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Vertigo -BPPV. W.M.C. Narampanawa. The Ear. Definition. An illusion or hallucination of movement which is usually rotational, either of oneself or the environment. Balance disorders. A common problem Many different potential etiologies Some time multifactorial

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Vertigo -BPPV

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    1. Vertigo -BPPV W.M.C. Narampanawa

    2. The Ear

    3. Definition An illusion or hallucination of movement which is usually rotational, either of oneself or the environment

    4. Balance disorders • A common problem • Many different potential etiologies • Some time multifactorial • Diagnostic & management challenge • Some time unable to make definitive diagnosis

    5. Dizziness – four basic types • Vertigo – illusion of movements, usually rotational, can be an illusion of tilting or swaying • Pre syncope – light headedness • Disequilibrium – general sense of imbalance on walking • Others –(psycho physiologic) difficult to characterize

    6. Introduction • Dizziness is a common presenting complaint • Dizziness may result from a disorder that affects any of the body parts involved in balance or from certain drugs. • The person's description of the problem and the results of a physical examination may suggest a cause, which may lead to additional tests.

    7. vertigo • vertigo is the most common (40-50%) • Of the various causes of vertigo, benign positional vertigo (BPV) is the most common cause • Approximately 25-40% of patients who present with dizziness have BPV.

    8. Near-syncope • Due to reduced blood flow to the entire brain and is classically described as feeling faint or lightheaded

    9. Disequilibrium • Is essentially a gait disorder • Often caused by various neurological problems like cervical spondylosis, extra pyramidal disease and cerebellar disease • Patients typically describe their dizziness only when walking.

    10. Psychophysiologic dizziness • This is the least understood and is thought to be due to altered central integration of sensory signals arising from normal end organs

    11. BPPV/ BPV • BPV was first described by Adler in 1897 and then by Bárány in 1922 • Using positional testing, BPV can readily be diagnosed

    12. BPPV • B” = Benign • Not a brain tumor • Can be severe and disabling

    13. BPPV • “P” = Paroxysmal • Episodic, not persistent • Helpful feature in the differential diagnosis

    14. BPPV • P” = Positional • Occurs with position of head • Turning over in bed • Looking up • Bending over

    15. BPPV • V” = Vertigo • An illusion of motion • “The room is spinning” • Other descriptions • Rocking • Tilting • Descending in an elevator

    16. Anatomy: Utricle • Utricle • Connected to SCC • Contains endolymph • Otoliths (otoconia) • Calcium carbonate • Attached to hair cells • Macule (end organ)

    17. Vestibular system • Tells brain which way the head moves without looking • SCC: angular acceleration • Utricle: linear acceleration

    18. Pathophysiology of BPPV • Otoliths become detached from hair cells in utricle • Inappropriately enter the semicircular canal

    19. Physiology • Normal situation • As one turns head to the right • Endolymph moves SCC receptors fire  “head turning right” • Stop turning head endolymph stops moving  SCC receptors stop firing  “head has stopped moving”

    20. Pathophysiology of BPPV • BPPV • Stop turning head  otoliths keep moving  drag endolymph  receptors continue to fire inappropriately  “head is still moving” • Eyes  “head is NOT moving” • Brain  room must be spinning in the opposite direction

    21. Incidence • Incidence of BPV is 64 cases per 100,000 population per year (US) • Women are affected twice as often as men • in general, is a disease of elderly persons, although onset can occur at any age

    22. Diagnosis - History • characteristically describe that the room or world is spinning • Diagnosis of posterior canal BPV is based on a characteristic history and a positive Hallpike test • Lateral Canal BPPV -Lateral Roll test

    23. Vertigo may occur with • Rolling over in bed • Lying down • Sitting up • Leaning forward • Turning the head in a horizontal plane

    24. Symptoms are usually worse in the morning • Nausea is typically present (vomiting is less common) • individual episodes of vertigo in BPV last for seconds at a time

    25. Diagnosis - Examination • diagnosis of PC BPV is indicated by a positive Hallpike test • The neurologic examination is otherwise unremarkable

