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Positional Vertigo
B.P.P.V.
Dr. Abdulrahman Hagr MBBS FRCS(c)
Assistant Professor King Saud University
Otolaryngology Consultant
Otologist, Neurotologist & Skull Base Surgeon
King Abdulaziz Hospital
Benign paroxysmal
positional vertigo
History
Pathology
Management
History
P/E
Treatment
Latency
directional characteristics
brief duration
Reversibility
fatigability .
BPPV
Schuknecht 1969 (Cupulolithiasis )
loose otoconia from the utricle
PSCC
McClure
1979 Canalithiasis mechanism
Benign paroxysmal
positional vertigo
History
Pathology
Management
History
P/E
Treatment
Incidence
Etiology
Primary or idiopathic (50%70%)
Secondary (30%50%)
Viral labyrinthitis (15%)
Head trauma
(10%)
Mnires disease (5%)
Migraines
(< 5%)
Inner ear surgery (< 1%)
BPPV: Pathophysiology
Degenerative debris from
utricle (otoconia)
Canalithiasis Theory
floating freely in the endolymph
Cupulolithiasis Theory
Adhering to the cupula
PSCC?
PSCC
Hangs down like the
water trap in a drain
pipe
Allowing the crystals to
settle in the bottom of
the canal.
Benign paroxysmal
positional vertigo
History
Pathology
Management
History
P/E
Treatment
History
Sudden
Seconds
Severe vertigo
Bouts of vertigo remissions
Chronic balance problems
Worse in the morning
History
Associated with change in head position.
rolling over or getting into bed
assuming a supine position.
arising from a bending position
looking up to take an object off a shelf
tilting the head back to shave
turning rapidly.
Benign paroxysmal
positional vertigo
History
Pathology
Management
History
P/E
Treatment
Dix-Hallpike Maneuver
Hagr 6 D
1.
2.
3.
4.
5.
6.
Benign paroxysmal
positional vertigo
History
Pathology
Management
History
P/E
Diagnosis
Treatment
Test Results
ENG limitation
D/D
Postural hypotension
anti-hypertensive drugs
CV problems
Drugs
Cupula sensitive to gravity
PAN-1
PAN-2
Heavy water
Fistula
D/D
History is virtually pathognomonic
Only type of vertigo
Benign paroxysmal
positional vertigo
History
Pathology
History
P/E
Treatment
Treatment
Patient education
Medical
Exercise
Surgical
Patient education
Medical
Relieve of nausea
Promethazine
Prochlorperazine
Epley Maneuver
Epley Maneuver
Reclined head hanging 45 degree turn
Epley Maneuver
Rotate 45 degrees contralateral
Epley Maneuver
Head and body rotated to 135 degrees
from supine
Epley Maneuver
Keep head turn and to sitting
Turn forward chin down 20 degrees
Video
Brandt-Daroff Exercises
?Surgical
Section of singular nerve
Canal occlusion
Vestibular nerve section
17% of cases
Supine head lateral provocative
Cupulolithiasis > canalithiasis
From reposition of PSCC for BPPV
Thank
You
BPPV Results
Bedside Evaluation
Static Vestibular Balance Nystagmus:
Check direction
Check for torsional component
Check for gaze suppression
BPPV
Cawthorne 1954
1st exercises for vestibular disorder
Semont
Liberatory maneuver
1st rapid single treatment
83.96% one maneuver 92.68% two
4.22% recurrence
Others less success, too violent
Dix-Hallpike Maneuver