Disclosures. Goals. Canalith Repositioning Basics to Advanced. John Li, M.D. We have no conflicts of interest to disclose.

Transcription

1 Canalith Repositioning Basics to Advanced John Li, M.D. Disclosures We have no conflicts of interest to disclose. Goals Beginner to Epert 2 hrs into 1 Definition, History, Physical, Diagnosis, Treatment Options Canalith Repositioning Advanced issues Complications, Other canals, Cupulolithiasis Advances Omniaial chairs, Infrared goggles 360 degree maneuver 1 1

2 Introduction PICTURE 2 BPPV most common single cause of vertigo Underestimated Misdiagnosed Concomitant pathology Evolving Different canals Posterior Horizontal Anterior Different mechanisms Canalithiasis Cupulolithiasis Definitions What is BPPV? Definition = Vertigo (a phantom sensation of motion) elicited by specific changes in head position. (movement provoked) Caused by placing the affected ear downward. (Classical BPPV) Associated with characteristic eye movements (classical nystagmus) 2 2

3 Dizziness Characteristics Triggered by movement. Thrown into a spin toppling towards the side of the affected ear. There is a lag period. The symptoms start very violently Dissipate within 20 or 30 seconds. This sensation reverses upon sitting erect again. Canalith Theory Presentation Onset is typically sudden. Thereafter, propensity for positional vertigo may etend for hours to weeks, occasionally to months or years Symptoms may periodically clear and then recur. Severity variable 3 3

4 Predisposing Etiologic Factors Trauma: Rarely seen before age 35 unless history of head trauma Inactivity: Acute alcoholism, major surgery, CNS disease, etc., Concomitant ear pathology: About 20% have perilymph fistula, secondary endolymphatic hydrops, history suggesting infarction Natural Course Variable 6 Weeks limited course Chronic condition Acute relapsing Laboratory Tests PICTURE Infrared Video Hallpike Best way to record rotational eye movements. Other tests are nonspecific 4 4

5 The Hallpike Maneuver PICTURE Standard clinical test for BPPV. Pathognomonic Epley modification: From behind patient; easier, to visualize the eyeball rotation. A negative test is meaningless Turn the head, drop back. Classical Nystagmus Parallels the symptoms. Predominantly rotatory nystagmus, fast phase toward undermost ear Latency (~5 sec) Limited duration (<20 sec) Reversal upon return to upright Response decline upon repetitive provocation Nystagmus Ais The ais of nystagmus is fied to SCC The OH NO hands to face trick 5 5

6 Why Turn 45 Degrees? Treatment Options Watch and Wait. Eercises and Vestibular therapy. Surgery. Labyrinthectomy Vestibular nerve section (VNS) Singular neurectomy (Gacek 1974): PSC occlusion: "The Canalith Repositioning Procedure". Prognosis Non lethal condition Variable recurrence rate (10% 50%) 6 6

7 The Procedure (Canalith Repositioning Made Quite Simple) Why Choose CRP? 95% 97% success. It works immediately, allowing return to productivity. (Why wait?) Painless, little to no side effects. Less epensive than surgery or Vestibular Rehabilitation. Position 1 Start. Sitting, head turned 45 degrees towards ipsilateral side. Position 1. Supine, degrees head hanging tilt, head turned 45 degrees towards ipsilateral side. 7 7

8 Position 2 3 Position 2. Supine, 45 degrees head hanging tilt, head turned 45 degrees towards contralateral side. Position 3 Lying on side with contralateral shoulder down, head turned 45 degrees below horizon towards contralateral side. Position 4 5 Position 4 Sitting, head turned at least 90 degrees towards contralateral side. Position 5 Straight ahead, head tilted forward. CRP video 8 8

9 Secrets Repeat Di Hallpike at end of treatment. if positive, repeat treatment 2 3. Prevent Failure: Correct positioning through Ape area. The Ape Area Failure vs. success Head must be tilted as far posteriorly (30 degrees head hanging) as possible before rotating from position 2 to

10 Not enough tilt 10 10

11 Correct Conclusions Simplified CRP is easy to learn and is scientifically sound. It is felt that CRP should be considered first line therapy for the treatment of BPPV. Advanced BPPV Cupulolithiasis vs. Canalithiasis of the Posterior and Horizontal Canals and other Advanced Issues 11 11

