Benign Positional Vertigo

Taleb Mohammed Mansoor

Khaleil Ebrahem Al-Matroushi

Medical Presentations http://hastaneciyiz.blogspot.com

2

The Ear

3

The Inner Ear

4

Benign Paroxysmal Positional Vertigo (BPPV)

• Inner ear problem that results in short lasting, but severe, room-spinning vertigo.

• Benign: not a very serious or progressive condition

• Paroxysmal: sudden and unpredictable in onset • Positional: comes with a change in head position• Vertigo: causing a sense of dizziness.

5

Canalolithiasis Theory

• The most widely accepted theory of the pathophysiology of BPV

• Otoliths (calcium carbonate particles) are normally attached to a membrane inside the utricle and saccule

• The utricle is connected to the semicircular ducts

• These otoliths may become displaced from the utricle to enter the posterior semicircular duct since this is the most dependent of the 3 ducts

• Changing head position relative to gravity causes the free otoliths to gravitate longitudinally through the canal.

• The concurrent flow of endolymph stimulates the hair cells of the affected semicircular canal, causing vertigo.

6

Canalolithiasis Theory

7

Causes

• Idiopathic• Infection (viral neuronitis)• Head trauma• Degeneration of the peripheral end organ• Surgical damage to the labyrinth

8

Symptoms

• Starts suddenly • first noticed in bed, when waking from sleep. • Any turn of the head bring on dizziness. • Patients often describe the occurrence of vertigo

with – tilting of the head, – looking up or down (top-shelf vertigo) – rolling over in bed.

• nausea and vomiting. • There is no new hearing loss or tinnitus.

9

Diagnosis

• Lab Studies: – No pathognomonic laboratory test for BPV exists.

Laboratory tests may be ordered to rule out other pathology.

• Imaging Studies: – Head CT scan or MRI.

• Procedures: – The Dix-Hallpike test, along with the patient's history,

aids in the diagnosis of BPV.

10

The Dix-Hallpike test

11

Treatment

• Medications

• The Canalith Repositioning Procedure (CRP)

• Surgery

12

Medications

• Antiemetic

• Antihistaminic

• Anticholinergic

13

Canalith Repositioning Procedure ( CRP )

• The treatment of choice for BPPV.

• Also known as the Epley maneuver,

• The patient is positioned in a series of steps so as to slowly move the otoconia particles from the posterior semicircular canal back into the utricle.

• Takes approximately 5 minutes.

• The patient is instructed to wear a neck brace for 24 hours and to not bend down or lay flat for 24 hours after the procedure.

• One week after the CRP, the Dix-Hallpike test is repeated.

• If the patient does experience vertigo and nystagmus, then the CRP is repeated with a vibrator placed on the skull in order to better dislodge the otoconia.

14

The Epley Maneuver

15

Clinical Trial

Ruckenstein (2001) Therapeutic efficacy of the Epley canalith repositioning maneuver. Laryngoscope

• Eighty-six patients • 74% of cases that were treated with one or two canalith repositioning

maneuvers had a resolution of vertigo as a direct result of the maneuver.

• A resolution attributable to the first intervention was obtained in 70% of cases within 48 hours of the maneuver.

• An additional 14% of cases that were treated had a resolution of vertigo.

• Only 4% of cases (three patients) manifested BPV that persisted after four treatments.

16

Brandt-Daroff Exercises

• method of treating BPPV, usually used when the office treatment fails.

• These exercises should be performed

– for two weeks, three times per day

– for three weeks, twice per day.

• In each time, one performs the maneuver as shown five times.

• 1 repetition = maneuver done to each side in turn (takes 2 minutes)

17

Brandt-Daroff Exercises

                                                    

18

Clinical Trial

Radtke et al (1999) A modified Epley's procedure for self-treatment of benign paroxysmal positional vertigo. Neurology

• Compared the efficacy of a modified Epley's procedure (MEP) and Brandt-Daroff exercises (BDE) for self-treatment of (PC-BPPV)

• 54 patients.

• PC-BPPV resolved within 1 week in – 18 of 28 patients (64%) using the MEP

– 6 of 26 patients (23%) performing BDE

• The MEP is more suitable for self-treatment of PC-BPPV than conventional BDE

19

Surgery

• Singular neurectomy

• Vestibular Nerve Section

• Posterior Canal Plugging Procedure

20

Singular neurectomy

• Old procedure

• Section the nerve that transmits information from the posterior semicircular canal ampulla toward the brain.

• Can cause hearing loss in 7-17% of patients and fails in 8-12%.

21

Clinical Trial

Gacek (1995) Technique and results of singular neurectomy for the management of benign paroxysmal positional vertigo. Acta Otolaryngol

• One hundred thirty-seven patients

• 1972-1994.

• (94%) experienced complete relief of vertigo following SN.

• (2%) experienced partial relief of positional vertigo following SN and

• (4%) failed to have any improvement of symptoms following SN.

• (3%) had a partial sensorineural following SN.

22

Posterior Canal Plugging Procedure

• Recently developed procedure • Replaced the singular neurectomy. • A mastoidectomy is performed through an incision made behind the ear. • The balance center is then uncovered and • The posterior semicircular canal is opened, exposing the delicate

membranous channel in which the crystalline debris is floating. • The canal is then gently, but firmly packed off with tissue so the debris

can no longer move within the canal and strike against the nerve endings.

• The canal is then sealed and the incision closed.• One-night hospital stay is advised. • The patient returns in one week for suture removal. • less than 20% hearing loss.

23

Clinical Trial

Walsh (1999)Long-term results of posterior semicircular canal occlusion for intractable benign paroxysmal positional vertigo. Clin Otolaryngol

• 13 patients who • All patients reported complete and immediate resolution of their

positional vertigo, which has been maintained in the long term. • All patients developed a transient mild conductive hearing loss

secondary to a middle ear collection, which usually resolved within 4 weeks.

• Five patients developed a transient mild high frequency sensorineural hearing loss which resolved in all cases within 6 months.

• There were no reports of sensorineural hearing loss nor tinnitus in the long term.

24

Vestibular Nerve Section

• done when the attacks of vertigo cannot be controlled with medication.

• An incision is made behind the ear and balance-hearing nerve is located.

• The balance part of the nerve is cut. • The operation is done with a neurosurgeon and

takes two hours. • The success rate (no vertigo attacks) is over 90%. • The hearing is usually not affected.

25

Vestibular Nerve Section

26

Clinical Trial

Thomsen et al, (2000) Vestibular neurectomy Auris Nasus Larynx

• 42 patients.

• The vertigo was controlled in 88% of the patients

• postoperative imbalance occurred in 14 patients

27

Summary

• BPPV– Common complain– Vertigo when changing head position– Diagnosed by Dix-hallpike– Treated by CRP– Surgery if CRP fails

Medical Presentations http://hastaneciyiz.blogspot.com