BENIGN PAROXYSMAL

POSITIONAL VERTIGO

FISIOLOGI KESEIMBANGAN
Korteks Lobus Temporalis ( Persepsi )
Batang Otak / Cerebellum( Koordinasi)

R. Mekanik
Vestibular
(labirin)

R cahaya
Visual
(retina)

R.Proprioseptif
Somatosensori
(Muskuloskeletal)

Perubahan posisi kepala

Perpindahan c endolimph di labirin

Permeabilitas membran berubah, influx Ca
Depolarisasi, lepasnya NT eeksitatorik S
Aferen
Pusat pusat alat keseimbangan tubuh di otak

Basic Anatomy

BPPV
Barany 1921
Dix-Hallpike 1952 important
features of nystagmus
Abnormal sensation of motion
elicited by certain critical positions
Provocative position nystagmus
At least 20% of vertigo
Underestimated

BPPV
Subclassification : scc
post/lat/ant/bilat
Pathophysiology :

Canalithiasis
cupulolithiasis

Pathophysiology

Pathophysiology (cont.)

Cupulolithiasis :
Harold Schuknecht 1962
Densities (otocania) adherent to
cupula of crista ampullaris
Basophilic particles -1969

Canalithiasis :
John Epley 1980
Densities free floating in canal portion
Parnes , McClure 1991 found
particles in post SCC

BPPV ...

Frequency : 10-64/100000
Sex : 64% women
Age : older population ( 51-57)
younger than 35 head trauma.
History :

sudden
days-weeks
occassionally months -years
episodes.

Physical :
neurological examination normal
except Dix-Hallpike
pathognomonic

BPPV

Nystagmus : characterization and

types
RT / LT , vertical / horizontal ,
changing
Tortional = Rotational clockwise /
counterclockwise
Geotropic- toward the earth
Ageotropic opposite

BPPV
Classic post SCC geotropic
rotatory nystagmus
Horizontal SCC purely horizontal
nystagmus
Non-fatiguing nystagmus
cupulolithiasis > canalithiasis

Classic BPPV

Involved the POST SCC

Geotropic NG with affected ear down
Rotatory , fast phase toward the
undermost ear
Latency few seconds
Duration limited < 20 seconds
Reversal upon return upright position
Response decline upon repetitive
provocation

Lat. SCC PPV

Most common atypical BPPV
3-9% of cases
Consequence of Epley maneuver
Horizontal purely nystagmus
Cupulolithiasis rather than
canalithiasis
Modified Epley / lampert maneuver

Lat. SCC PPV

Ant. SCC PPV

Rare 2%
Down-beating /torsional NG for the
opposite ear on Dix-Hallpike
maneuver

BPPV - Causes

Predisposing factors :

Inactivity
Acute alcoholism
Major surgery
CNS disease

Causes ( cont. )
Idiopathic 39%
Ear disease 29%

OM 9%
Vestibular neuritis 7%
Meniers dis 7%
Otosclerosis 4%
Sudden SNHL 2%

Trauma 21%

Causes ( cont. )
Trauma 21%
CNS diseases 11%
Acustic neuroma 2%
Cervical vertigo 2%

BPPV - D.D

Meniers disease
Inner ear concussion
Alcohol intoxication
Labyrinthitis
Vascular loop syndrome
Post. Fossa lesions : acustic neuroma ,
meningioma
Central origion : stroke , MS , cerebellar
degeneration
Vertibral artery insuffeciency
Cervical vertigo

BPPV - Treatment

Watchful waiting
Vestibular suppressant medications
Vestibular rehabilitation
Canalith repositioning
Surgery care

Labyrinthectomy
Post. Canal occlusion
Singula neurectomy
Transtympanic aminpglycoside application

Trials about BPPV

General
Labeled benign paroxysmal
positional vertigo is not always
benign
Evaluation of the effectiveness of
canalith reepositioning procedurs
CRP
Several studies

Trials

Blakely 1994 :
50% improvement in the control and
CRP group !! ( 2-3 months)

Lynn 1995 :
Randomized-controlled : 89%
negative DH in CRP group , 27% in
the control group

John Li (1995) :

Trials

John Li (1995) :
Comparison CRP / CRP + mastoid oscillation
and control
Modified Epley maneuver
Use of colar and head elevation after CRP
No spontaneous resolution within aweek
60% symptoms improvement in CRP group
92% symptoms improvement in CRP
+mastoid oscilation and 70% negative DH

Trials

R. steenerson 1996 :
Comparison of CRP and vestibular
habituation training
Tow approaches are effective in
symptomatic relief ( 3 months)
CRP faster relief and fewer treatments

Trials

K. Yimatae (2003)
Randomized-controoled
Modified Epley maneuver, no mastoid oscillator
and no instructions after the maneuver
Subjective and objective weekly follow-up
CRP group 76% negative DH, 48% control
group
CRP group 96% symptoms improvement ,
90% control group
Non-cured patients need > 6 procedures in 2
weeks , should considering liberatory maneuver

Elderly population and

BPPV

S. Angeli 2003 :
Effectiveness of CRP and VR
Modified Epley :

Elderly comorbidities : degenerative osteoarthritis

disease , CVA , peripheral neuropathy, cognitive and
autonomic dysfunctions
S/E of CRP neck torsion and extension result in
vertibrobasilar artery insufficiency, strain on the
spine column, dislodged carotid a. emboli
Avoid liberatory maneuver

64% CRP group negative DH after a month

Overall 77% with CRP and VR

CRP Meta-Analysis
B. Woodworth - 2004

CRP - First line of treatment

Non-invasive
Easy to perform in the office
No need to expensive instrumentations
Repeat maneuver if needed
Potential to provide rapid relief of
vertigo

Meta - Analysis
9 randomized-controlled trials
Symptoms resolution and elimination
of positive Dix-Hallpike test
CRP more effective than control ( x5 )
Untreated patients - symptoms
improvements with time but positive
DH
So Resolution of vertigo avoidance of
provocative positions

CRP Epley maneuver

CRP Semont maneuver

Mastoid oscillator

Brandt-Daroff Exsercise

Lampert maneuver- Lat.

SCC BPPV

Vestibular rehabilitaions

Complications of CRP
Failure 25% (12%-56)
Recurrence 13% in 6 months
Side effects

Nausea
Vomiting
Fainting
Sweating

Worse vertigo LAT SCC PPV

THANK YOU