bppv journal
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PC-BPPV
Using the Dix-Hallpike Maneuver in the directionof the involved ear canal (gold standard)
Mechanism: Otolithic debris away from the cupula
endolymph hidrodynamic drag stimulation of thecupula
Excitation of the posterior canal activation ofipsilateral superior oblique and contralateral inferiorrectus muscles upbeating and torsional nystagmus
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Special precautious: History of neck surgery Cervical radiculopathy Vascular dissection syndrome
The side-lying test may be used as analternative
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Dix-Hallpike maneuver
A. Seating the patient upright
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B. Head is turned 45 degree in the direction of the involved ear (B: right ear in this figure)
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C. The patient is then moved from the sitting to the supine position, ending with the headhanging at 20 degree off the end of table
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Side-lying Test
A. Seating the patient upright
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B. Head turned 45 degree angle away from involved ear
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C. Patient lies on the side of the involved ear
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HC-BPPV
Supine-roll test (Pagnini McClure maneuver) Nystagmus would appear:
Geotropic: beat toward the ground (canalolithiasis) Apogeotropic: beat toward the ceiling (cupulolithiasis)
Although difficult, it s important to determine itslateralization although difficult
Nystagmus appears stronger when head is turnedtoward the affected ear
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Other than the Pagnini, lying down nystagmus(LDN) or head-bending nystagmus (HBN) couldbe used as an alternative
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AC-BPPV
SHH as well as Dix-Hallpike maneuver oneither side may evoke downbeat nystagmuswith an ipsitorsional (upper poles of the eyesbeating toward involved ear) component.
The torsional nystagmus may not be asapparent as PC-BPPV
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Mixed-canal type of BPPV
BPPV may involve multiple semicircular canals PC- and HC- are the most common
combination MC BPPV frequently involves canals on the
same side Trauma may increase the risk of MC BPPV
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Differential Diagnosis
Posterior circulation stroke may mimic BPPV Lesions involving cerebellum
Central paroxysmal positional vertigo as aninfarction in dorsolateral to the fourthventricle or nodulus
Solitary plaque involving the brachiumconjunctivum