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BPPV

Benign Paroxysmal Positional Vertigo Chad Caswell

Vertigo

Sensation of rotation or movement of you or your surroundings. Dizziness or a spinning sensation. Dizziness, a malfunction of the inner ear that makes the patient feel like everything is whirling around.

Causes of Vertigo

Visual malfunction Somatosensory malfunction

Nerve damage
Positional (inner ear)

Anatomy of the Inner Ear

Anatomy of the Inner Ear

Etiology

Cupulolithiasis

Utricular otoconia Attach to cupula in ampulla Density difference between cupula and endolymph Angular to linear

Canalithiasis

Most common cause in posterior canal Movement of freefloating debris in endolymph causes currents that deflect the cupula

Causes of BPPV

Diagnosis - History
Sudden, severe attacks of vertigo Specific head movements 5-30s, but often overestimated Lightheadedness, nausea, imbalance Screen for secondary causes 2.1% familial tendency

Diagnosis Dix-Hallpike

Tests for posterior canal BPPV Maneuver Nystagmus Return to seated position 1-3s latency Nystagmus fatigues with repeated testing

Nystagmus

Diagnosis Roll Test


Tests for horizontal canal BPPV Maneuver Ageotropic = Cupulolithiasis Geotropic = Canalithiasis Other criteria is same as for Dix-Hallpike

Diagnosis Subjective BPPV


Patient reports vertigo with positioning No nystagmus is seen

Frenzel Goggles

Prognosis

Self-limiting Dizziness, falls, ADLs Usually resolves in 6-12 months Repositioning techniques improve prognosis

Epley maneuver 67-89% effective Semont maneuver 52-90% effective Prolonged positioning 90% effective

Surgery for patients with no relief in 12 months

Medical

Drugs are only used to treat symptoms since physical treatments are so effective Antihistaminic antiemetics for nausea

Meclizine

Antivert Dramamine

Surgical

Singular neurectomy

Cut the posterior ampullary nerve

Eliminates excitatory signals

Complications Best surgical option Obstructs membranous labyrinth Particle movement in endolymph is prevented Efficacious and safe in short and long term

Posterior semicircular canal occlusion


Posterior semicircular canal occlusion

Therapeutic Treatment

Treatment for nausea and vertigo


Epley maneuver Semont maneuver Prolonged positioning techniques Brandt-Daroff exercises

Treatment to create habituation

Treatment for balance dysfunction

Epley Maneuver

AKA Particle repositioning maneuver Canalithiasis Series of positions Otoconia moved from posterior canal to utricle Often combined with oscillations and nausea medication

Semont Maneuver

Liberatory maneuver Cupulolithiasis Brisk positional changes Frees debris attached to cupula One study states that there is no difference in efficacy between the Semont and Epley maneuvers

Prolonged Positioning

Horizontal canal Patient lies on side with unaffected ear downward for 12 hours Sometimes converts BPPV to posterior canal

Then treated by Epley maneuver

Brandt-Daroff Exercises

Used to create habituation

Figure skaters

Only used if repositioning techniques arent effective First used as a treatment technique Then used as a daily exercise routine to create habituation 3 sets of 5 reps daily

Treatment for Balance Dysfunction


Tai Chi Strengthening Balance retraining Education Safety techniques Balance Master

References

Walsh RM, Bath AP, Cullen JR, Rutka JA. Long-term results of posterior semicircular canal occlusion for intractable benign paroxysmal positional vertigo. Clin Otolaryngol Allied Sci. 1999;24(4):316-23. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003;169(7):681-93. Uneri A. Migraine and benign paroxysmal positional vertigo: an outcome study of 476 patients. ENT. 2004;83(12):814-815. Cizzi M, Ayyagari S, Khattar V. The familial incidence of benign paroxysmal positional vertigo. Acta Otolaryngol. 1998;118(6):774-7. Richard W, Bruintjes TD, Oostenbrink P, van Leeuwen RB. Efficacy of the Epley maneuver for posterior canal BPPV: a long-term, controlled study of 81 patients. ENT. 2005;84(1):22-25. Hain TC, Uddin M. Pharmacological treatment of vertigo. CNS Drugs. 2003;17(2):85-100. Helminski JO, Janssen I, Kotaspouikis D, et al. Strategies to prevent recurrence of benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg. 2005;131(4):344-8.

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