BPPV AND PARTICLE REPOSITIONING MANEUVERS

DR.ANITA BHANDARICONSULTANT NEUROTOLOGIST

VERTIGO AND EAR CLINICJAIPUR

The ampulla contains the cupula – a gelatinous mass with the same density as the endolymph. Cupula forms an impermeable barrier across the lumen of the ampulla. Hence the particles in scc may only exit via the end with no ampulla.

SECONDARY CAUSES OF BPPVSECONDARY CAUSES OF BPPVHead injury

Prolonged bed rest

Vestibular neuritis

Meniere’s disease – hydropically induced damage to macula of utricle

Migraine

Ear surgery

BPPV by canal typeBPPV by canal typePosterior Horizontal Anterior

Estimated frequency

81-89% 8-17% 1-3%

Provocative maneuver

Dix Hallpike Supine Roll Test (Pagnini-McClure)

Dix Hallpike

Nystagmus Upbeat, torsional

Horizontal Direction Changing

Downbeat, torsional

POSTERIOR CANAL BPPVPOSTERIOR CANAL BPPVMost common– posterior canal is most gravity dependant in upright and supine position

Once debris enter the post. canal ,the cupula at the shorter most dependant arm trap the debris.

Debris can exit only through the longer arm through the crus commune [non-ampullary]

CAUSE OF LIMITED CAUSE OF LIMITED DURATIONDURATION

CAUSE OF FATIGUABILITYCAUSE OF FATIGUABILITY

DIX-HALLPIKE TESTDIX-HALLPIKE TEST

EPLEYEPLEY’S MANEUVER’S MANEUVER

EPLEYEPLEY’S MANEUVER’S MANEUVER

EPLEYEPLEY’S MANEUVER’S MANEUVER

SEMONTSEMONT’S MANEUVER’S MANEUVER

SEMONTSEMONT’S MANEUVRE’S MANEUVRE

SEMONTSEMONT’S MANEUVER’S MANEUVER

SEMONTSEMONT’S MANEUVER’S MANEUVER

Liberatory maneuver for pBPPV and cupulolithiasis

Used to overcome otoconia jam after Epley’s maneuver

BRANDT – DAROFF EXERCISESBRANDT – DAROFF EXERCISES

Used as a home program

Indications o Posterior canal cupulolithiasis o Persistant posterior canal canalithiasis

Mechanismo Dislodge debris attached to cupulao Habituation through central compensation

BRANDT – DAROFF EXERCISESBRANDT – DAROFF EXERCISES

BRANDT – DAROFF EXERCISESBRANDT – DAROFF EXERCISES

Things to remember

o The exercises may dislodge more otoconia from the utricle causing an increase in symptoms.

o May cause multiple canal involvement.

o Important to hold for 30 seconds in each position.

HORIZONTAL SCC BPPVHORIZONTAL SCC BPPV

Pagnini-McClure maneuvre

Geotropic nystagmus – debris are away from ampulla , side showing stronger nystagmus is the side involved

Apogeotropic nystagmus – indicates cupulolithiasis

LOWER INCIDENCE OF LOWER INCIDENCE OF HORIZONTAL CANAL BPPVHORIZONTAL CANAL BPPV

SEQUENCE OF EVENTS IN SEQUENCE OF EVENTS IN hBPPVhBPPV

McCLURE PAGNINI MANEUVER McCLURE PAGNINI MANEUVER SUPINE ROLL TESTSUPINE ROLL TEST

SUPINE ROLL TESTSUPINE ROLL TEST

LEMPERT MANEUVRELEMPERT MANEUVRE

LEMPERTLEMPERT’S BARBECUE ROLL’S BARBECUE ROLL

GUFONI MANEUVERGUFONI MANEUVER

VANUCCHI MANEUVERVANUCCHI MANEUVER

Forced prolonged positioning

Sleep in lateral position with healthy ear down for 12 hours.

CUPULOLITHIASISCUPULOLITHIASIS

Coined by Schuknetch

Rare , more common in horizontal canal

Caused by otoliths attached to cupula of scc

When cupula is horizontal no vertigo

When non-horizontal constant input persistant dizziness

Nystagmus : persistant non-fatiguable as long as patient is in the same position

SEQUENCE OF EVENTS IN SEQUENCE OF EVENTS IN CUPULOLITHASISCUPULOLITHASIS

ANTERIOR CANAL BPPVANTERIOR CANAL BPPV

Anterior canal BPPV is usually transitory and most often the result of “canal switch” that occurs in the course of treatment more common forms of BPPV

SUBJECTIVE BPPVSUBJECTIVE BPPV

No nystagmus is detected but patient feels dizzy on provocative tests

PRP beneficial

Reasonso Subtle nystagmus o Fatigued nystagmuso Inadequate neural signal to stimulate the VOR

CONTRAINDICATIONS OF CONTRAINDICATIONS OF PARTICLE REPOSITIONINGPARTICLE REPOSITIONINGCervical spine problems

Uncontrolled hypertension

Retinal detachment

OTHER CAUSES OF OTHER CAUSES OF POSITIONAL NYSTAGMUSPOSITIONAL NYSTAGMUS

Direction changing nystagmus – central

Down beating positional nystagmus – nodulus

Down beating nystagmus on Dix-Hallpike – anterior canal BPPV . Treated by Epley’s maneuvre

SURGERYSURGERY

Very limited role

o Posterior canal occlusion

o Singular neurectomy

THANKSTHANKS