Download BPPV & vestibular neuronitis

B.P.P.V. &
Vestibular
neuronitis
Dr. Vishal Sharma
Benign Paroxysmal
Positional Vertigo
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
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
Pathogenesis
POSTR
S.C.C.
CUPULA
UTRICLE
MACULA
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
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
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
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
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
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
Frenzel glasses
Dix – Hallpike
maneuver
(Nylen – Barany
maneuver)
Step 1 (for Right ear)
3
Step 2
Step 3
Step 4
Steps 1 to 3
Step 3 to 4
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
Epley’s particle
repositioning
maneuver
for right ear
Step 1
3
Step 2
Step 3
Step 4
Step 5
Step 6
Step 5 to 6
Step 7
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
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
Advice after maneuver
 Wait for 30 minutes before going home
 Do not drive yourself home
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.
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
Semont’s maneuver for Rt
posterior canal BPPV
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
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
Home Epley’s maneuver
Brandt-Daroff Exercise
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.
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)
Posterior SCC plugging
Gacek’s singular neurectomy
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
Etiology of atypical BPPV
Nystagmus (fast component)
Semicircular canal
stimulated
Nystagmus Direction
Right Lateral
Right horizontal
Left Lateral
Left horizontal
Right Superior
Down beating, counter-clockwise
Left Superior
Down beating, clockwise
Right Posterior
Up beating, counter-clockwise
Left Posterior
Up beating, clockwise
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
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 DixHallpike maneuver ***
*** during Dix Hallpike maneuver, opposite (upper)
superior SCC gets stimulated & its clock wise
movement becomes ageotropic nystagmus
Roll Test for
lateral canal BPPV
1
2
3
4
5
Roll test for lateral canal BPPV
1. Patient lies supine with nose pointing up
2. Head turned 900 right rapidly & kept for 30 sec
3. Head turned back to supine position for 30 sec
4. Head turned 900 left rapidly & kept for 30 sec
5. Head turned back to supine position for 30 sec
Watch for nystagmus after each step
0
360
contra-lateral
Roll over maneuver
for left lateral canal
BPPV
1
2
3
4
5
1. Patient lies supine with nose pointing up
2. Head turned 900 into Rt lateral decubitus
3. Head turned further 900 into prone position
4. Head turned further 900 into Lt lateral decubitus
5. Head turned further 900 into supine position
Each position kept for 30 sec & watch for nystagmus
Vestibular neuronitis
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
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
Presence of
Spontaneous, unidirectional,
Absence of
Direction changing nystagmus
horizontal, nystagmus beating
Hearing loss
towards healthy ear,
Other cranial nerve deficits
suppressed by optic fixation
Brain-stem & Cerebellar signs
Rhomberg test: fall towards
Middle ear infection
diseased side
High fever
Caloric test: I/L canal paresis
Neck rigidity
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
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
Thank You