Understanding Benign Paroxysmal Positional Vertigo: Diagnosis and Treatment Options

1. BENIGN PAROXYSMAL POSITIONAL VERTIGO WASEEM WATAD

2. Basic Anatomy

3. BPPV • Barany 1921 • Dix-Hallpike 1952 – important features of nystagmus • Abnormal sensation of motion elicited by certain critical positions • Provocative position  nystagmus • At least 20% of vertigo • Underestimated

4. BPPV … • Subclassification : scc post/lat/ant/bilat • Pathophysiology : • Canalithiasis • cupulolithiasis

5. Pathophysiology

6. Pathophysiology (cont.) • Cupulolithiasis : • Harold Schuknecht 1962 • Densities (otocania) adherent to cupula of crista ampullaris • Basophilic particles -1969

7. Canalithiasis : • John Epley – 1980 • Densities free floating in canal portion • Parnes , McClure – 1991 found particles in post SCC

8. BPPV ... • Frequency : 10-64/100000 • Sex : 64% women • Age : older population ( 51-57) younger than 35 – head trauma. • History : • sudden • days-weeks • occassionally months -years • episodes.

9. Physical : • neurological examination – normal • except – Dix-Hallpike  pathognomonic

10. BPPV … • Nystagmus : characterization and types • RT / LT , vertical / horizontal , changing • Tortional = Rotational – clockwise / counterclockwise • Geotropic- toward the earth • Ageotropic – opposite

11. BPPV … • Classic post SCC – geotropic rotatory nystagmus • Horizontal SCC – purely horizontal nystagmus • Non-fatiguing nystagmus – cupulolithiasis > canalithiasis

12. Classic BPPV • Involved the POST SCC • Geotropic NG with affected ear down • Rotatory , fast phase toward the undermost ear • Latency – few seconds • Duration – limited < 20 seconds • Reversal upon return upright position • Response decline upon repetitive provocation

13. Lat. SCC PPV • Most common atypical BPPV • 3-9% of cases • Consequence of Epley maneuver • Horizontal purely nystagmus • Cupulolithiasis rather than canalithiasis • Modified Epley / lampert maneuver …

14. Lat. SCC PPV

15. Ant. SCC PPV • Rare – 2% • Down-beating /torsional NG for the opposite ear on Dix-Hallpike maneuver

16. BPPV - Causes • Predisposing factors : • Inactivity • Acute alcoholism • Major surgery • CNS disease

17. Causes ( cont. ) • Idiopathic – 39% • Ear disease – 29% • OM – 9% • Vestibular neuritis – 7% • Menier’s dis – 7% • Otosclerosis – 4% • Sudden SNHL – 2% • Trauma – 21%

18. Causes ( cont. ) • Trauma – 21% • CNS diseases – 11% • Acustic neuroma – 2% • Cervical vertigo – 2%

19. BPPV - D.D • Menier’s disease • Inner ear concussion • Alcohol intoxication • Labyrinthitis • Vascular loop syndrome • Post. Fossa lesions : acustic neuroma , meningioma • Central origion : stroke , MS , cerebellar degeneration • Vertibral artery insuffeciency • Cervical vertigo

20. BPPV - Treatment • Watchful waiting • Vestibular suppressant medications • Vestibular rehabilitation • Canalith repositioning • Surgery care • Labyrinthectomy • Post. Canal occlusion • Singula neurectomy • Transtympanic aminpglycoside application

21. Trials about BPPV

22. General • Labeled benign paroxysmal positional vertigo is not always benign • Evaluation of the effectiveness of canalith reepositioning procedurs – CRP • Several studies …

23. Trials … • Blakely – 1994 : • 50% improvement in the control and CRP group !! ( 2-3 months) • Lynn – 1995 : • Randomized-controlled : 89% negative DH in CRP group , 27% in the control group • John Li (1995) :

24. Trials… • John Li (1995) : • Comparison CRP / CRP + mastoid oscillation and control • Modified Epley maneuver • Use of colar and head elevation after CRP • No spontaneous resolution within aweek • 60% symptoms improvement in CRP group • 92% symptoms improvement in CRP +mastoid oscilation and 70% negative DH

25. Trials… • R. steenerson –1996 : • Comparison of CRP and vestibular habituation training • Tow approaches are effective in symptomatic relief ( 3 months) • CRP faster relief and fewer treatments

26. Trials … • K. Yimatae (2003) • Randomized-controoled • Modified Epley maneuver, no mastoid oscillator and no instructions after the maneuver • Subjective and objective weekly follow-up • CRP group – 76% negative DH, 48% control group • CRP group – 96% symptoms improvement , 90% control group • Non-cured patients need > 6 procedures in 2 weeks , should considering liberatory maneuver

27. Elderly population and BPPV • S. Angeli – 2003 : • Effectiveness of CRP and VR • Modified Epley : • Elderly comorbidities : degenerative osteoarthritis disease , CVA , peripheral neuropathy, cognitive and autonomic dysfunctions • S/E of CRP – neck torsion and extension result in vertibrobasilar artery insufficiency, strain on the spine column, dislodged carotid a. emboli • Avoid liberatory maneuver • 64% CRP group – negative DH after a month • Overall 77% with CRP and VR

28. CRP Meta-Analysis B. Woodworth - 2004 • CRP - First line of treatment • Non-invasive • Easy to perform in the office • No need to expensive instrumentations • Repeat maneuver if needed • Potential to provide rapid relief of vertigo

29. Meta - Analysis • 9 randomized-controlled trials • Symptoms resolution and elimination of positive Dix-Hallpike test • CRP more effective than control ( x5 ) • Untreated patients - symptoms improvements with time but positive DH • So Resolution of vertigo – avoidance of provocative positions

30. CRP – Epley maneuver

31. CRP – Semont maneuver

32. Mastoid oscillator

33. Brandt-Daroff Exsercise

34. Lampert maneuver- Lat. SCC BPPV

35. Vestibular rehabilitaions

36. Complications of CRP • Failure – 25% (12%-56) • Recurrence – 13% in 6 months • Side effects • Nausea • Vomiting • Fainting • Sweating • Worse vertigo – LAT SCC PPV

37. THANK YOU …