BENIGN PAROXYSMAL POSITIONAL VERTIGO

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BENIGN PAROXYSMAL POSITIONAL VERTIGO

• WASEEM WATAD

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Basic Anatomy
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BPPV

• Barany 1921
• Dix-Hallpike 1952 important features of
  nystagmus
• Abnormal sensation of motion elicited by certain
  critical positions
• Provocative position ? nystagmus
• At least 20 of vertigo
• Underestimated

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BPPV

• Subclassification scc post/lat/ant/bilat
• Pathophysiology
• Canalithiasis
• cupulolithiasis

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Pathophysiology
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Pathophysiology (cont.)

• Cupulolithiasis
• Harold Schuknecht 1962
• Densities (otocania) adherent to cupula of crista
  ampullaris
• Basophilic particles -1969

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

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BPPV ...

• Frequency 10-64/100000
• Sex 64 women
• Age older population ( 51-57)
• younger than 35 head trauma.
• History
• sudden
• days-weeks
• occassionally months -years
• episodes.

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• Physical
• neurological examination normal
• except Dix-Hallpike ? pathognomonic

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BPPV

• Nystagmus characterization and types
• RT / LT , vertical / horizontal , changing
• Tortional Rotational clockwise /
  counterclockwise
• Geotropic- toward the earth
• Ageotropic opposite

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BPPV

• Classic post SCC geotropic rotatory nystagmus
• Horizontal SCC purely horizontal nystagmus
• Non-fatiguing nystagmus cupulolithiasis gt
  canalithiasis

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Classic BPPV

• Involved the POST SCC
• Geotropic NG with affected ear down
• Rotatory , fast phase toward the undermost ear
• Latency few seconds
• Duration limited lt 20 seconds
• Reversal upon return upright position
• Response decline upon repetitive provocation

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Lat. SCC PPV

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

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Lat. SCC PPV
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Ant. SCC PPV

• Rare 2
• Down-beating /torsional NG for the opposite ear
  on Dix-Hallpike maneuver

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BPPV - Causes

• Predisposing factors
• Inactivity
• Acute alcoholism
• Major surgery
• CNS disease

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Causes ( cont. )

• Idiopathic 39
• Ear disease 29
• OM 9
• Vestibular neuritis 7
• Meniers dis 7
• Otosclerosis 4
• Sudden SNHL 2
• Trauma 21

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Causes ( cont. )

• Trauma 21
• CNS diseases 11
• Acustic neuroma 2
• Cervical vertigo 2

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BPPV - D.D

• Meniers disease
• Inner ear concussion
• Alcohol intoxication
• Labyrinthitis
• Vascular loop syndrome
• Post. Fossa lesions acustic neuroma ,
  meningioma
• Central origion stroke , MS , cerebellar
  degeneration
• Vertibral artery insuffeciency
• Cervical vertigo

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BPPV - Treatment

• Watchful waiting
• Vestibular suppressant medications
• Vestibular rehabilitation
• Canalith repositioning
• Surgery care
• Labyrinthectomy
• Post. Canal occlusion
• Singula neurectomy
• Transtympanic aminpglycoside application

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Trials about BPPV
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General

• Labeled benign paroxysmal positional vertigo is
  not always benign
• Evaluation of the effectiveness of canalith
  reepositioning procedurs CRP
• Several studies

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Trials

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

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Trials

• John Li (1995)
• 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

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Trials

• 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

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Trials

• 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 gt 6 procedures in 2 weeks
  , should considering liberatory maneuver

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Elderly population and BPPV

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

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CRP Meta-Analysis B. Woodworth - 2004

• 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

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Meta - Analysis

• 9 randomized-controlled trials
• Symptoms resolution and elimination of positive
  Dix-Hallpike test
• CRP more effective than control ( x5 )
• Untreated patients - symptoms improvements with
  time but positive DH
• So Resolution of vertigo avoidance of
  provocative positions

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CRP Epley maneuver
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CRP Semont maneuver
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Mastoid oscillator
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Brandt-Daroff Exsercise
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Lampert maneuver- Lat. SCC BPPV
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Vestibular rehabilitaions
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Complications of CRP

• Failure 25 (12-56)
• Recurrence 13 in 6 months
• Side effects
• Nausea
• Vomiting
• Fainting
• Sweating
• Worse vertigo LAT SCC PPV

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