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 …