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 Paroxysmal: sudden and unpredictable in onset Positional: comes with a change in head position Vertigo: causing a sense of dizziness.
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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.

Canalolithiasis Theory

Causes
Idiopathic Infection (viral neuronitis) Head trauma Degeneration of the peripheral end organ Surgical damage to the labyrinth

Symptoms
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.

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Diagnosis
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.
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The Dix-Hallpike test

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Treatment
Medications The Canalith Repositioning Procedure (CRP) Surgery

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Medications
Antiemetic Antihistaminic Anticholinergic

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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.
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The Epley Maneuver

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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.
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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)

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Brandt-Daroff Exercises

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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

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Surgery
Singular neurectomy Vestibular Nerve Section Posterior Canal Plugging Procedure

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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%.

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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.

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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.
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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.
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Vestibular Nerve Section

done when the attacks of vertigo cannot be controlled with medication. An incision is made behind the ear and balancehearing 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.
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Vestibular Nerve Section

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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

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Summary
BPPV
Common complain Vertigo when changing head position Diagnosed by Dix-hallpike Treated by CRP Surgery if CRP fails

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