Benign Paroxysmal Positional Vertigo. Jeff Walter PT, DPT, NCS

Transcription

1 Benign Paroxysmal Positional Vertigo Jeff Walter PT, DPT, NCS

2 Benign Paroxysmal Positional Vertigo: (BPPV) Benign = not malignant Paroxysmal = recurrent, sudden intensification of symptoms Positional = placement (of ear) Vertigo = sensation of rotation BPPV is the most common peripheral vestibular disorder

3 BPPV (cont) Patients tend to report complaints with: bed mobility (rolling or supine to sit) reaching for object on floor, under cupboard or top shelf washing hair working under the car changing a light bulb dental chair diagnostic procedures involving head dependency (CT, MRI, surgery)

4 Data from 2005 at GHSRH (Walter, unpublished data) The prevalence of BPPV to appears increase with age Age Ranges Number of patients with BPPV: Total: 71 Percentages % % % % % % % %

5 BPPV (cont) Primary Complaints poor balance vertigo difficulty walking lightheadedness nausea sense of tilt blurred/jumping vision

6 BPPV: Mechanism #1 Cupulolithiasis (Schuknecht 1969): Otoconia adherent to the cupula of the affected semicircular canal. The canal becomes gravity sensitive which is not the normal function of the semicircular canals. Characteristics immediate onset of vertigo and nystagmus sx duration : long lasting, gradually decays over a period of minutes

7 BPPV Mechanism #2 Canalithiasis (Parnes and McClure 1992): Free floating otoconia within the semicircular canal resulting in abnormal endolymphatic flow with the affected canal. Characteristics latency: range: 1 to 40 seconds, typically 3 to 5 seconds nystagmus and vertigo following the latency (5 to 45 seconds) reversal of nystagmus temporarily fatigues with repetition

8 Mathematical model for BPPV (Squires et al 2004)

9 Clinical Implications of Mathematical Models for BPPV (rajguru 2004, squires 2004) Latency of BPPV is explained by movement of detached otoconia through the ampulla, as pressure caused by moving otoconia is negligible until otoconia enter the narrow duct of the semicircular canal. Typical otoconia move at a rate of 0.2 mm/s, or about 1% of the circumference of the canal each second. Particle-wall interaction accounts for the considerable variation in duration and latency of BPPV. Dispersion of a clump of otoconia creates more rather than less nystagmus. Thus, dispersion is not a viable explanation of fatigability. Cupulolithiasis is predicted to cause a far weaker nystagmus than canalithiasis. Inertial effects of treatment maneuvers cause negligible movement of otoconia.

10 Predisposing factors Head trauma / sudden acceleration or deceleration of the head (Gordon 2004) Inner ear disease Labyrinthitis Vestibular neuritis Ischemic event Meniere s (Karlberg 2000) Bilateral incomplete ototoxicity (Black 2005) s/p stapedectomy (Magliulo 2005) Genetic (Gizzi 1998) Osteopenia / Osteoporosis (Jeong 2009)

11 Osteoporosis and BPPV (Jeong 2009)

12 Predisposing factors Sleeping position / Prolonged immobility Cakir 2006 and Lopez- Escamez 2005 Affected ear in BPPV correlated with habitual ear dependency Von Brevern 2004 Right BPPV > left (1.4 to 1)

13 Courtesy of Tim Hain MD

14 Prevalence? Oghalai et al % with unrecognized BPPV in an inner-city geriatric population Patients with unrecognized BPPV were more likely to have: reduced activities of daily living scores sustained a fall in the previous 3 months depression Von Brevern et al 2006 Population-based study Utilized a validated neurotologic interview for detection of BPPV Lifetime prevalence: 2.4% F>M Duration days to > than months

15 Testing Maneuvers: BPPV Posterior Canal Barany = Dix-Hallpike = Hallpike Sidelying Test Robert Barany Horizontal Canal Roll Test Charles Hallpike

16 What not to do with testing:

17 Sidelying Test to identify Posterior Canal BPPV: position 2 = right, 4 = left

18 Sidelying vs. Dix-Hallpike Cohen HS. Side-lying as an alternative to the Dix- Hallpike test of the posterior canal. Otol Neurotol Mar;25(2): Tests appear to have comparable sensitivity for identification of BPPV 2. The sidelying test could be useful when range-of-motion limitations or environmental limitations preclude use of the Hallpike maneuver. 3. Consider the sidelying tests for pts with low back pain

19 Roll Test to Identify Horizontal Canal BPPV Performed to identify horizontal canal BPPV variant Head inclined 30 degrees from a horizontal plane Rotation performed ~60 degrees to each side, observe for nystagmus In patients with cervical ROM restriction consider rolling the patient from left to right with head fixed on the body

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21 Physiology Utriculofugal cupular displacement is excitatory for the anterior / posterior canal and inhibitory for the horizontal canal Utriculopetal cupular displacement is excitatory for the horizontal canal and inhibitory for the anterior / posterior canal

22 Canal Specific eye movements: slow phase component of VOR RPC = right posterior canal RHC = right horizontal canal RAC = right anterior canal LPC = left posterior canal LHC = left horizontal canal LAC = left anterior canal

