Transcript BPPV - Michigan Audiology Coalition

BPPV
Benign Paroxysmal Positional Vertigo
By
Wendy Carender, PT, NCS
Advanced Vestibular Certified Physical Therapist
Disclosure Statement
•
I have no relevant financial or nonfinancial
relationships to disclose.
Team of Audiologists at UMHS
•
Audiologists in Vestibular Testing Center
– Assist in the Identification of BPPV:
• Dix-Hallpike and Positional Testing during VNG
– Assist in the Management of BPPV
• Perform particle repositioning maneuvers for simple cases
•
Patients are referred to Vestibular PT and/or
Otolaryngologist for additional treatment and
diagnosis.
BPPV ( Positional Vertigo)
•
Benign: not life threatening, however symptoms
may be intense
•
Paroxysmal : occurs suddenly
•
Positional: provoked by change in position of
the head
•
Vertigo: sense of rotation or spinning usually
lasting less than one minute
BPPV
•
Most common peripheral vestibular disorder
– 2.4% of all people will experience BPPV at some
point in their lifetime ( Fife TD, Inversion DJ, Lempert T.
Neurology 2008)
– Causes approximately 50 % of dizziness in older
adults ( Froehling DA, Silverstein MD, Mohr DN. Mayo Clinic Proc
1991)
• Increased risk of falling
•
Enormous Health Care Burden
– Estimated $2 billion per year
•
Easy to diagnosis and treat at the bedside
BPPV Causes
•
Primary cause in people over age 50 is idiopathic
•
Primary cause in people under age 50 is head
injury
•
Increase frequency of BPPV found in patients with
Migraine, Vestibular Neuritis and Meniere’s
Disease
•
BPPV occasionally occurs following other ear
surgery (stapedectomy) (AtacanE, Sennaroglu L,
Dene A. Laryngoscope 2001)
•
BPPV may develop after long periods of inactivity
BPPV History
• History most important part of Vestibular Exam
• First episode typically provoked by rolling over in
bed or getting out of bed
• 4 questions on Dizziness Handicap Inventory that
are helpful to screen for BPPV
- Looking up cause dizziness
- Getting in/out of bed
- Rolling over in bed
- Bending over
BPPV Anatomy
•
Vestibular organ: 3 semi-circular canals, utricle and
saccule.
•
Semi-circular canals: detect rotational movements and are
filled with endolymph
– Ampulla: One end of each semicircular canal is widened to
form an Ampulla
– Cupula: sensory receptor located within the Ampulla
•
2 otolith organs measure linear acceleration and detect head
tilt
– Utricle (horizontally aligned) contains otoconia
– Saccule (vertically aligned)
Anatomy of the Inner Ear
Source of figures: Furman JM, Cass SP. Vestibular Disorders: A Case Study Approach, 2nd ed., © 2003.
Picture of Otolithic Macula
Otoconia
•
Otoconia: calcium carbonate crystals that are
attached to the otolithic membrane in the utricle
•
BPPV occurs when otoconia detach from the
utricular membrane and migrate into the semicircular canals.
•
Head movement
endolymph flow
signal to brain
otoconia shift
cupular deflection
false
vertigo and nystagmus.
Direction of Endolymph Flow is Important
Ampullopetal flow = flow towards ampulla (to seek)
In the horizontal SCC, this is excitatory. In the vertical canals, this is inhibitory.
Ampullofugal flow = flow away from ampulla (to flee)
In the horizontal canal, this is inhibitory. In the vertical canals, it is excitatory.
Ewald’s Observations on
Semi Circular Canal Function
•
Eye movements occur in the plane of the SCC
being stimulated AND in the direction of the
endolymph flow
•
In the vertical canals, ampullofugal endolymph
flow canals causes a greater response (eye
movements) than ampulopetal flow
•
In the horizontal canals, ampullopetal
endolymph flow causes a greater response than
ampullofugal flow
Connections of SCCs with Extraocular Muscles
Figure source: Baloh RW, Honrubia V. Clinical neurophysiology of the vestibular system, 2nd edition. Philadelphia, PA: F.A. Davis Company; ©1990.
