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B.P.P.V. & Vestibular neuronitis Dr. Vishal Sharma.

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Presentation on theme: "B.P.P.V. & Vestibular neuronitis Dr. Vishal Sharma."— Presentation transcript:

1 B.P.P.V. & Vestibular neuronitis Dr. Vishal Sharma

2 Benign Paroxysmal Positional Vertigo

3 Introduction Most common cause of vertigo arising from peripheral labyrinthine dysfunction 20% of vertigo cases in all age groups 50% of vertigo cases in elderly pt Average age of onset: 50-60 years Male : female = 2:1

4 Etiology Idiopathic (50% of all cases) Head injury (pt < 50 yrs) Vestibular degeneration (pt > 50 yrs) Viral labyrinthitis Otitis media Meniere’s disease Following ear surgery Prolonged bed rest



7 Pathogenesis Otoconial debris (calcium carbonate) released from degenerating macula of adjacent utricle  floats freely in endolymph  settles on cupula of posterior semicircular canal in a critical head position  causes displacement of cupula & vertigo

8 Types of BPPV Posterior semicircular canal BPPV: 80 - 85 % Lateral semicircular canal BPPV: 15 - 17 % Superior semicircular canal BPPV: < 5 % Lateral & superior semicircular canal BPPV mostly caused by faulty treatment maneuvers of posterior semicircular canal BPPV

9 Symptoms 95% cases have unilateral BPPV Vertigo in a certain head position Inability to roll in bed or to look up high Nausea & vomiting in severe conditions There is no hearing loss Absence of other neurologic symptoms

10 Nystagmus in B.P.P.V.  Duration: < 1 minute due to adaptation  Asthenia (fatiguing): on repeating maneuver  Latent period: of 2–20 sec before nystagmus  Direction: fixed, rotatory, geotropic & reverses on return to sitting position  Associated symptoms: vertigo, vomiting, excessive sweating

11 Management of B.P.P.V. Diagnosis: Dix-Hallpike positional maneuver Treatment: Epley’s canalith repositioning maneuver Semont’s liberatory maneuver Home exercises Surgical treatment

12 Diagnosis Dix-Hallpike test is diagnostic for posterior semicircular canal BPPV Dix-Hallpike test done with Frenzel’s glasses & video display gives better accuracy Electro-nystagmography does not record rotatory component of nystagmus Other investigations not required for diagnosis

13 Frenzel glasses

14 Dix – Hallpike maneuver (Nylen – Barany maneuver)

15 Step 1 (for Right ear) 3

16 Step 2

17 Step 3

18 Step 4

19 Steps 1 to 3

20 Step 3 to 4

21 Dix-Hallpike Maneuver 1. Pt in sitting position on a couch looking ahead 2. Pt’s head turned 45° towards diseased ear 3. Pt moved rapidly into supine position with head hanging 30° below couch. Pt’s eyes observed for nystagmus for 1 minute 4. Pt moved rapidly back into sitting position 5. Maneuver repeated for opposite ear

22 Epley’s particle repositioning maneuver for right ear

23 Step 1 3

24 Step 2

25 Step 3

26 Step 4

27 Step 5

28 Step 6

29 Step 5 to 6

30 Step 7


32 Epley’s Maneuver for Rt ear 1. Pt in sitting position on a couch looking ahead 2. Pt’s head turned 45° towards diseased ear 3. Pt moved rapidly into supine position with head hanging 30° below couch 4. Pt’s head rotated by 90° to opposite side 5. Further 90° head + trunk rotation

33 Epley’s Maneuver for Rt ear 6. Pt moved rapidly back into sitting position & pt’s head brought in midline 7. Slight flexion of pt’s head Cervical collar given to pt for 48 hours Pt must have nystagmus at every step of Epley’s manoeuvre if it is done properly 80% pt get cured by a single maneuver

34 Advice after maneuver  Wait for 30 minutes before going home  Do not drive yourself home

35 Home advice  Avoid violent head jerks & head positions that trigger positional vertigo for at least 1 week  Sleep in 45 o head end elevation for 48 hr.  1 week after tx, carefully put yourself in position that usually makes you dizzy. Let your doctor know how you felt.

36 If Epley’s maneuver fails Repeat Epley’s maneuver after 1 month Try Semont’s maneuver Advice home exercises If all maneuvers & exercises fail, diagnosis is clear & symptoms are intolerable: Surgical Therapy

37 Semont’s maneuver for Rt posterior canal BPPV

38 1. Sit upright with head turned 45° toward left 2. Drop quickly to right by 90 0. Debris moves towards apex of posterior SCC. Wait for 30 sec after nystagmus stops. 3. Move head & trunk swiftly toward left by 180 0 Debris moves towards exit of posterior SCC. Wait again for 30 sec after nystagmus stops. 4. Sit upright again. Debris falls into utricle. 5. Performed 3 times a day for 2 weeks

39 Home Exercises 1. Brandt-Daroff Exercise 2. Home Epley’s Maneuver Indications: Diagnosis is clear & patient well-trained Absence of other causes of vertigo Pt must report immediately if neurological symptoms appear during exercise due to vertebral artery compression

40 Home Epley’s maneuver

41 Brandt-Daroff Exercise

42 1. Sit upright. 2. Drop quickly to right by 90 0, with head angled upward by 45 0. Stay for 30 seconds. 3. Sit upright again. Stay for 30 seconds. 4. Drop quickly to left by 90 0, with head angled upward by 45 0. Stay for 30 seconds. 5. Sit upright again. Perform 5 sets, thrice / day for 2 weeks.

