BENIGN PROXYSMAL POSITIONAL VERTIGO

Group Member: Nurul Huda Norkasani Priscilla Tang Shu FernNorwahidah Ahmad

Azri

INTRODUCTION

• BPPV is a common cause of dizziness– BPPV is the most common cause of dizziness in the

elderly– Approximately 50% of people over the age of 65 will

experience BPPV– Frequently seen in elderly– More frequent in females than males

• Characterized by short episodes of dizziness associated with changes in head position

DEFINITION

• Benign--not malignant or life threatening• Paroxysmal--response (nystagmus) builds,

peaks, fatigues• Positioning--response provoked by change in

head or body position• Vertigo--sensation of movement, usually

described as spinning or turning

ANATOMY OVERVIEW

Pathophysiology of BPPV

• Transient episodes of vertigo (<1 minute)• Initiated by position change• Characterized by periods of exacerbation and

remission• Usually unilateral• Little benefit from medication

BPPV Characteristics

• Lying down or getting up– getting in and out of bed

• Rolling over in bed• Bending over

– picking something up• Looking up

– Shaving– Washing hair in shower

• Going to dentist or beauty salon

Mechanism underlying of BPPV

Dislodged otoconia from the utricle settle in a semicircular canal causing overexcitability with angular head movements

How do the otoconia become dislodged?

Etiology

• Primary or idiopathic BPPV• Head trauma• Vestibular neuritis• Viral labyrinthitis• History of inner ear pathology• History of otologic surgery• Migraines

Mechanism underlying of BPPV

Canalithiasis vs. CupulolithiasisCopyright ©2003 CMA Media Inc. or its licensors

Parnes, L. S. et al. CMAJ 2003;169:681-693

Fig. 4: Left inner ear

Mechanism Underlying of BPPV

Cupulolithiasis- -otoconia in the utricle break loose and adhere to the cupula of the posterior semicircular canal

Canalithiasis--otoconia are free floating in the posterior semicircular canal; when the head moves into a provoking position, the otoconia sink into the most dependent position in the canal, causing endolymph to move

SYMPTOMS

• In the elderly population, BPPV and dizziness are associated with falls, and falls represent a significant risk of serious injury and death.

(Oghalai et al., 2000)

• Most prominent clinical feature of BPPV is positional vertigo.

• In addition to vertigo, symptoms include dizziness, difficulty concentrating, nausea, imbalance.

• Many patients report prolonged mild imbalance that some persisted for a few weeks after resolution of positional vertigo.

(Serafini et al. 1996; Di Girolamo et al. 1998)

• Besides that, nystagmus, or also known as abnormal eye movement, is considered the hallmark sign of BPPV.

• Since certain head positions exacerbate symptoms, patients may self limit their activities, thus affecting social, psychological, and physical aspects of daily living.

(Sakaida et al., 2003)

• BPPV may be experienced for a very short duration or it may last a lifetime.

• Each single BPPV attack lasts a few seconds.• But after a series of attacks, patients may

complain of prolonged dizzyness and imbalance lasting from hours to days.

• The symptoms occurs in an intermittent pattern that varies by duration, frequency, and intensity.

(Furman & Cass, 1999)

Hallpike Test

• Diagnosis of BPPV is commonly made on the basis of typical signs such as nystagmus and symptoms including vertigo and nausea provoked by the Hallpike test.

(Parnes et al. 2003; Hilton & Pinder 2004)

The patient is placed in a sitting position with the head turned 45° towards the affected side and then reclined

past the supine position

Management

• Has few ways of treatment:

1.Canalith repositioning procedure / Epley maneuver

2.Semont maneuver3.Brandt-Daroffs exercise4.Drugs medication5.Surgery6.Others - DizzyFIX

1. Canalith Repositioning Procedure / Epley maneuver

• was induced by Epley in 1992.• based on the theory of canalolithiasis (J.M. Epley 1992)

• Function: - enabled the otolithic debris to move under the influence

of gravity from the posterior semicircular canal into the utricle (J.M. Epley 1992; Mayo Clinic 2012)

• Evidence based (Stavros G. Korres et al. 2007) : - Immediately success in 165 patients from 204 patients.- 23 more patients proved successful after its repetition in a

second session. - Total success rate was 92.1%

• Procedures:

Figure 1: The Epley CRP when the posterior semicircular canal of the left ear is affected.

• TAKE NOTE:

- After carry out this procedure, patient is advised not to bend over, lie back, or tilt the head during the next 48 hours.

- Patient is asked to sleep in a slightly elevated position.

- Avoid turning during sleep toward the affected ear side.

- These can be done assisted by someone professionals who has experiences to do so.

Particle Repositioning Maneuver (PRM)

• The modified version of CRP.• Aim still the same just the procedure has little changes.

(L. S. Parnes et al. 1993; 1997)

“enabled the otolithic debris to move under the influence of gravity from the posterior semicircular canal into the utricle”

(J.M. Eplet 1992; Mayo Clinic 2012)

• Take less than 5 minutes to complete.

• TAKE NOTE:- Patients are then typically asked to remain upright for the

next 24–48 hours in order to allow the otoliths to settle .:. to prevent a recurrence of the BPPV.