Patterns of nystagmus associated with excitation
of individual semicircular canals
slow-phase
Left posterior
fast-phase
up-counterclockwise
Left superior
down-counterclockwise
Left lateral
Medical Illustration Copyright © 2009 Nucleus Medical Art. All rights reserved. www.nucleusinc.com
left-beating
2 Types of BPPV
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Canalithiasis
– Most common form of BPPV
– Otoconia float freely in endolymph
– Latency (2-30 sec) in onset of vertigo and
nystagmus after the patient moves into the
provoking position
– Fluctuation in intensity of vertigo and nystagmus,
with a typical crescendo-decrescendo pattern, which
resolves within 60 seconds.
2 Types of BPPV
•
Cupulolithiasis
– Not as common
– Otoconia adhere to the cupula
– Immediate onset of vertigo and nystagmus when the
patient moves into the provoking position
– Persistence of vertigo and nystagmus as long as the
patient remains in the provoking position (> 60 sec)
•
Important to differentiate between canalithiasis
and cupulolithiasis to help guide your choice of
treatment
Canal Involvement
•
Prevalence of BPPV (Fife and Lempert 2008)
– Posterior canal: 81-89%
– Horizontal/Lateral canal: 8-17%
– Superior/Anterior canal: 1-3% of cases
•
Video goggles used to record eye movement: (Imai et
al 2005, Lopez-Escamez, et al 2005)
– Posterior Canal: 41-65%
– Horizontal canal: 21-33%
– Superior canal: 17%
– Multi-canal: 20% Common following head trauma.
•
Use Goggles for accurate diagnosis!
Dix-Hallpike Test (Barany Maneuver)
•
1952- Margaret Dix, MD and Charles S. Hallpike, MD
•
Gold standard test for diagnosis of posterior semi-circular
canal BPPV
•
Contraindications: severe RA, recent neck trauma or neck
surgery, vertebral basilar insufficiency, Chiari
Malformation
•
Infrared Goggles to record eye movements or room light
•
To perform the Dix-Hallpike test, begin with patient long
sitting on the treatment table with head rotated 45◦ right or
left, then quickly go to supine with head hanging slightly off
the table (20◦ extension).
•
Repetition of Dix-Hallpike results in fatigue of nystagmus
Picture Dix-Hallpike Test
Picture of Sidelying Test
•
To test the right ear,
turn patient head 45 ⁰
to the left side and
have them quickly lay
down on their right
shoulder.
•
Wait at least 30
seconds for any
nystagmus to appear.
Pattern of Nystagmus for Positive Dix-Hallpike
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Vertical Component
– Upbeating: posterior canal
– Downbeating: anterior canal or possibly central
•
Torsional Component (named from patient perspective)
– Right Hallpike: right torsion, clockwise, beating towards the dependent
right ear
– Left Hallpike: left torsion, counter clockwise, beating towards the
dependent left ear
•
Horizontal Component: horizontal canal, perform Roll Test
•
Duration
– Less than 60 seconds: Canalithiasis
– Greater than 60 seconds: Cupulolithiasis
•
Return to sitting: pattern of nystagmus reverses
Right Dix-Hallpike Video
Left Dix-Hallpike Video
Left Dix-Hallpike Video
VNG testing to diagnosis BPPV
•
Do NOT rely on the tracings for accurate
diagnosis of Posterior or Anterior Canal BPPV!
-Vertical channel: direction of nystagmus is accurate.
-Horizontal channel: cannot correctly identify the
direction of the torsional component of nystagmus
(Vanderheyden, Heidenreich, Carender 2013 prepublication)
•
Focus on video to correctly identify the torsional
component of the nystagmus.
Do NOT use tracings to diagnose BPPV
Right Dix-Hallpike Video During VNG Testing
Left Dix-HallpikeTracing
Left Dix-Hallpike Video During VNG Testing
BPPV
•
Treatment options:
– Particle Repositioning Maneuvers (PRM): 75-80% success
rate in treating posterior canal BPPV in one office visit.
