bppv & vertigo
TRANSCRIPT
Benign Paroxysmal Positional Vertigo
Most common - labyrinthine dysfunction abnormal sensation of motion that is elicited by
certain critical provocative positions Provocative positions
Head turn to affected side - getting out of bed Extend head back to look up “Top shelf vertigo”
Causes Idiopathic – 50% Head trauma, middle ear infection, viral
labyrinthitis, ear surgery
Pathophysiology
Otoliths (calcium carbonate particles) -normally attached to a membrane in utricle & saccule
Utricle is connected to semicircular canal
Two theories Canalolithiasis Cupulolithiasis
Canalolithiasis Otoliths displaced from utricle -
enter the posterior semicircular duct (most dependent SCC )
Changing head position relative to gravity causes the free otoliths to gravitate through the canal.
The concurrent flow of endolymph stimulates the hair cells of the affected semicircular canal causing vertigo.
Cupulolithiasis Otoconia attached
to cupula of scc Change in head
position result in displacement of cupula results in vertigo.
Sixth decade F>M Clinical features
Sudden onset rotatory vertigo Few secs Triggered by provocative movements No other aural symptoms
Dix-Hallpike maneuvre
Pt seats on the table Pt’s head held, turned
45 deg to Rt & pt placed at supine position – head hangs 30 deg below horizontal
Pt’s eyes observed for nystagmus
Test repeated on Lt side
Comparision of positional nystagmus of BPPV with lesions of the CNS
BPPV CNSLatent period
A few seconds nil
Distress Present nil
Direction of nystagmus
Direction fixed – towards the undermost ear
Direction changing
Duration of nystagmus
Less than 30 sec Persists while position maintained
Fatiguablity
Nystagmus stop with repeated testing
Nystagmus persists with repeated testing
Epley’s manoeuvre for left posterior semicircular canal BPPV
(S) Start: patient is seated (1) Place head over end of table, 45 degrees to left. (2) Keeping head tilted downward, rotate to 45
degrees right. (3) Rotate head and body until facing downward
135 degrees from supine. (4) Keeping head turned right, bring patient to
sitting position. (5) Turn head forward, chin down 20 degrees. Pause at each position until nystagmus approaches
termination
Instructions following Epley’s maneuvre
Rest 10 min Sleep in semi-
recumbent For at least 1 week
Use two pillows Avoid bad side No head turning
far up or down
Surgical mangement
Posterior canal wall plugging debris can no longer
move within the canal Singular nerve
section Section the nerve that
transmits information from the posterior semicircular canal ampulla toward the brain.
Differential diagnosis of Vertigo
“Subjective sense of imbalance”
History Rotatory ? Onset (1st episode) Duration Progression Severity Episodic ?
Aggravating or relieving factors
Associated auditory/neurological symptoms
h/o chronic ear ds, trauma, surgery, intake of drugs
Rotatory Episodic
Seconds Hours
Prolonged Weeks
Unsteadiness Episodic
Seconds Hours to days
Prolonged Weeks to months
Rotatory vertigo
BPPV Labyrinthine
fistula Perilymphatic
fistula Caloric effect Cervical vertigo
Meniere’s disease Delayed
endolymphatic hydrops
Following middle ear surgery
Episodic - Few seconds Episodic - Few min to 24 hours
Vestibular neuronitis Acute labyrinthitis Trauma
Head injury Labyrinthectomy Vestibular neurectomy
Secondaries in CP angle
Prolonged - Days to weeks
Unsteadiness
Rapid movements Drugs Tranquilisers,
anticonvulsants Travel sickness hyperventilation
Episodic - seconds Episodic – hours to days
Late stage of vestibular neuritis, acute labyrinthitis
Elderly patients Drugs
Anticonvulsants, Gentamicin Vestibular schwannoma Functional
Prolonged – weeks to months
Examination ENT
Nystagmus Involuntary, rhythmical, oscillatory movement of
eyes Slow / fast component – direction of the nystagmus Procedure
Examiner keeps finger about 30 cm from the patients eyes in the central position & moves it right or left
Do not exceed 30 degree from the centre Enhanced with Frenzel glasses or in darkness
( optic fixation is lost)
Otoscopic examination & Tuning fork test Fistula test
Induce nystagmus - pressure changes in the external ear which are then transmitted to labyrinth
pressure induced by Intermittent pressure over the tragus Siegel’s pneumatic speculum
Fistula test negative – normal Fistula test positive
Labyrinthine fistula Perilymph fistula Post stapedectomy fistula
False negative fistula test Cholesteatoma covering the fistula
False positive fistula test ( positive fistula test in absence of fistula)
Meniere’s disease ( Hennebert’s sign)
Cranial nerves Cerebellar function
Gait Romberg’s test
Dysmetria Dysdiadokokinesia
Management
Investigations Audiomety Caloric test
Induce nystagmus by thermal stimulation of vestibular system Bithermal caloric test
Supine, head tilted forward 30 deg Ears irrigated with water
40 sec Alternately with water at 30 & 44 deg C
Time taken from irrigation to end of nystagmus charted on calorigram
Cold water – nystagmus to opposite side Warm water – nystagmus to same side (COWS) Depending upon the response to caloric test
Canal paresis – depressed function of ipsilateral labyrinth, vestibular nerve, vestibular nuclei
Directional preponderance – peripheral and central lesion
Electronystagmography Method of detecting & recording nystagmus
Rotational chair test Computerized dynamic posturography
Treatment Suppress vestibular symptoms Wait for vestibular compensation Treat the underlying cause
Medical Surgical