bppv pa 2016 b&w formatted - entpa.org ent for the pa-c... · • thrown into a spin...

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Sixth Annual ENT for the PA-C | March 30 – April 3, 2016| Orlando, FL

Canalith Repositioning Basics to Advanced

John Li, M.D.


Disclosures

• “We have no conflicts of interest to disclose.”


Goals

• Beginner to Expert – 2 hrs into 1

• Definition, History, Physical, Diagnosis, Treatment Options

• Canalith Repositioning

• Advanced issues

– Complications, Other canals, Cupulolithiasis

– Advances – Omniaxial chairs, Infrared goggles

– 360 degree maneuver

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Introduction

• BPPV most common single cause of vertigo

• Underestimated

• Misdiagnosed

• Concomitant pathology

PICTURE 2


Definitions

• Evolving

• Different canals– Posterior

– Horizontal

– Anterior

• Different mechanisms– Canalithiasis

– Cupulolithiasis


What is BPPV?

• Definition = Vertigo (a phantom sensation of motion) elicited by specific changes in head position. (movement provoked)

• Caused by placing the affected ear downward. (Classical BPPV)

• Associated with characteristic eye movements (classical nystagmus)

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Dizziness Characteristics

• Triggered by movement.

• Thrown into a spin ‐‐ toppling towards the side of the affected ear.

• There is a lag period.

• The symptoms start very violently

• Dissipate within 20 or 30 seconds.

• This sensation reverses upon sitting erect again.


Canalith Theory


Presentation

• Onset is typically sudden.

– Thereafter, propensity for positional vertigo may extend for hours to weeks, occasionally to months or years

– Symptoms may periodically clear and then recur.

• Severity ‐variable

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Predisposing Etiologic Factors

• Trauma: Rarely seen before age 35 unless history of head trauma

• Inactivity: Acute alcoholism, major surgery, CNS disease, etc.,

• Concomitant ear pathology: About 20% have perilymph fistula, secondary endolymphatic hydrops, history suggesting infarction


Natural Course

• Variable

• 6 Weeks limited course

• Chronic condition

• Acute relapsing


Laboratory Tests

• Infrared Video Hallpike ‐‐ Best way to record rotational eye movements.

• Other tests are nonspecific

PICTURE

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The Hallpike Maneuver

• Standard clinical test for BPPV.

• Pathognomonic

• Epley modification: From behind patient; easier, to visualize the eyeball rotation.

• A negative test is meaningless

• Turn the head, drop back.

PICTURE


“Classical Nystagmus”• Parallels the symptoms.

• Predominantly rotatory nystagmus , fast phase toward undermost ear

• Latency (~5 sec)

• Limited duration (<20 sec)

• Reversal upon return to upright

• Response decline upon repetitive provocation


Nystagmus Axis• The axis of nystagmus is fixed to SCC

• The “OH NO” hands to face trick

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Why Turn 45 Degrees?


Treatment Options

• Watch and Wait.

• Exercises and Vestibular therapy.

• Surgery.– Labyrinthectomy

– Vestibular nerve section (VNS)

– Singular neurectomy (Gacek 1974):

– PSC occlusion:

• "The Canalith Repositioning Procedure".


Prognosis

• Non‐lethal condition

• Variable recurrence rate (10% ‐ 50%)

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The Procedure (Canalith Repositioning Made Quite Simple)


Why Choose CRP?

• 95% ‐97% success.

• It works immediately, allowing return to productivity. (Why wait?)

• Painless, little to no side effects.

• Less expensive than surgery or Vestibular Rehabilitation.


Position 1

• Start. Sitting, head turned 45 degrees towards ipsilateral side.

• Position 1. Supine, 20‐30 degrees head hanging tilt, head turned 45 degrees towards ipsilateral side.

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Position 2‐3

• Position 2. Supine, 45 degrees head hanging tilt, head turned 45 degrees towards contralateral side.

• Position 3 Lying on side with contralateral shoulder down, head turned 45 degrees below horizon towards contralateral side.

Position 4‐5

• Position 4 Sitting, head turned at least 90 degrees towards contralateral side.

• Position 5 Straight ahead, head tilted forward.


CRP video

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Secrets

• Repeat Dix Hallpike at end of treatment.‐‐ if positive, repeat treatment 2‐3x.

• Prevent Failure:

– Correct positioning through “Apex” area.


The “Apex” Area

• Failure vs. success

• Head must be tilted as far posteriorly (30 degrees head hanging) as possible before rotating from position 2 to 3.

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Not enough tilt

1111


Correct


Conclusions

• Simplified CRP is easy to learn and is scientifically sound.

• It is felt that CRP should be considered first line therapy for the treatment of BPPV.


Advanced BPPV

Cupulolithiasis vs. Canalithiasis of the Posterior and Horizontal Canals – and other Advanced Issues

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Pathophysiology:Canalithiasis v. Cupulolithiasis

John Li, MD PA


Canalith Theory (Hula Hoop)


Cupulolithiasis

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Weighted Switch


Cupulolithiasis versus Canalithiasis• Both exist.