• Modified Epley (Canalithiasis)
• Liberatory/Semont (Cupulolithiasis)
– Brandt-Daroff Habituation Exercises.
– Watch and wait: otoconia dissolve over time.
• Caution patient to avoid provoking positions due to increased fall risk
– Surgery: posterior canal plugging.
– Medication: Vestibular Suppressants (Meclizine, Valium) are
typically not helpful since this is a “mechanical problem”.
Treatment options-Maneuvers
Semicircular Canal
Involvement
Posterior- upbeating
torsional nystagmus
Canalithiasis
Cupulolithiasis
nystagmus< 60 seconds
nystagmus> 60 seconds
-Modified Epley (Particle
Repositioning Maneuver)
-Liberatory Maneuver
(mastoid vibration)
-Liberatory Maneuver
-Brandt-Daroff Exercises
Anterior- downbeating
torsional nystagmus
-Liberatory Maneuver
modified for AC
-Reverse Epley
-Liberatory Maneuver AC
(mastoid vibration)
-Brandt-Daroff Exercises
Horizontal- horizontal
geotropic or ageotropic
nystagmus
-Lempert 360 BBQ Roll
- Casini (Modified Semont)
-Appiani (modified Liberatory) -Brandt-Daroff modified for
Horizontal Canal
-Forced Prolonged Positioning
Modified Epley Maneuver (Left Ear)
•
Wait dizziness PLUS 30 seconds in each position.
•
Eye movements should remain ipsi-torsional throughout the maneuver.
•
180⁰ rotation of the head is required to effectively clear the debris
(position B to D)
Video of Epley Maneuver-Home Version
Guidelines for a Successful PRM
•
Each position must be held a minimum of 30 seconds to
allow the particle to settle ( Hain et al, 2004).
•
Perform at least 2 maneuvers within the treatment session
to optimize outcome. Wait at least 2 minutes in-between
maneuvers.
•
Only treat one ear, one canal at a time (24 hour period)
•
Activity Restriction: patients without activity restrictions
required more treatment sessions (Cakir, et al 2006)
– Sit for 15 minutes with head level in the clinic
– Avoid bending over or laying flat the rest of the day (can
sleep in regular position at night)
Liberatory/Semont Maneuver for Treatment of
Posterior Canal BPPV (Cupulolithiasis Variant)
•
Treatment shown for right
posterior canal
•
Turn head 45° away from the
affected side (left)
•
Quickly lay on affected side (right)
and wait 1 minute
•
Quickly move the patient to
opposite sidelying (< 1.5 seconds)
without changing the head position
and wait for 1 minute
•
Slowly return to sitting with the
head level
Figure source: Parnes LS, Agrawal S, Atlas J. Diagnosis and management of BPPV. CMAJ 2003;169(7):681-693.
Video for Liberatory/Semont Maneuver
Additional Recommendations for
Treatment of BPPV
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Patient with bilateral posterior canal BPPV: treatment of
choice is Liberatory Maneuver to avoid triggering excessive
nausea. Treat one ear per session.
•
Treatment for severe nausea: Zofran or Compazine prior to
maneuvers.
•
Use tilt table if patient has limited cervical extension.
•
Cupulolithiasis not responding to maneuvers: add mastoid
vibration for 20 seconds in each position during maneuver.
•
Canal Conversion during PRM: 6% risk of conversion from
posterior to horizontal canal during the particle
repositioning maneuver.
Brandt-Daroff Habituation Exercises
•
Not as effective as repositioning maneuvers (Cohen HS,
Kimball KT. OtolNeurotol 2005;26: 1034-1040))
•
Mechanism
• dislodges otoconia debris from the cupula
• otoconia dissolve in endolymph
• central adaptation occurs so patient less symptomatic
•
5 Repetitions, 2x/day for 2 weeks
Figure source: Google Images
Supine Roll test for Horizontal Canal BPPV
•
Supine Roll Test: tested in tranverse plane along the
longitudinal axis of the body with head elevated 20-30⁰
0° neck flexion
Figure source: Heidenreich KD, Carender WJ, Heidenreich MJ, Telian SA. Annals of Vascular Surgery 2010; 24(4):553.e5.
