Benign Positional Vertigo

1. 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