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Benign paroxysmal positionalvertigo (BPPV) – hands on

PD Dr. med. Alexander A. TarnutzerDepartment of NeurologyUniversity Hospital Zurich

EAN Spring School 2018Staré Splavy, Czech Republic

Ocular vertigo/dizziness

psychophysiologic dizziness

Internal-medicine related dizziness

vestibular migraine

central vestibulopathy

bilateral vestibulopathy

unilateral vestibulopathy

multisensory vertigo/dizziness

Unclear vertigo/dizziness

Canalolithiasis

0 5 10 15 20 25 30 35 40 45 50

%

> 65 years< 65 years

Specialized dizzy clinic - most frequent diagnoses

Micro CTBradshaw et al. 2009

Cochlea

Semicircular canals

Labyrinth

Otolith organs

Floating calciumcristals

Canalolithiasis

1 2 3

Canalolithiasis Cupulolithiasis

1 2 3

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Canalolithiasis

Hall, Ruby & Mc Clure 1979

Benigner paroxysmaler Lagerungsschwindel: Häufigkeit

• 50% idiopathic• 17% post-traumatic• 15% after vestibular neuritis

Baloh et al. 1987

Pathomechanism

Direct detachement after neuronal damage

posteriorsemicircular

canal

lateral semicircular

canal

geotropic

Provocationmaneuver

Hallpike-Dix Supine roll Supine roll

lateral semicircular

canal

apogeotropic

Provocation maneuverPosterior / anterior semicircular canals

posterioranterior

SCC

Hallpike-Dix

Modified after PD Dr. A. Palla Furman & Cass NEJM 1999

posterioranterior

SCC

Hallpike-Dix

Furman & Cass NEJM 1999

Provocation maneuver

Modified after PD Dr. A. Palla

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Demonstration Hallpike-Dix maneuver

With permission from D. Nuti, Siena

Posterior canalolithiasis

Posterior canalolithiasis Provocation maneuverLateral semicircular canals

lateral

SCC

Supine roll

Fife Semin Neurol 2009

geotropic or apogeotropichorizontal nystagmus

(± torsional component)

Modified after PD Dr. A. Palla

Lateral canalolithiasis

Apogeotropic variant:Otoconia in the short arm

Geotropic variant:Otoconia in the long arm

Asprella 2005

apogeotropicnystagmus

geotropicnystagmus

Lateral canalolithiasis

Modified after PD Dr. A. Palla

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Lateral canal canalolithiasisReversial of beating direction !

Modified after PD Dr. A. Palla

Demonstration supine roll maneuver(=barbacue maneuver)

Lateral canalolithiasis –geotropic variant

Courtesy of D. Straumann

Lateral canalolithiasis –apogeotropic variant

Courtesy of D. Nuti, Siena

Lateral canalolithiasisdetermining the affected side

GEOtropic variant APOgeotropic variant

The affected side is the side with thestronger nystagmus

The affected side is the side with theweaker nystagmus

Suggested sequence of provocation maneuver

1. Hallpike-Dix both sides2. Supine roll boht sides with repetitions3. Hallpike-Dix both sides.

Attention!Wait long enough!

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Posteriorsemicircular

canal

Lateral semiciruclar

canal

geotropic

Provocationmaneuver

Liberation maneuver

Hallpike-Dix Supine roll

Gufoni head-down

Lateral semicircular

canal

apogeotropic

Supine roll

Epley Gufoni head-up

Repositioning maneuvers

Furman 1999

Posterior canal: Epley maneuver

Furman 1999

Epley maneuver

Furman 1999

Epley maneuver

Furman 1999

Epley maneuver

Epley maneuver

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Posterior semicircular canal

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Demonstration Epley maneuver

Back somersaultPosterior

semicircularcanal

Lateral semiciruclar

canal

geotropic

Provocationmaneuver

Liberation maneuver

Hallpike-Dix Supine roll

Gufoni head-down

Lateral semicircular

canal

apogeotropic

Supine roll

Epley Gufoni head-up

Repositioning maneuvers

To the side withLESS NYSTAGMUS

Gufoni maneuver head-down

1 2

45°

330 s

Gufoni maneuver head-down

Gufoni-Mastrosimone 1999

2 minutes

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sitting

Horizontal semicircular canal

sitting lying on left side

on left side, face down

Gufoni head-down

Courtesy of D. Straumann

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Gufoni maneuver head-up

1 2

45°

330 s

Gufoni maneuver head-up

Appiani et al. 2005

2 minutes

Gufoni head-up

Courtesy of D. Straumann

Demonstration Gufoni maneuver(nose up and nose down)

Reposition maneuver: which side?

• Epley: Start on the side with positive Hallpike-Dix• Gufoni: towards the side with less nystagmus (geotropic: head-

down; apogeotropic: head-up)• No liberation maneuver to the other side on the same day (risk of

re-repositioning!)• For bilateral canalolithiasis: liberation maneuvers on distinct days

Comments on thecanalolith liberation maneuvers (1)

• „Mobilization“ of the canaloliths by tapping or vibrating themastoid.

• Immediately after the liberation maneuver, many patientsreport a pull towards the side of the affected labybyrinth(otoconia falling onto the utriculus?).

• Treatment success evaluation: repeat the provocationmaneuver and if needed repeat the libaration maneuver.

• Mild imbalance of stance and gait for a few days is normal after a successful liberation maneuver.

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• Repeat provocation maneuver à confirmation of successful

treatment for both the patient and the treating physician.

• After repositioning, patients should avoid vibrations (jogging,

jumping) and head hanging positions (dentist!) for three days.

• Have patients call five days after repositioning maneuver to

report treatment success/failure.

• Decide whether repetition of repositioning maneuver is

required.

• Success rate of liberation maneuvers: about 80-90%

Comments on thecanalolith liberation maneuvers (2)

Liberation maneuvers on specializedturntable (Rotundum®)

www.rotundum.ch

“Type 2 BPPV” (subjective)

• typical BPPV complaints

• No pathologic nystagmus duringHallpike-Dix or Barbacuemaneuver

• Short attacks of vertigo whensitting up from head hangingposition (Hallpike-Dix)

Sitting up

from right Hallpike from left Hallpike

Proposed mechanism for type 2 BPPV treatment

5 s 5 s20 x / d

Every day for 2 weeks

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The Foster maneuver

www.halfsomersaultmaneuver.com

BPPV right posterior

„unsuccessful“ liberation maneuver

• In case of treatment failure or atypical nystagmus à exclude centralcauses à MRI– periventricular (4th ventricle) lesions (MS-plaque, neoplasms) – (small) cerebellar lesions (ischemic, hemorrhagic) Additional cases

Cupulolithiasis right posterior canal Lateral canal àà cupulolithiasis, apogetropicvariant

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Canalolithiasis left anterior canal (during Hallpike-Dix maneuver with the head turned right)