Roll Test for Horizontal Canal BPPV
•
Roll Test is used for horizontal canal BPPV.
– Patient is supine with the head flexed 20°. Head is
quickly turned to one side for 60 seconds and
nystagmus is observed. Return to head center
position and wait a few seconds. Then the head is
quickly turned to the other side for 60 seconds. If
the patient does not have full cervical rotation, then
have the patient quickly roll onto their right or left
sides.
– Similar to Head and Body Right/Left Positional
Testing
Horizontal/Lateral Canal BPPV
Lateralization of Side of Involvement
•
Positive Roll Tests =
horizontal nystagmus and vertigo
would occur when the head is turned to both sides due to the
co-planar orientation of the canals
•
Geotropic (towards the earth) Nystagmus:
– debris located in the long arm of the horizontal canal
– side of greatest intensity is the affected lateral canal
•
Ageotropic (away from the earth) Nystagmus:
– debris attached to the cupula OR otoconia lie close
to the ampulated end of the canal.
– side of lesser intensity is the affected lateral canal
Left Geotropic Horizontal Canal BPPV
Geotropic HSC BPPV is due to canalithiasis where the otoconial
debris lies far away from the ampullated end of the canal.
In left ear down position, there is ampullopetal migration of otoconia. This is excitatory in the left HSC
and pt develops a Left Beating nystagmus.
In right ear down position, there is ampullofugal migration of otoconia. This is inhibitory,
and the pt develops a Right Beating nystagmus.
Figure courtesy of J.A White, MD, PhD
Roll Test- Horizontal Nystagmus
Treatment of Geotropic Horizontal Canal
BPPV Right Ear-Lempert BBQ Roll
•
270⁰ -vs- 360⁰ log roll- 30 seconds in each position
– Use caution to avoid over rotation with the 360° maneuver!
Video BBQ Roll Maneuver-Home Version
Modified Libertory maneuver (Appiani) for
Horizontal Canalithiasis (Geotropic)
Patient begins with head in a
neutral position and quickly
lies down on the unaffected
side and waits for one minute.
Patient turns head 45 degrees
downward and waits for one
minute.
Photo from Herdman 2007
Patient slowly returns to sitting
with their head level.
Treatment show is for the
LEFT ear
Conversion of Ageotropic Nystagmus to
Geotropic Nystagmus in Horizontal Canal
•
Head Shaking (Vanmicci et al 1992)
– 20 head oscillations in the horizontal plane with the
patient supine and head tilted 30⁰ forward
•
Rapid Rolling (Lempert 1994)
– Rapidly roll from side to side 10 times.
•
Head Pitching ( Califano, et al 2008)
– Pitch head 60⁰ forward and 45⁰ backward 20 times.
Modified Semont (Casini) for Horizontal
Canal Cupulolithiasis (Ageotropic )
•
Patient moves quickly from
sitting with head in neutral
to sidelying on the affected
side.
•
Head is immediately turned
so the nose is down 45⁰.
•
Patient stays in this position for
2 minutes, then slowly returns
to sitting.
•
Treatment shown for the right
ear
Photo from Herdman 2007
Factors Contributing to Recurrence
•
Rate of recurrence is 15% per year, cumulative.
•
Rate of recurrence may be as high as 25% in
the first year, 44% in second year (Hain,
Helminski, 2000)
•
Factors contributing to recurrence:
– Head Trauma
•
A daily routine of Brandt-Daroff Exercise or
Epley maneuver does not affect the time to
recurrence or the rate of recurrence.
– Helminski JO, JanssenI, Hain TC. Otol & Nerotol 2008;29:976-981.
Clinical Practice Guidelines: BPPV
•
Otolaryngology-Head and Neck Surgery 2008
– Recommended against full vestibular testing or
radiographic imaging in “routine” cases.
• Dix-Hallpike and Positional Testing with Videogoggles
would be indicated if BPPV is suspected.
– Recommend against treatment with vestibular
suppressants like benzodiazepines or antihistamines.
