Vertigo -BPPV
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Transcript of Vertigo -BPPV
W.M.C. Narampanawa
Vertigo -BPPV
The Ear
Definition An illusion or hallucination of movement which is usually rotational, either of oneself or the environment
A common problemMany different potential etiologiesSome time multifactorialDiagnostic & management challengeSome time unable to make definitive
diagnosis
Balance disorders
Vertigo – illusion of movements, usually rotational, can be an illusion of tilting or swaying
Pre syncope – light headednessDisequilibrium – general sense of imbalance on
walkingOthers –(psycho physiologic) difficult to
characterize
Dizziness – four basic types
Dizziness is a common presenting complaint
Dizziness may result from a disorder that affects any of the body parts involved in balance or from certain drugs.
The person's description of the problem and the results of a physical examination may suggest a cause, which may lead to additional tests.
Introduction
vertigo is the most common (40-50%)
Of the various causes of vertigo, benign positional vertigo (BPV) is the most common cause
Approximately 25-40% of patients who present with dizziness have BPV.
vertigo
Due to reduced blood flow to the entire brain and is classically described as feeling faint or lightheaded
Near-syncope
Is essentially a gait disorder Often caused by various neurological
problems like cervical spondylosis, extra pyramidal disease and
cerebellar diseasePatients typically describe their
dizziness only when walking.
Disequilibrium
This is the least understood and is thought to be due to altered central integration of sensory signals arising from normal end organs
Psychophysiologic dizziness
BPV was first described by Adler in 1897 and then by Bárány in 1922
Using positional testing, BPV can readily be diagnosed
BPPV/ BPV
B” = BenignNot a brain tumorCan be severe and disabling
BPPV
“P” = ParoxysmalEpisodic, not persistentHelpful feature in the differential diagnosis
BPPV
P” = PositionalOccurs with position of head
Turning over in bedLooking upBending over
BPPV
V” = VertigoAn illusion of motion“The room is spinning”Other descriptions
RockingTiltingDescending in an elevator
BPPV
Anatomy: UtricleUtricle
Connected to SCCContains
endolymphOtoliths (otoconia)
Calcium carbonate
Attached to hair cells
Macule (end organ)
Tells brain which way the head moves without lookingSCC: angular accelerationUtricle: linear acceleration
Vestibular system
Pathophysiology of BPPVOtoliths become
detached from hair cells in utricle
Inappropriately enter the semicircular canal
Normal situationAs one turns head to the rightEndolymph moves SCC receptors fire
“head turning right”Stop turning head endolymph stops
moving SCC receptors stop firing “head has stopped moving”
Physiology
BPPVStop turning head otoliths keep moving
drag endolymph receptors continue to fire inappropriately “head is still moving”
Eyes “head is NOT moving”
Brain room must be spinning in the opposite direction
Pathophysiology of BPPV
Incidence of BPV is 64 cases per 100,000 population per year (US)
Women are affected twice as often as men
in general, is a disease of elderly persons, although onset can occur at any age
Incidence
characteristically describe that the room or world is spinning
Diagnosis of posterior canal BPV is based on a characteristic history and a positive Hallpike test
Lateral Canal BPPV -Lateral Roll test
Diagnosis - History
Rolling over in bed Lying down Sitting up Leaning forward Turning the head in a horizontal plane
Vertigo may occur with
Symptoms are usually worse in the morning
Nausea is typically present (vomiting is less common)
individual episodes of vertigo in BPV last for seconds at a time
diagnosis of PC BPV is indicated by a positive Hallpike test
The neurologic examination is otherwise unremarkable
Diagnosis - Examination
Classic nystagmus occurs when the patient's head is dependent and turned to the affected side
The most common nystagmus seen is torsional or rotatory
Nystagmus usually occurs within 10 seconds after positioning but may present as late as 40 seconds
Dix - Hallpike test
Duration varies from a few seconds to a minute and associated the sensation of vertigo
Response fatigues if the patient is repeatedly placed into the provoking position
Dix – Hallpike test
Caution: For patients with cervical spondylosis
warn the patient that symptoms of vertigo
Instruct the patient to keep his or her eyes open no matter how bad he or she feels
Avoid in pts with IHD
Hallpike test
Hallpike testSeat the patient
close enough to the end of the table
lies supinehead should be
extended backward an additional 30-45°.
Hallpike testTurn the patient's
head 45°This position
orients the head such that the posterior semicircular canal is going to be in the same plane as the upcoming head movement
Hallpike testlay the patient
down until the head is dependent
This step does not need to be performed rapidly.