43 Surgical treatment Considered when Epley maneuver, Semont maneuver + Brandt-Daroff exercises have failed and diagnosis of BPPV is clear 1. Posterior semicircular canal plugging (Parnes) 2. Singular neurectomy (Gacek)

44 Posterior SCC plugging

45 Gacek’s singular neurectomy

46 Atypical BPPV Lateral Canal BPPV: debris in lateral SCC Superior Canal BPPV: debris in superior SCC Cupulo-lithiasis: Debris stuck to canal side of semicircular canal cupula Vestibulo-lithiasis: Loose debris present on vestibule-side of semicircular canal cupula Multi-canal BPPV: debris in multiple SCC

47 Etiology of atypical BPPV

48 Nystagmus (fast component)

49 Semicircular canal stimulated Nystagmus Direction Right LateralRight horizontal Left LateralLeft horizontal Right SuperiorDown beating, counter-clockwise Left SuperiorDown beating, clockwise Right PosteriorUp beating, counter-clockwise Left PosteriorUp beating, clockwise

50 Diagnosis: Lateral canal BPPV: Roll test  horizontal nystagmus towards lower ear Superior canal BPPV: Dix Hallpike test  torsional ageotropic nystagmus Treatment: Lateral canal BPPV: 360 0 contralateral Roll test, canal plugging in failure cases Superior canal BPPV: Epley’s maneuver of opposite side, canal plugging

51 Posterior SCC BPPV Superior SCC BPPV Up-beating, torsional nystagmus Down-beating, torsional nystagmus Geotropic (superior pole moves towards lower ear) during Dix-Hallpike maneuver Ageotropic (superior pole moves towards upper ear) during Dix- Hallpike maneuver *** *** during Dix Hallpike maneuver, opposite (upper) superior SCC gets stimulated & its clock wise movement becomes ageotropic nystagmus

52 Roll Test for lateral canal BPPV

53 1 2 3 4 5

54 Roll test for lateral canal BPPV 1. Patient lies supine with nose pointing up 2. Head turned 90 0 right rapidly & kept for 30 sec 3. Head turned back to supine position for 30 sec 4. Head turned 90 0 left rapidly & kept for 30 sec 5. Head turned back to supine position for 30 sec Watch for nystagmus after each step

55 360 0 contra-lateral Roll over maneuver for left lateral canal BPPV

56 1 2 3 4 5

57 1. Patient lies supine with nose pointing up 2. Head turned 90 0 into Rt lateral decubitus 3. Head turned further 90 0 into prone position 4. Head turned further 90 0 into Lt lateral decubitus 5. Head turned further 90 0 into supine position Each position kept for 30 sec & watch for nystagmus

58 Vestibular neuronitis

59 Clinical presentation Occurs most commonly in middle-aged adults Acute, sustained peripheral vestibular dysfunction with nausea, vomiting, severe vertigo & imbalance Preceded by upper respiratory tract infection After 24 hours of onset, vertigo intensity decreases progressively & most patients recover from severe vertigo & imbalance within 1-3 weeks

60 Third most common cause of peripheral vertigo after BPPV & Meniere’s disease Etiology: Viral infection of vestibular nerve Acute localized ischemia of vestibular nerve Auto-immune injury of vestibular nerve Recurrence of symptoms due to dormant Herpes virus in Scarpa’s vestibular ganglion

61 Presence ofAbsence of Spontaneous, unidirectional, horizontal, nystagmus beating towards healthy ear, suppressed by optic fixation Direction changing nystagmus Hearing loss Other cranial nerve deficits Brain-stem & Cerebellar signs Rhomberg test: fall towards diseased side Middle ear infection High fever Caloric test: I/L canal paresisNeck rigidity

62 Treatment of Acute attack  Reassurance  Bed rest + head support  Inj. Prochlorperazine (Stemetil): 12.5 mg I.V., T.I.D. – Q.I.D.  Inj. Promethazine (Phenergan): 25 mg I.V., T.I.D. – Q.I.D.  Inj. Diazepam (Calmpose): 5 mg I.V. stat

63 Subsequent Treatment Oral Cinnarizine: 25 mg TID to 75 mg BD for 7 days Oral Betahistine: 16 mg TID for 2 - 4 weeks 3-week course of methyl prednisolone tapered from 100 mg down to 10 mg daily may reduce long- term loss of vestibular function Anti-viral drugs have no benefit

64 Thank You

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