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Bppv & vertigo
Benign paroxysmal positional vertigo (BPPV) is the most common cause of positional vertigo. It involves abnormal sensations of movement triggered by certain head positions. Calcium particles in the inner ear can become dislodged and enter the semicircular canals, stimulating hair cells and causing vertigo. The Dix-Hallpike maneuver is used for diagnosis - a patient is positioned to provoke nystagmus if BPPV is present. Treatment involves maneuvers like the Epley maneuver to reposition the particles.
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Bppv & vertigo
- 1. Benign Paroxysmal Positional Vertigo
- 2. Most common- labyrinthine dysfunction abnormal sensation of motion that is elicited by c e rta in c ritic a l p ro vo c a tive p o s itio ns 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
- 3. Pathophysiology Otoliths(calcium carbonate particles) -normally attached to a membrane in utricle & saccule Utricle is connected to semicircular canal Two theories Canalolithiasis Cupulolithiasis
- 4. Canalolithiasis Otolithsdisplaced 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.
- 5. Cupulolithiasis Otoconiaattached to cupula of scc Change in head position result in displacement of cupula results in vertigo.
- 6. Sixth decade F>M Clinical features Sudden onset rotatory vertigo Few secs Triggered by provocative movements No other aural symptoms
- 7. 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
- 8. Comparision of positionalnystagmus of BPPV with lesions of the CNS BPPV CNS Latent period A few seconds nil Distress Present nil Direction of Direction fixed – towards nystagmus 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
- 9. Epley’s manoeuvre forleft posterior semicircular canal BPPV
- 10. (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
- 11. Instructions following Epley’smaneuvre 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
- 12. 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.
- 13. Differential diagnosis of Vertigo
- 14. “Subjective sense ofimbalance” 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
- 15. Rotatory Episodic Seconds Hours Prolonged Weeks Unsteadiness Episodic Seconds Hours to days Prolonged Weeks to months
- 16. Rotatory vertigo Episodic- Few seconds Episodic - Few min to 24 hours BPPV Labyrinthine fistula Perilymphatic fistula Caloric effect Cervical vertigo Meniere’s disease Delayed endolymphatic hydrops Following middle ear surgery
- 17. Prolonged - Daysto weeks Vestibular neuronitis Acute labyrinthitis Trauma Head injury Labyrinthectomy Vestibular neurectomy Secondaries in CP angle
- 18. Unsteadiness Episodic -seconds Episodic – hours to days Rapid movements Drugs Tranquilisers, anticonvulsants Travel sickness hyperventilation
- 19. Prolonged – weeksto months Late stage of vestibular neuritis, acute labyrinthitis Elderly patients Drugs Anticonvulsants, Gentamicin Vestibular schwannoma Functional
- 20. 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
- 21. 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
- 22. Fistula testnegative – 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)
- 23. Cranial nerves Cerebellar function Gait Romberg’s test Dysmetria Dysdiadokokinesia
- 24. 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
- 25. Time takenfrom 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
- 26. Electronystagmography Method of detecting & recording nystagmus Rotational chair test Computerized dynamic posturography
- 27. Treatment Suppress vestibular symptoms Wait for vestibular compensation Treat the underlying cause Medical Surgical