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2003. 6. 25
BPPV
Vestibule ()
Crista ampullaris ()
BPPV
Historical aspects(I)
- Barany(1921); first description of positioning nystagmus - Dix & Hallpike(1952); the provocative positioning maneuver and defining the syndrome - Schuknecht(1969); basophilic deposits on the cupula of the posterior SCC(PSC) in postmortem 2 BPPV patients(cupulolithiasis) - Hall, Ruby, & McClure(1979); something moving inside the canal rather than adhering to the cupula of the PSC(canalolithiasis) - Parnes & McClure(1992); free-floating endolymph particles-PSC occlusion
BPPV
BPPV
Historical aspects(II)
- Cipparone et al.(1985); the existence of a BPPV due to involvement of the HSC - McClure(1985); first reported come clinical features of BPPV originating from the HSC in 7 patients(the particles penetrate onto the non-ampullary arm(long arm or posterior part) of the HSC - Pagnini et al.(1989); clinical features of HSC BPPV in 15 patients(geotropic nystagmus) canalolithiasis type - Baloh(1995); ageotropic or apogeotropic nystagmus cupulolithiasis type - Bertholon(2002); Possible ASC BPPV
BPPV
Terminology
1.Nystagmus(fast component) (Rt., Lt., Up, Down.) 2. a.Canalolithiasis - Long arm(non-ampullary or post. portion) - Short arm(ampullary or ant. portion) b.Cupulolithiasis 3. Geotropic vs a(po)geotropic nystagmus 4. Ampullopetal(utriculopetal)(HSC) vs ampullofugal(utriculofugal)(PSC, ASC) 5. Ewalds law
BPPV
1.Nystagmus(fast component)
(Rt., Lt., Up, Down.) * => ; right beat ; up-beat
2.Canalolithiasis
a.Long arm(non-ampullary or post. portion)
Canalolithiasis
Long arm
) Right HSC
BPPV
Geotropic()
Ageotropic()
BPPV
PSC
ASC
Slow phase
Fast phase
BPPV
Etiology of BPPV
1) 2) 3) 4) 5) 6) 7) 8) idiopathic(M/C) post-trauma Neurolabyrinthitis SNHL URI COM Postoperation(ear, general) Ototoxicity
BPPV
BPPV
Diagnosis of PSC-BPPV
* Dix-Hallpike Maneuver
BPPV
BPPV
BPPV
BPPV
Diagnosis of HSC-BPPV
1. Lateral head turning test(Roll test); supine position with head tilted 30 upward -> 90 lateral head rotation in the left or right side -> horizontal bilateral direction changing nystagmus(geotropic or ageotropic) 2. Determination of the lesion side (still controversial) 1) geotropic type; strong nystagmus side 2) ageotropic type; weak nystagmus side by the Ewalds the 2nd law (Baloh, Nuti)
BPPV
BPPV
BPPV
Treatments of PSC-BPPV
I.Non-surgical
a) Brandt-Daroff habituation exercise(1980) b) Liberatory maneuver(Semont, 1988) c) Canalith Repositioning Procedure(Epley, 1992)
II. Surgical
a) Singular neurectomy(Gacek, 1974) b) PSC occlusion(Parnes, 1990)
BPPV
1.
2. 3.
.
. ; a.
.
30 . b. 30 .
Liberatory maneuver
(Semont, 1988)
BPPV
1. (1).
2.
a. . b. 2-3
. 5
c. .
BPPV
BPPV
BPPV
Treatment of HSC-BPPV
* Canalolithisis type; 1. Baloh(1994), Epley(1995), Lempert(1996); 360 rotation of the supine patient toward the unaffected ear; displace the debris more effectively from the non-ampullary arm of the HSC toward utricle
BPPV
Treatment of HSC-BPPV
2. Vannuchi et al.(1994); Forced prolonged position(FPP)- on the basis of the canalolithiasis theory for geotropic HSC BPPV -> The patient lies on the healthy side for 12 hours. Under the effect of gravity the particle gradually slip into the vestibule from the nonampullary arm of the HSC
BPPV
BPPV
Treatment of HSC-BPPV
* Cupulolithiasis type; 1. Nuti et al.(1998): change from ageotropic to geotropic type(ex; head-shaking -> 360 barbecue method) 2. Jo et al.(2000); cupulolith repositioning maneuver(CuRM) 3. Casani et al.(2002); modified fourth step of Semont maneuver (canalolithiasis type; combination of 360
BPPV
BPPV
BPPV
HSC
6% supine to head lateral horizontal (geotropic, ageotropic) direction changing >30sec <3sec no*
BPPV
BPPV
1 1 6 7 8 9 4 37
1 1 11 9 10 11 4 48
5 2 2 2 11
* Canal
1. PSC canalolithiasis; 28 cupulolithiasis; 3 2. HSC canalolithiasis; 14 cupulolithiasis; 2 3. ASC canalolithiasis; 1 4. Combined type 2 (PSC + HSC) 5. Change of SCC after Tx.(1) (PSC canalolithiasis -> HSC canalolithiasis)
BPPV
BPPV
* Recurrence
PSC canalolithiasis 28 3 Case 1 + Case 2 Case 3 + +
20 19 30
+ +
7 40
BPPV
Conclusions
BPPV
. , canalolithiasis cupulolithiasis . 2 . *
BPPV
Crista ampullaris
cupula
BPPV
(macule)
(otoconia or otolith)
BPPV