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BPPV
BPPV
The Ear
Canalolithiasis Theory
The most widely accepted theory of the pathophysiology of BPV Otoliths (calcium carbonate particles) are normally attached to a membrane inside the utricle and saccule The utricle is connected to the semicircular ducts These otoliths may become displaced from the utricle to enter the posterior semicircular duct since this is the most dependent of the 3 ducts Changing head position relative to gravity causes the free otoliths to gravitate longitudinally through the canal. The concurrent flow of endolymph stimulates the hair cells of the affected semicircular canal, causing vertigo.
Canalolithiasis Theory
Causes
Idiopathic Infection (viral neuronitis) Head trauma Degeneration of the peripheral end organ Surgical damage to the labyrinth
Symptoms
Starts suddenly first noticed in bed, when waking from sleep. Any turn of the head bring on dizziness. Patients often describe the occurrence of vertigo with
tilting of the head, looking up or down (top-shelf vertigo) rolling over in bed.
Diagnosis
Lab Studies:
No pathognomonic laboratory test for BPV exists. Laboratory tests may be ordered to rule out other pathology.
Imaging Studies:
Head CT scan or MRI.
Procedures:
The Dix-Hallpike test, along with the patient's history, aids in the diagnosis of BPV.
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Treatment
Medications The Canalith Repositioning Procedure (CRP) Surgery
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Medications
Antiemetic Antihistaminic Anticholinergic
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Clinical Trial
Ruckenstein (2001) Therapeutic efficacy of the Epley canalith repositioning maneuver. Laryngoscope Eighty-six patients 74% of cases that were treated with one or two canalith repositioning maneuvers had a resolution of vertigo as a direct result of the maneuver. A resolution attributable to the first intervention was obtained in 70% of cases within 48 hours of the maneuver. An additional 14% of cases that were treated had a resolution of vertigo. Only 4% of cases (three patients) manifested BPV that persisted after four treatments.
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Brandt-Daroff Exercises
method of treating BPPV, usually used when the office treatment fails. These exercises should be performed for two weeks, three times per day for three weeks, twice per day. In each time, one performs the maneuver as shown five times. 1 repetition = maneuver done to each side in turn (takes 2 minutes)
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Brandt-Daroff Exercises
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Clinical Trial
Radtke et al (1999) A modified Epley's procedure for self-treatment of benign paroxysmal positional vertigo. Neurology Compared the efficacy of a modified Epley's procedure (MEP) and Brandt-Daroff exercises (BDE) for self-treatment of (PC-BPPV) 54 patients. PC-BPPV resolved within 1 week in
18 of 28 patients (64%) using the MEP 6 of 26 patients (23%) performing BDE
The MEP is more suitable for self-treatment of PC-BPPV than conventional BDE
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Surgery
Singular neurectomy Vestibular Nerve Section Posterior Canal Plugging Procedure
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Singular neurectomy
Old procedure Section the nerve that transmits information from the posterior semicircular canal ampulla toward the brain. Can cause hearing loss in 7-17% of patients and fails in 8-12%.
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Clinical Trial
Gacek (1995) Technique and results of singular neurectomy for the management of benign paroxysmal positional vertigo. Acta Otolaryngol One hundred thirty-seven patients 1972-1994. (94%) experienced complete relief of vertigo following SN. (2%) experienced partial relief of positional vertigo following SN and (4%) failed to have any improvement of symptoms following SN. (3%) had a partial sensorineural following SN.
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Clinical Trial
Walsh (1999)Long-term results of posterior semicircular canal occlusion for intractable benign paroxysmal positional vertigo. Clin Otolaryngol 13 patients who All patients reported complete and immediate resolution of their positional vertigo, which has been maintained in the long term. All patients developed a transient mild conductive hearing loss secondary to a middle ear collection, which usually resolved within 4 weeks. Five patients developed a transient mild high frequency sensorineural hearing loss which resolved in all cases within 6 months. There were no reports of sensorineural hearing loss nor tinnitus in the long term.
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Clinical Trial
Thomsen et al, (2000) Vestibular neurectomy Auris Nasus Larynx 42 patients. The vertigo was controlled in 88% of the patients postoperative imbalance occurred in 14 patients
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Summary
BPPV
Common complain Vertigo when changing head position Diagnosed by Dix-hallpike Treated by CRP Surgery if CRP fails
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