Specialized dizzy clinic - most frequent diagnoses Canalolithiasis Unclear vertigo/dizziness multisensory vertigo/dizziness Benign paroxysmal positional vertigo (BPPV) hands on unilateral vestibulopathy bilateral vestibulopathy central vestibulopathy vestibular migraine > 65 years < 65 years PD Dr. med. Alexander A. Tarnutzer Department of Neurology University Hospital Zurich EAN Spring School 2018 Staré Splavy, Czech Republic Internal-medicine related dizziness psychophysiologic dizziness Ocular vertigo/dizziness 0 5 10 15 20 25 30 35 40 45 50 % Labyrinth Canalolithiasis Semicircular s Cochlea Otolith organs Micro CT Bradshaw et al. 2009 Floating calcium cristals Canalolithiasis Cupulolithiasis 1 2 3 1 2 3 1
Canalolithiasis Benigner paroxysmaler Lagerungsschwindel: Häufigkeit 50% idiopathic 17% post-traumatic 15% after vestibular neuritis Hall, Ruby & Mc Clure 1979 Baloh et al. 1987 Pathomechanism posterior lateral geotropic lateral apogeotropic Provocation maneuver Hallpike-Dix Supine roll Supine roll Direct detachement after neuronal damage Provocation maneuver Posterior / anterior s Provocation maneuver posterior anterior SCC posterior anterior SCC Hallpike-Dix Hallpike-Dix Modified after PD Dr. A. Palla Furman & Cass NEJM 1999 Modified after PD Dr. A. Palla Furman & Cass NEJM 1999 2
Posterior olithiasis Demonstration Hallpike-Dix maneuver With permission from D. Nuti, Siena Posterior olithiasis Provocation maneuver Lateral s lateral SCC Supine roll geotropic or apogeotropic horizontal nystagmus (± torsional component) Fife Semin Neurol 2009 Modified after PD Dr. A. Palla Lateral olithiasis Lateral olithiasis Apogeotropic variant: Otoconia in the short arm apogeotropic nystagmus Geotropic variant: Otoconia in the long arm geotropic nystagmus Asprella 2005 Modified after PD Dr. A. Palla 3
Lateral olithiasis Reversial of beating direction! Demonstration supine roll maneuver (=barbacue maneuver) Modified after PD Dr. A. Palla Lateral olithiasis geotropic variant Lateral olithiasis apogeotropic variant Courtesy of D. Straumann Courtesy of D. Nuti, Siena Lateral olithiasis determining the affected side Suggested sequence of provocation maneuver GEOtropic variant The affected side is the side with the stronger nystagmus APOgeotropic variant The affected side is the side with the weaker nystagmus 1. Hallpike-Dix both sides 2. Supine roll boht sides with repetitions 3. Hallpike-Dix both sides. Attention! Wait long enough! 4
Repositioning maneuvers Posterior : Epley maneuver Posterior Lateral semiciruclar geotropic Lateral apogeotropic Provocation maneuver Hallpike-Dix Supine roll Supine roll Liberation maneuver Epley Gufoni head-down Gufoni head-up Furman 1999 Epley maneuver Epley maneuver Furman 1999 Furman 1999 Epley maneuver Epley maneuver Furman 1999 5
Posterior 6
Demonstration Epley maneuver Back somersault Repositioning maneuvers Posterior Lateral semiciruclar geotropic Lateral apogeotropic Provocation maneuver Hallpike-Dix Supine roll Supine roll Liberation maneuver Epley Gufoni head-down Gufoni head-up To the side with LESS NYSTAGMUS Gufoni maneuver head-down Gufoni maneuver head-down 1 2 30 s 3 45 2 minutes Gufoni-Mastrosimone 1999 7
Horizontal sitting sitting lying on left side Gufoni head-down on left side, face down Courtesy of D. Straumann 8
Gufoni maneuver head-up Gufoni maneuver head-up 1 2 30 s 3 45 2 minutes Appiani et al. 2005 Gufoni head-up Demonstration Gufoni maneuver (nose up and nose down) Courtesy of D. Straumann Reposition maneuver: which side? Epley: Start on the side with positive Hallpike-Dix Gufoni: towards the side with less nystagmus (geotropic: headdown; apogeotropic: head-up) No liberation maneuver to the other side on the same day (risk of re-repositioning!) For bilateral olithiasis: liberation maneuvers on distinct days Comments on the olith liberation maneuvers (1) Mobilization of the oliths by tapping or vibrating the mastoid. Immediately after the liberation maneuver, many patients report a pull towards the side of the affected labybyrinth (otoconia falling onto the utriculus?). Treatment success evaluation: repeat the provocation maneuver and if needed repeat the libaration maneuver. Mild imbalance of stance and gait for a few days is normal after a successful liberation maneuver. 9
Comments on the olith liberation maneuvers (2) Liberation maneuvers on specialized turntable (Rotundum ) Repeat provocation maneuver à confirmation of successful treatment for both the patient and the treating physician. After repositioning, patients should avoid vibrations (jogging, jumping) and head hanging positions (dentist!) for three days. Have patients call five days after repositioning maneuver to report treatment success/failure. Decide whether repetition of repositioning maneuver is required. Success rate of liberation maneuvers: about 80-90% www.rotundum.ch Type 2 BPPV (subjective) Sitting up typical BPPV complaints No pathologic nystagmus during Hallpike-Dix or Barbacue maneuver Short attacks of vertigo when sitting up from head hanging position (Hallpike-Dix) from right Hallpike from left Hallpike Proposed mechanism for type 2 BPPV treatment 20 x / d 5 s 5 s Every day for 2 weeks 10
The Foster maneuver BPPV right posterior www.halfsomersaultmaneuver.com unsuccessful liberation maneuver In case of treatment failure or atypical nystagmus à exclude central causes à MRI periventricular (4th ventricle) lesions (MS-plaque, neoplasms) (small) cerebellar lesions (ischemic, hemorrhagic) Additional cases Cupulolithiasis right posterior Lateral à cupulolithiasis, apogetropic variant 11
Canalolithiasis left anterior (during Hallpike-Dix maneuver with the head turned right) 12