– Recommend clinicians reassess BPPV patients
within one month of treatment to confirm resolution.
Case Study 1 -History
•
47 yo female with daily episodes of vertigo
triggered by reclining back in bed.
•
Vertigo was particularly severe when lying on
her left side.
•
It did not respond to a trial of Brandt-Daroff
Habituation Exercises recommended an outside
PT.
•
Based on this history, would you suspect BPPV?
Case Study 1 -Exam Findings
•
No spontaneous or gaze nystagmus in room
light
•
Normal pursuits and saccades
•
No spontaneous or post head shake nystagmus
with fixation removed using infrared goggles
•
Gait was steady
Persistent Positional Nystagmus:
A Case of Superior Semicircular Canal BPPV.
Heidenreich, Kerber, Carender 2011
Modified Liberatory Maneuver
Case Study 2 - History
•
54 yo male sudden onset of vertigo, nausea,
vomiting and imbalance lasting 24 hours. He
then experienced brief episodes of positional
vertigo and nausea when lying down or rolling
over to both directions in bed.
•
Based on this history, would you suspect BPPV?
Case Study 2 – Positional Testing
Is this a positive Dix-Hallpike?
Positional Testing Reveals Ageotropic
Pattern of Horizontal Nystagmus
Case 2- Horizonal Canal BPPV
•
Head and Body Right and Left Positional
testing: similar to Roll Tests that Physical
Therapists use to identify Horizontal canal
BPPV
•
Horizontal Canal BPPV: video and tracings are
both helpful for correct diagnosis
Case 2- Diagnosis of Horizontal Canal
BPPV
A) Right Horizontal Canal - canalithiasis
B) Left Horizontal Canal – canalithiasis
C) Right Horizontal Canal – cupulolithiasis
D) Left Horizontal Canal – cupulolithiasis
Horizontal Canal BPPV
•
Positive Roll Tests = horizontal, bidirectional
nystagmus
•
Geotropic (towards the earth) Nystagmus:
– side of greatest intensity is the affected lateral canal
•
Ageotropic (away from the earth) Nystagmus:
– side of lesser intensity is the affected lateral canal
Vestibular PT Evaluation (later same day)
•
Roll Tests in room light
– Right Roll: left beating horizontal nystagmus lasting
> 60 seconds
– Left Roll: right beating horizontal nystagmus lasting
> 60 seconds.
– Nystagmus appeared to be of equal intensity to both
sides. Speed of the roll/head movement will affect
the response!
– Patient was more symptomatic when rolling to the
RIGHT side.
Case 2 –Vestibular PT Treatment
•
Left Horizontal Canal-Cupulolithiasis
•
3 sessions of Vestibular PT combined with daily
home program
•
Resolved with Brandt-Daroff modified for
Horizontal Canal combined with Casini
Maneuver for the Left ear
Caloric Testing
•
73% Left Caloric weakness
•
Otolaryngologist Diagnosis included: Vestibular
Neuritis and Horizontal Canal BPPV involving
the left ear
Thank You
•
Margot Beckerman, Au.D., CCC-A, Assistant
Director University of Michigan Vestibular
Testing Center
•
Crystal VanderHeyden, Au.D.
•
Shaleta Harvard, Au.D.
References
•
Herdman, S. Vestibular Rehabilitation. 3rd Editiion. F.A.
Davis Company 2007.
•
www.vestibular.org Vestibular Disorders Association.
•
Journal: Bhattacharyya, N, Baugh, R et al. Clinical practice
guideline: Benign Paroxysmal Positional Vertigo. Supplement
to Othlaryngology-Head and Neck Surgery. Vol 139,
November 2008.
•
Heidenreich KD, Kerber KA, Carender WJ. Persistent
Positional Vertigo: A Case of Superior Semicircular Canal
BPPV? Laryngoscope, 121:1818-1820, 2011
•
http://www.youtube.com/user/UMHealthSystem#p/u
Questions?
•
Please contact Wendy Carender, PT
[email protected]
•
University of Michigan
Vestibular Testing Center: 734-936-9420
Thank you!