• Procedures:

Figure 2: Positional repositioning maneuver with right ear affected

2. Semont maneuver

According to A. Semont et al. 1988,• A maneuver which only be apply if patient showed failure

towards CRP/PRM treatment.• Based on the capulolithiasis theory. • It is the rapid changes if head position freed deposits that

were attached to the cupula.

• Aim/Objectives : still SAME

• Evidence based:- 711 patients as the subjects.- 84% response rate after 1 treatment.- 93% response rate after second treatment.

• Procedures:

Figure 3: Semont Maneuver for right ear affected.

• S. J. Herdman et al (1993); Cohen and Jerabek (1999)

- No difference in efficacy shown between the Semont (liberatory) manoeuvre and PRM.

• Parnes et al. (2003) - state the opinion that “the liberatory manoeuvre is

effective but complicated in elderly and obese patients.

- shows no increased efficacy compared with the simple particle repositioning manoeuvre (PRM).

3. Brandt-Daroffs exercise

According to Brand Th, Daroff RB (1980) in Physical therapy for benign paroxysmal positional vertigo.

• based on the theory of cupulolithiasis.• proposed the first effective therapy for BPPV that

consisted of a set of physiotherapeutic exercises. • Need to be repeat many times a day for two to three

weeks.

• Presribed by the clinician as home treatment and a habituation exercise.

• Designed to allow the patient to become accustomed to the position which causes the vertigo symptoms.

• The Brandt-Daroff exercises are performed in a similar procedures to the Semont maneuver.

• Procedures difference between Brandt-Daroffs exercise and Semont maneuver is when the patient rolls onto the unaffected side, the head is rotated toward the affected side (D. L. Vesely et al. 1996).

According to Theraputic Guidelines (2011),• Symptoms of giddiness will be shown. But, the symptoms

should resolve over a period of several days in most cases. • Initial stage of therapy:

- Certain medications may be taken to control any nausea.- Prolonged use should be avoided.

Figure 4: Brandt-Daroffs exercise

(Theraputic Guidelines 2011)

4. Drugs medication

• Mayo Clinic (2012):- Drug medication will be given if the patient

is considered to have acute or severe exacerbation of BPPV.

- But, mostly not indicated. - Drugs that may be involve are:

anti-histamine (meclizine) anti-cholinergic (scopolamine).

• This medication is used to treat vertigo/dizziness syndromes.

5. Surgery

• Only be suggest if the vestibular rehabilition does not work anymore to the patient.

• Choices of surgical treatment that can be done are:

a) Singular neurectomy (Gacek 1978, 1982, 1995; D. A. Schessel et al. 1998)

- It is a section of the posterior ampullary nerve- Sends impulses exclusively from the posterior semicircular

canal to the balance part of the brain.- Was popularized by Gacek in the 1970s. - At first the initial reports show high efficacy but there was a

significant risk of sensorineural hearing - Procedure has been found to be technically demanding.- Largely been replaced by the simpler posterior semicircular

canal occlusion.

b) Posterior semicircular canal occlusion. - Obstruction of the semicircular canal lumen will prevent

endolymph flow.

- Thus, it effectively:fixes the cupula renders it unresponsive to normal angular acceleration forces to stimulate free-floating particles within the endolymph or a fixed cupular deposit*

(L. S. Parnes and J. A. McClure 1990, 1991, 1996)

6. Others – DizzyFIX

• Home medical device.• Has the ability to perform the treatment of Epley maneuver. • Improves accuracy by comparison to instructions and expert

training alone.

• Evidence based:- 40 patients suffering from BPPV was given a DizzyFIX. - After one week of home treatment, 35 patients (88 percent) had

no evidence of nystagmus with Dix-Hallpike maneuvers.

(Bromwich et al. 2008, 2010)

• Few tips if a person experience dizziness associated with BPPV:

Be aware of the possibility of losing your balance, which can lead to falling and serious injury.

Sit down immediately when you feel dizzy. Use good lighting if you get up at night. Walk with a cane for stability if the patient is at risk of

falling.

(Mayo Clinic 2012)

References• Di Girolamo, S., Paludetti, G., Briglia, G., Cosenza, A., Santarelli, R. & Dinardo, W.

1998. Postural control in benign paroxysmal positional vertigo before and after recovery. Acta Otolaryngol 118:289–93.

• Furman, J.M. & Cass, S.P. 1999 Benign paroxysmal positional vertigo. N Engl J Med 341(21): 1590-6.

• Hilton, M. & Pinder, D. 2004. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev (2):CD003162

• Parnes, L.S., Agrawal, S.K. & Atlas, J. 2003. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). Canadian Medical Association Journal 169:681–93.

• Oghalai, J.S., Manolidis, S., Barth, J.L., Stewart, M.G. & Jenkins, H.A. 2000. Unrecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngol Head Neck Surgery Journal 122:630-4.

• Sakaida, M., Takeuchi, K., Ischinaga, M., Adachi, M. & Majima, Y. 2003. Long term outcome of benign paroxysmal positional vertigo . Journal of Neurology. 60:1532-1534.

• Serafini, G., Palmieri, A.M.R. & Simincelli, C. 1996. Benign paroxysmal positional vertigo of posterior semicircular canal: results in 160 cases treated with Semont’s maneuver. Ann Otol Rhinol Laryngol 105:770–5.

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