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Benign Positional Vertigo. Taleb Mohammed Mansoor Khaleil Ebrahem Al-Matroushi. The Ear. The Inner Ear. 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

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Benign Positional Vertigo

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benign positional vertigo

Benign Positional Vertigo

Taleb Mohammed Mansoor

Khaleil Ebrahem Al-Matroushi

benign paroxysmal positional vertigo bppv
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.
canalolithiasis theory
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.
  • Idiopathic
  • Infection (viral neuronitis)
  • Head trauma
  • Degeneration of the peripheral end organ
  • Surgical damage to the labyrinth
  • 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.
  • 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.
  • Medications
  • The Canalith Repositioning Procedure (CRP)
  • Surgery
  • Antiemetic
  • Antihistaminic
  • Anticholinergic
canalith repositioning procedure crp
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.
clinical trial
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.
brandt daroff exercises
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)
clinical trial18
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
  • Singular neurectomy
  • Vestibular Nerve Section
  • Posterior Canal Plugging Procedure
singular neurectomy
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%.
clinical trial21
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.
posterior canal plugging procedure
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.
clinical trial23
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.
vestibular nerve section
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.
clinical trial26
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
  • BPPV
    • Common complain
    • Vertigo when changing head position
    • Diagnosed by Dix-hallpike
    • Treated by CRP
    • Surgery if CRP fails