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Benign Positional Vertigo
Taleb Mohammed Mansoor
Khaleil Ebrahem Al-Matroushi
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The Ear
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The Inner Ear
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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.
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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.
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Canalolithiasis Theory
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Causes
• Idiopathic• Infection (viral neuronitis)• Head trauma• Degeneration of the peripheral end organ• Surgical damage to the labyrinth
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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.
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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.
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The Dix-Hallpike test
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Treatment
• Medications
• The Canalith Repositioning Procedure (CRP)
• Surgery
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Medications
• Antiemetic
• Antihistaminic
• Anticholinergic
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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.
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The Epley Maneuver
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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.
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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)
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Brandt-Daroff Exercises
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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
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Surgery
• Singular neurectomy
• Vestibular Nerve Section
• Posterior Canal Plugging Procedure
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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%.
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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.
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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.
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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.
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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.
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Vestibular Nerve Section
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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
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Summary
• BPPV– Common complain– Vertigo when changing head position– Diagnosed by Dix-hallpike– Treated by CRP– Surgery if CRP fails