Benign Paroxysmal Positioning Vertigo - PowerPoint PPT Presentation

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Benign Paroxysmal Positioning Vertigo

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Positioning--response provoked by change in head or body position ... Patient centers head and returns to upright, seated position ... – PowerPoint PPT presentation

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Title: Benign Paroxysmal Positioning Vertigo


1
Benign Paroxysmal Positioning Vertigo
  • Nancy Silbernagel, M.A., CCC-A
  • HCMC Staff Audiologist

2
Definition
  • Benign--not malignant or life threatening
  • Paroxysmal--response (nystagmus) builds, peaks,
    fatigues
  • Positioning--response provoked by change in head
    or body position
  • Vertigo--sensation of movement, usually described
    as spinning or turning

3
Incidence
  • Accounts for 20 of vertigo cases presenting to
    ENT office
  • Frequently seen in elderly
  • More frequent in females than males

4
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5
Typical Presentation
  • Transient episodes of vertigo (
  • Initiated by position change
  • Characterized by periods of exacerbation and
    remission
  • Usually unilateral
  • Little benefit from medication

6
BPPV Characteristics
  • Lying down or getting up
  • getting in and out of bed
  • Rolling over in bed
  • Bending over
  • picking something up
  • Looking up
  • Shaving
  • Washing hair in shower
  • Going to dentist or beauty salon

7
Etiology
  • Ideopathic
  • Head trauma

8
  • Cupulolithiasis- -otoconia in the utricle break
    loose and adhere to the cupula of the posterior
    semicircular canal
  • Canalithiasis--otoconia are free floating in the
    posterior semicircular canal when the head moves
    into a provoking position, the otoconia sink into
    the most dependent position in the canal, causing
    endolymph to move

9

10
Evaluation
  • Dix Hallpike
  • Patient sitting upright
  • Turn head 45º to right
  • Eyes remain open
  • Assist patient into supine, head hanging
    position maintain 45º head turn to right
  • Patient focuses on target observe eyes for
    nystagmus
  • Maintain head hanging position for 30-40 seconds
    if response occurs, wait for nystagmus to fatigue
  • Patient centers head and returns to upright,
    seated position
  • When seated, patient focuses on target if
    response was demonstrated, may see nystagmus
    reversal
  • Repeat with head hanging left

11
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12
  • Diagnosis is based on a positive Dix-Hallpike
  • Head hanging right- counterclockwise nystagmus
  • Head hanging left-clockwise nystagmus

13
Classic Characteristics
  • Latency-10-40 seconds
  • Paroxysmal
  • Rotary nystagmus
  • Duration
  • Fatigues with repetition
  • Nystagmus may reverse in upright position

14
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15
Management
  • Nothing
  • Medication is of little benefit
  • Adaptation exercises (Brandt-Daroff)
  • Surgery
  • Canalith Repositioning Procedures
  • Epley and Semont maneuvers
  • Move otoconia from posterior canal into utricle
    (90 success rate)

16
Canalith Repositioning Procedure (CRP)
  • Supporting patients neck, quickly assist patient
    into supine, head hanging position maintain 45º
    head position
  • Otoconia move toward center of PSC
  • Without lifting the patients head, help patient
    turn head to the opposite Hallpike position
  • Otoconia reach common crus
  • Rotate head and body until patient is lying on
    side and nose is pointing to floor
  • Otoconia pass through common crus
  • Maintaining head position from 3, assist patient
    to a seated position
  • Otoconia enter utricle
  • Ask patient to center head and to tilt head down
    20º
  • Otoconia move into utriclear duct
  • Repeat positions 1-5 until there is no nystagmus
    in any position
  • Patient should remain in each position for
    latency duration of nystagmus

17
Canalith Repositionging Procedure

18
  • CRP is only done when a positive Dix-Hallpike is
    observed
  • Cant base diagnosis on patient history alone
  • Which ear will you treat?
  • Acceptance of CRP has possibly lagged because
    patients were inappropriately treated patient
    underwent maneuver, did not have BPPV, symptoms
    persisted, and CRP ruled unsuccessful

19
Semont

20
Patient instructions following CRP
  • Sleep semi-recumbent for one night
  • Avoid provoking head positions for one week
  • Avoid moving head up and down
  • Move head and body as a unit
  • Can wear soft cervical collar as reminder for
    heard movement
  • Do not sleep on the side that was just treated

21
Bilateral BPPV
  • Much less common
  • If you see it, usually will see with head trauma
  • Must treat one side at a time so you dont undo
    the side you just treated
  • Harder to cleargenerally will have multiple
    visits

22
Horizontal Canal BPPV
  • Otoconia migrate to the lateral canal
  • Less common than posterior canal BPPV
  • Can happen after CRP if head is lifted between
    first and second positions

23
Horizontal Canal BPPV
  • Roll test
  • Body supine
  • Head inclined 30º
  • Turn head to either side

24
Horizontal Canal BPPV
  • Patients usually describe a strong and prolonged
    vertigo
  • Often report dizziness when turning over in bed
    but not in other positions
  • Can last up to or longer than a minute
  • See a horizontal nystagmus, not rotary
  • Nystagmus is typically present in both head
    positions but one is usually significantly worse
  • Nystagmus can be geotropic or ageotropic
  • Most commonly canalithiasis with geotropic
    nystagmus that is greater on the affected side

25
Maneuver for Horizontal Canal BPPV

26
Summary
  • Etiology is ideopathic or head trauma
  • Diagnosis is based on positive Dix-Hallpike
  • CRP/Epley highly successful
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