo is not always benignbenign
Evaluation of the effectiveness of Evaluation of the effectiveness of canalith reepositioning procedurs – canalith reepositioning procedurs – CRP CRP
Several studies … Several studies …
Trials …Trials …
Blakely – 1994 :Blakely – 1994 :– 50% improvement in the control and 50% improvement in the control and
CRP group !! ( 2-3 months)CRP group !! ( 2-3 months) Lynn – 1995 :Lynn – 1995 :
– Randomized-controlled : 89% Randomized-controlled : 89% negative DH in CRP group , 27% in negative DH in CRP group , 27% in the control group the control group
John Li (1995) :John Li (1995) :
Trials…Trials…
John Li (1995) :John Li (1995) :– Comparison CRP / CRP + mastoid oscillation Comparison CRP / CRP + mastoid oscillation
and controland control– Modified Epley maneuver Modified Epley maneuver – Use of colar and head elevation after CRPUse of colar and head elevation after CRP– No spontaneous resolution within aweekNo spontaneous resolution within aweek– 60% symptoms improvement in CRP group60% symptoms improvement in CRP group– 92% symptoms improvement in CRP 92% symptoms improvement in CRP
+mastoid oscilation and 70% negative DH+mastoid oscilation and 70% negative DH
Trials…Trials…
R. steenerson –1996 :R. steenerson –1996 :– Comparison of CRP and vestibular Comparison of CRP and vestibular
habituation traininghabituation training– Tow approaches are effective in Tow approaches are effective in
symptomatic relief ( 3 months)symptomatic relief ( 3 months)– CRP faster relief and fewer treatmentsCRP faster relief and fewer treatments
Trials …Trials … K. Yimatae (2003)K. Yimatae (2003)
– Randomized-controoled Randomized-controoled – Modified Epley maneuver, no mastoid oscillator Modified Epley maneuver, no mastoid oscillator
and no instructions after the maneuverand no instructions after the maneuver– Subjective and objective weekly follow-up Subjective and objective weekly follow-up – CRP group – 76% negative DH, 48% control CRP group – 76% negative DH, 48% control
groupgroup– CRP group – 96% symptoms improvement , 90% CRP group – 96% symptoms improvement , 90%
control groupcontrol group– Non-cured patients need > 6 procedures in 2 Non-cured patients need > 6 procedures in 2
weeks , should considering liberatory maneuverweeks , should considering liberatory maneuver
Elderly population and Elderly population and BPPVBPPV
S. Angeli – 2003 :S. Angeli – 2003 :– Effectiveness of CRP and VREffectiveness of CRP and VR– Modified Epley :Modified Epley :
Elderly comorbidities : degenerative osteoarthritis Elderly comorbidities : degenerative osteoarthritis disease , CVA , peripheral neuropathy, cognitive disease , CVA , peripheral neuropathy, cognitive and autonomic dysfunctionsand autonomic dysfunctions
S/E of CRP – neck torsion and extension result in S/E of CRP – neck torsion and extension result in vertibrobasilar artery insufficiency, strain on the vertibrobasilar artery insufficiency, strain on the spine column, dislodged carotid a. embolispine column, dislodged carotid a. emboli
Avoid liberatory maneuver Avoid liberatory maneuver
– 64% CRP group – negative DH after a month 64% CRP group – negative DH after a month – Overall 77% with CRP and VROverall 77% with CRP and VR
CRP Meta-Analysis CRP Meta-Analysis B. Woodworth - 2004B. Woodworth - 2004
CRP - First line of treatmentCRP - First line of treatment– Non-invasiveNon-invasive– Easy to perform in the officeEasy to perform in the office– No need to expensive instrumentationsNo need to expensive instrumentations– Repeat maneuver if neededRepeat maneuver if needed– Potential to provide rapid relief of Potential to provide rapid relief of
vertigovertigo
Meta - AnalysisMeta - Analysis
9 randomized-controlled trials 9 randomized-controlled trials Symptoms resolution and elimination Symptoms resolution and elimination
of positive Dix-Hallpike testof positive Dix-Hallpike test CRP more effective than control ( x5 )CRP more effective than control ( x5 ) Untreated patients - symptoms Untreated patients - symptoms
improvements with time but positive improvements with time but positive DHDH
So Resolution of vertigo – avoidance So Resolution of vertigo – avoidance of provocative positions of provocative positions
CRP – Epley maneuverCRP – Epley maneuver
CRP – Semont maneuverCRP – Semont maneuver
Mastoid oscillatorMastoid oscillator
Brandt-Daroff ExserciseBrandt-Daroff Exsercise
Lampert maneuver- Lat. Lampert maneuver- Lat. SCC BPPVSCC BPPV
Vestibular rehabilitaionsVestibular rehabilitaions
Complications of CRPComplications of CRP
Failure – 25% (12%-56)Failure – 25% (12%-56) Recurrence – 13% in 6 monthsRecurrence – 13% in 6 months Side effects Side effects
– Nausea Nausea – VomitingVomiting– FaintingFainting– SweatingSweating
Worse vertigo – LAT SCC PPVWorse vertigo – LAT SCC PPV
THANK YOU …THANK YOU …