bppv hands on ean 2018 v1
Transcript of bppv hands on ean 2018 v1
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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)