Check for reproduction of symptoms and nystagmus
the fast phase of the nystagmus should be upbeat (toward the forehead)
Hallpike test
Return the patient to the upright positionNystagmus may be observed in the
opposite directionPatient may describe that the world is
spinning in the opposite direction The neurologic examination findings
should be otherwise normal; if not, strongly consider alternative diagnoses
Hallpike test
Horizontal Canal BPV
Lateral Roll test Body supine
Head inclined 30º
Turn head to either side
2 variantsGeotropic
Apogeotropic
Geotropic LC BPPVFree particles in the
long arm of the LSC (Canalolithiasis)
Horizontal Ny. towards lowermost ear
Stronger Ny. on turning towards side of lesion.
Apogeotropic LSC BPPVCupololithiasisHorizontal
Ny.awayfrom lowermost ear
Stronger Ny. on turningaway from side of lesion.
Positional vertigo
Onset Sudden Slow, gradualIntensity Severe Ill definedDuration Paroxysmal ConstantNausea Frequent InfrequentCNS signs Absent Usually
presentTinnitus/hearing loss
Can be present Absent
Nystagmus Torsional/horizontal
Vertical
Nystagmus Fatigable Non-fatigable
PERIPHERAL CENTRAL
Idiopathic (50-60%) Infection (viral neuronitis) Head trauma, especially in younger
patients Degeneration of the peripheral end
organ Surgical damage to the labyrinth
Causes
MigraineLabyrinthitisMeniere’s diseaseVestibular neuronitisStroke Acoustic schwanoma
DD
Chronic otomastoiditisMedications (alcohol, phenytoin,
diuretics, salicylates, quinidine, quinine, barbiturates, antibiotics)
OtosclerosisOtotoxicityPosttraumatic injuriesVertebrobasilar insufficiency
DD
No pathognomonic laboratory test for BPV exists
Currently, no imaging study can demonstrate the presence of otoliths
Head CT scanning or MRI is indicated if the diagnosis is in doubt
Investigations
Epley maneuver Medical treatment is generally
ineffective but may be used to lessen the symptoms.
Management
Ongoing CNS disease (ie, stroke or transient ischemic attack [TIA])
Unstable heart diseaseSevere neck disease (eg, rheumatoid
arthritis) or history of cervical spine fracture or surgery
Carotid bruit on examination indicating carotid stenosis
Body habitus preventing performance of the maneuver.
Epley maneuver Contraindications
Goal is to move the otoliths out of the posterior semicircular canal and back into the utricle where they belong
The success rate of the Epley maneuver is very high (approximately 85-90%)
Epley maneuver
The head must be in the dependent (head-hanging) position
Maintain each position until the symptoms and nystagmus have disappeared (at least 30 seconds)
If the patient cannot tolerate the maneuver because of vomiting or severity of the vertigo, premedicate with a vestibular sedative
Epley maneuver general guidelines
Epley maneuver steps
patient sit upright on the bed with the head turned 45° to the affected side
Epley maneuver steps
Place your hands on either side of the patient's head and guide the patient down with the head dependent (as in the Hallpike test).
Epley maneuver steps
Rotate the head 90° to the opposite side with the patient's face upward and be sure to maintain the head-dependent position
Epley maneuver steps
Ask the patient to roll onto his or her side while holding the head in this position
Then rotate the head so that it is facing downward (tell the patient to look to the ground).
Epley maneuver steps Raise the patient to
a sitting position while maintaining head rotation
sitting the patient up so that he or she is sitting with his or her legs hanging over the edge of the bed
Epley maneuver steps Simultaneously
rotate the head to a central position and move it 45° forward.
Lempert(Barbecue) Maneuver
Common Maneuvers for LSC BPPV
generally ineffective but may be used to lessen the symptoms
natural history of BPV is to resolve with time as the otoliths eventually dissolve while in the semicircular canals.
Medical treatment
antihistaminic antiemetics Benzodiazepines Anticholinergics Sympathomimetic vestibular suppressants
Drug Category
Patients with persistent vomiting or intractable vertigo may require admission for hydration and vestibular suppressant medication.
Surgical elimination of posterior canal function is restricted to rare cases of long-standing refractory BPV.
Admission
Head exercise therapy (positional exercises of Brandt and Daroff, Casani’s, Appiani’s) that promotes central accommodation may be helpful for BPV
Avoid provocative movements (and limit activities)
Further Care
Tends to resolve spontaneously after several weeks or months
May experience recurrences months or years later
Prognosis
Thank you