    26. Dix - Hallpike test • Classic nystagmus occurs when the patient's head is dependent and turned to the affected side • The most common nystagmus seen is torsional or rotatory • Nystagmus usually occurs within 10 seconds after positioning but may present as late as 40 seconds

    27. Dix – Hallpike test • Duration varies from a few seconds to a minute and associated the sensation of vertigo • Response fatigues if the patient is repeatedly placed into the provoking position

    28. Hallpike test • Caution: For patients with cervical spondylosis • warn the patient that symptoms of vertigo • Instruct the patient to keep his or her eyes open no matter how bad he or she feels • Avoid in pts with IHD

    29. Hallpike test • Seat the patient close enough to the end of the table • lies supine • head should be extended backward an additional 30-45°.

    30. Hallpike test • Turn the patient's head 45° • This position orients the head such that the posterior semicircular canal is going to be in the same plane as the upcoming head movement

    31. Hallpike test • lay the patient down until the head is dependent • This step does not need to be performed rapidly.

    32. Hallpike test • Check for reproduction of symptoms and nystagmus • the fast phase of the nystagmus should be upbeat (toward the forehead)

    33. Hallpike test • Return the patient to the upright position • Nystagmus may be observed in the opposite direction • Patient may describe that the world is spinning in the opposite direction • The neurologic examination findings should be otherwise normal; if not, strongly consider alternative diagnoses

    34. Horizontal Canal BPV • Lateral Roll test Body supine Head inclined 30º Turn head to either side 2 variants Geotropic Apogeotropic

    35. Geotropic LC BPPV • Free particles in the long arm of the LSC (Canalolithiasis) • Horizontal Ny. towards lowermost ear • Stronger Ny. on turning towards side of lesion.

    36. Apogeotropic LSC BPPV • Cupololithiasis • Horizontal Ny.awayfrom lowermost ear • Stronger Ny. on turningaway from side of lesion.

    37. Positional vertigo PERIPHERAL CENTRAL

    38. Causes • Idiopathic (50-60%) • Infection (viral neuronitis) • Head trauma, especially in younger patients • Degeneration of the peripheral end organ • Surgical damage to the labyrinth

    39. DD • Migraine • Labyrinthitis • Meniere’s disease • Vestibular neuronitis • Stroke • Acoustic schwanoma

    40. DD • Chronic otomastoiditis • Medications (alcohol, phenytoin, diuretics, salicylates, quinidine, quinine, barbiturates, antibiotics) • Otosclerosis • Ototoxicity • Posttraumatic injuries • Vertebrobasilar insufficiency

    41. Investigations • No pathognomonic laboratory test for BPV exists • Currently, no imaging study can demonstrate the presence of otoliths • Head CT scanning or MRI is indicated if the diagnosis is in doubt

    42. Management • Epley maneuver • Medical treatment is generally ineffective but may be used to lessen the symptoms.

    43. Epley maneuver Contraindications • Ongoing CNS disease (ie, stroke or transient ischemic attack [TIA]) • Unstable heart disease • Severe neck disease (eg, rheumatoid arthritis) or history of cervical spine fracture or surgery • Carotid bruit on examination indicating carotid stenosis • Body habitus preventing performance of the maneuver.

    44. Epley maneuver • Goal is to move the otoliths out of the posterior semicircular canal and back into the utricle where they belong • The success rate of the Epley maneuver is very high (approximately 85-90%)

    45. Epley maneuver general guidelines • The head must be in the dependent (head-hanging) position • Maintain each position until the symptoms and nystagmus have disappeared (at least 30 seconds) • If the patient cannot tolerate the maneuver because of vomiting or severity of the vertigo, premedicate with a vestibular sedative

    46. Epley maneuver steps • patient sit upright on the bed with the head turned 45° to the affected side

    47. Epley maneuver steps • Place your hands on either side of the patient's head and guide the patient down with the head dependent (as in the Hallpike test).

    48. Epley maneuver steps • Rotate the head 90° to the opposite side with the patient's face upward and be sure to maintain the head-dependent position