12 Pathophysiology: Canalithiasis v. Cupulolithiasis John Li, MD PA Canalith Theory (Hula Hoop) Cupulolithiasis 12 12

13 Weighted Switch Cupulolithiasis versus Canalithiasis Both eist. Similarities: particles are out of place, similar nystagmus for PSCC Dissimilarities: location of those particles Cupulolithiasis: Position induced, non fatiguing, little latency Canalithiasis: Movement induced, fatiguing, latency Treatment Oscillation / Agitation Turn Cupuloliths to Canaliths Consider Semont if oscillation doesn t work Same Maneuvers for PSC Canalithiasis 13 13

14 Other Canals: Horizontal canal involvement (HSC) Anterior canal involvement (ASC) Anterior (Superior) Canal Horizontal Canal More potent than regular BPPV Recent Head trauma Recent CRP usually the result of a conversion. Typically a referral case Ewald s 3 rd Law 14 14

15 Physical Horizontal Nystagmus instead of rotatory Mimics Bilateral BPPV Sometimes truly a hybrid of 2 canals on the same side. Right Canalithiasis Treatment Bar B Que Spit maneuver Log roll away from the affected side. PICTURE ROLL 15 15

16 Horizontal Cupulolithiasis More comple Non fatiguing Position dependant Opposite beating nystagmus Opposite nystagmus intensity Neutral points Movie (HSC Cupulolithiasis) Neutral Points 16 16

17 Right Cupulolithiasis Actual Footage See actual footage of nystagmus conversion at end of talk (in interest of time) Diagnostic Matri HSCC CANALITHIASIS CUPULOLITHIASIS Nyst Nyst Same direction as head turn Stronger side is affected side Opposite direction as head turn Weaker side is affected side 17 17

18 Treatment Matri CANALITHIASIS CUPULOLITHIASIS PSCC Standard CRP (for ipsi ear) Standard CRP (for ipsi ear) HSCC Log roll AWAY from Log roll AWAY from affected side affected side ASCC Theoretical Theoretical What Happens When All Else Fails? Go to Advanced Options Make sure to have the right DX Consider Multiaial device w/ IR system Helps diagnosis as well as treat. Which canal? Cupulolithiasis vs Canalithiasis? Vestibular Rehab Surgery Labyrinthectomy, Neurectomy, PSC occlusion SURGICAL OPTIONS Labyrinthectomy Singular Neurectomy Gacek 1974 Aminoglycoside perfusion Shea Laser Obliteration of the Posterior Canal Ampulla Anthony Canal Occlusion Parnes and McClure

19 Canal Occlusion Parnes and McClure 1990 Disrupts the flow of particles within the endolymph Low incidence of SNHL blue-lined, then opened perilymphatic space of Posterior canal Canal Occlusion endolymphatic particles fascia / muscle plug particles can no longer flow The 360 o Maneuver 19 19

20 The 360 o Maneuver For Treatment Of Benign Positional Vertigo American Neurotology Society Torok Award Lecture 2005 Published in AJO John C. Li, M.D. 360 Based on Canalithiasis John Li, MD PA Move the Particles 20 20

21 Move the Particles Move the Particles Move the Particles 21 21

22 Move the Particles Move the Particles Theory 22 22

23 Theory Theory Theory 23 23

24 Theory Theory Theory 24 24

25 Theory Theory Theory 25 25

26 Why Bother with 360? Does it work? Above and beyond standard RX? Difficult patients that otherwise can t be treated Standard Treatment failures Difficult to Treat Patients Patients unable to tolerate manipulation Back problems Strokes Paralysis Patients who prone to panic Secured in a chair / immobilized All positioning is done eternally No fleion, etension or torsion The patient does not have to move a muscle. MAX for Epley / Semont Failures Standard treatment failures Canal jam Cupulolithiasis Involvement of other canals Involvement of multiple canals Distinguishes Pathology 26 26

27 MAX allows Canal specific (targeted) Canal independent (isolated) Left posterior semicircular canal can be treated independently of the right posterior semicircular canal, independently of the horizontal semicircular canals. Easy transition between each of the maneuvers CONCLUSIONS The ultimate goal of repositioning is to move particles 360 (roughly). Standard CRP works in 95% of cases Canals other than the posterior semicircular canals can be affected. Cupulolithiasis does eist. It is more difficult to treat than canalithiases. Surgery is the choice of last resort. Actual Footage 27 27