23 Review BPPV algorithm

24 Alternative causes of positional dizziness / nystagmus Migrainous positional vertigo Orthostatic hypotension Tumor or CVA near cerebellar vermis Superior Canal Dehiscence Peripheral vestibular hypofunction Phobia Vestibular Paroxysmia

25 Evidence: Treatment = Maneuvers Level A: American Academy of Neurology (AAN) 2008 American Academy of Otolaryngology: Recommendation 2008 Cochrane Database (Hilton 2004) Systemic Review (Helminski 2010) Vestibular sedatives are counterproductive for BPPV (Manning 1992)

26 Canalith Repositioning Maneuvers

27 John Epley MD The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg Sep;107(3):

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29 Modified Epley Notes for Posterior Canal BPPV Nystagmus in positions A, B and C of prior slides should be consistent; this is a positive prognostic finding of successful treatment. (Oh H, et al. Neurology 2007) Performance of a chin tuck in position C may assist in migration of otoconia toward the utricle. An absence of imbalance or vertigo with returning to a seated position after the maneuver is likely a positive prognostic finding of successful treatment. A reversal (unwinding) of nystagmus with returning to a seated position after the maneuver may be a negative prognostic finding, treatment should be repeated. (Oh et al)

30 Semont Maneuver for Right Posterior Canal BPPV (Semont A. 1988) Originally developed for cupulolithiasis Speed from position #2 to #3 is critical (Faldon 2008) Nystagmus in position #3 should be consistent with position #2 (upbeating and right torsion in this example)

31 Modified Gufoni s Maneuver for the Geotropic Variant of Left Horizontal Canal BPPV, Canalithiasis type. (Appiani 2001) The patient sits on the side of a treatment table with the head straight ahead. The patient is steadily moved into a sidelying position on the unaffected side and remains in this position one minute after the end of the geotropic nystagmus. The head of the patient is steadily turned 45 downward, and this position is held for two minutes. The patient slowly returns to the sitting position

32 Gufoni s Maneuver: References Appiani CG Francesco R 2009 Riggio F 2009 Casani AP 2010

33 Brandt-Daroff Exercise for anterior/posterior canal BPPV clockwise from the top

34 Post-maneuver instructions Head upright 1-5 days, sleep in recliner?? Relocated otoconia may restabilize within minutes following a maneuver (Otsuka 2010)

35 Management guidelines Repeated examination may be required to confirm BPPV (Pollack 2009) Pre-medication with vestibular sedatives (notably Valium) may be helpful, especially for the patient with high anxiety. Anesthesia can be considered in cases involving patients with severe motion sensitivity. Do not leave patient during or immediately after repositioning maneuvers. Approximately 13% of patients may experience a strong falling sensation during treatment (Uneri 2005) Vibration to the mastoid is used by some clinicians, efficacy unclear. May aid in cases of canal jam?

36 Management Guidelines (cont) Patients may become ill during testing or treatment, warn them beforehand Avoid prolonged dependency of affected ear, especially if patient has a history of recurrent BPPV Brandt exercises may be initiated 1-3 days after treatment assess treatment effectiveness reduce patient anxiety

37 Management Guidelines (cont) Tilt table may be used for the patient with cervical limitations

38 Management Guidelines (cont) BPPV can occur bilaterally. Treat the most symptomatic side first. Do not mistake BPPV with central positional nystagmus Treat BPPV prior to initiating balance / VOR exercises

39 Management Guidelines (cont) Follow-up visit Discuss presence of symptoms since initial treatment session Review patient s symptom diary (response to Brandt exercises) Repeat Hallpike and Roll testing bilaterally Repeat canalith repositioning maneuvers if indicated

40 Management Guidelines (cont) Follow-up visit (cont) Managed not cured Recurrence rate: (Hain, Helminski et al. 2000) One year: 25% Two year: 44% Instruct in self diagnosis and treatment if indicated Use of daily Brandt exercises does not appear to reduce recurrence rate (Helminski 2005) Daily performance of maneuvers does not appear to reduce the recurrence rate (Helminski 2008)

41 Self Treatment (Radke: Neurology 2004)

42 Efficacy Canalith repositioning manuevers (CRM) 70-95% resolution Gans & Harrington- Gans 2002 Korres 2004 Macias 2000 Nunez 2000 Pollak 2002 Roberts 2006 Ruckenstein 2001 Simhadri 2003 Steenerson 2005 Von Brevern 2006 CRM typically provides rapid relief of symptoms Spontaneous remission of condition is common

43 Efficacy Von Brevern et al 2006 Evaluated the efficacy of Epley's maneuver for treatment of PC-BPPV 24 h after applying the maneuver. METHODS: Epley's maneuver was compared with a sham procedure in 66 patients with PC-BPPV by using a doubleblind randomized study design.

44 Efficacy RESULTS: 24 h after treatment, 28 of 35 (80%) patients in the Epley's maneuver group had neither vertigo or nystagmus on positional testing compared with 3 of 31 (10%) patients in the sham group (p<0.001).