• Similarities: particles are out of place,

– similar nystagmus for PSCC

• Dissimilarities: location of those particles

• Cupulolithiasis:

– Position induced, non‐fatiguing, little latency

• Canalithiasis:

– Movement induced, fatiguing, latency


Treatment

• Oscillation / Agitation

• Turn Cupuloliths to Canaliths

• Consider Semont if oscillation doesn’t work

• Same Maneuvers for PSC Canalithiasis

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Other Canals:• Horizontal canal involvement (HSC)

• Anterior canal involvement (ASC)


Anterior (Superior) Canal


Horizontal Canal

• More potent than regular BPPV

• Recent Head trauma

• Recent CRP ‐‐ usually the result of a conversion.

• Typically a referral case

• Ewald’s 3rd Law

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Physical

• Horizontal Nystagmus instead of rotatory

• Mimics Bilateral BPPV

• Sometimes truly a hybrid of 2 canals on the same side.


Right Canalithiasis


Treatment• Bar‐B‐Que Spit maneuver

• Log roll away from the affected side.

PICTUREROLL

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Horizontal Cupulolithiasis

• More complex

• Non‐fatiguing

• Position dependant

• Opposite beating nystagmus

• “Opposite” nystagmus intensity

• “Neutral points”


Movie (HSC Cupulolithiasis)


Neutral Points

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Right Cupulolithiasis


Actual Footage

• See actual footage of nystagmus conversion at end of talk (in interest of time)


Diagnostic Matrix

HSCC CANALITHIASIS CUPULOLITHIASIS

Nyst Same direction as head turn

Opposite direction as head turn

Nyst Stronger side is affected side

Weaker side is affected side

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Treatment Matrix CANALITHIASIS CUPULOLITHIASIS

PSCC Standard CRP (for ipsi ear)

Standard CRP (for ipsi ear)

HSCC Log roll AWAY from affected side

Log roll AWAY from affected side

ASCC Theoretical Theoretical


What Happens When All Else Fails?

• Go to Advanced Options

• Make sure to have the right DX– Consider Multiaxial device w/ IR system

– Helps diagnosis as well as treat.• Which canal?

• Cupulolithiasis vs Canalithiasis?

• Vestibular Rehab

• Surgery– Labyrinthectomy, Neurectomy, PSC occlusion


SURGICAL OPTIONS

• Labyrinthectomy

• Singular Neurectomy ‐‐ Gacek ‐‐ 1974

• Aminoglycoside perfusion ‐‐ Shea ‐‐

• Laser Obliteration of the Posterior Canal Ampulla ‐‐ Anthony

• Canal Occlusion ‐‐ Parnes and McClure ‐‐ 1990

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Canal Occlusion

• Parnes and McClure ‐‐ 1990

• Disrupts the flow of particles within the endolymph

• Low incidence of SNHL


Canal Occlusion

of Posterior canal

“blue-lined”, then opened perilymphatic space

endolymphatic particles

fascia / muscle plug

particles can no longer flow


The 360o Maneuver

2020


The 360o Maneuver For Treatment Of Benign Positional Vertigo

American Neurotology SocietyTorok Award Lecture 2005

Published in AJOJohn C. Li, M.D.


360 Based on Canalithiasis

John Li, MD PA

Move the Particles

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Move the Particles

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Move the Particles

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Move the Particles

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Move the Particles

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Move the Particles

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Theory

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Theory

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Theory

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Theory

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Theory

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Theory

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Theory

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Theory

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Theory

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Theory

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Why Bother with 360?

• Does it work?

• Above and beyond standard RX?

– “Difficult” patients that otherwise can’t be treated

– Standard Treatment failures


Difficult to Treat Patients • Patients unable to tolerate manipulation

– Back problems

– Strokes

– Paralysis

• Patients who prone to panic

• Secured in a chair / immobilized

– All positioning is done externally

– No flexion, extension or torsion

– The patient does not have to move a muscle.


MAX for Epley / Semont Failures

• Standard treatment failures

– Canal jam

– Cupulolithiasis

– Involvement of other canals

– Involvement of multiple canals

• Distinguishes Pathology

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MAX allows

• Canal specific (targeted)

• Canal independent (isolated)

– Left posterior semicircular canal can be treated independently of the right posterior semicircular canal, independently of the horizontal semicircular canals.

• Easy transition between each of the maneuvers


CONCLUSIONS• The ultimate goal of repositioning is to move particles 360° (roughly).

• Standard CRP works in 95% of cases

• Canals other than the posterior semicircular canals can be affected.

• Cupulolithiasis does exist. It is more difficult to treat than canalithiases.

• Surgery is the choice of last resort.


Actual Footage

bppv pa 2016 b&w formatted - entpa.org ent for the pa-c... · • thrown into a spin...

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