B.P.P.V. & Vestibular neuronitis

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

5. Pathogenesis POSTR S.C.C. UTRICLE MACULA CUPULA

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 45o 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 900. Debris moves towards apex of posterior SCC. Wait for 30 sec after nystagmus stops. 3. Move head & trunk swiftly toward left by 1800 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 900, with head angled upward by 450. Stay for 30 seconds. 3. Sit upright again. Stay for 30 seconds. 4. Drop quickly to left by 900, with head angled upward by 450. 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)

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:3600 contralateral Roll test, canal plugging in failure cases • Superior canal BPPV: Epley’s maneuver of opposite side, canal plugging