Benign Paroxysmal Positional Vertigo(BPPV) of the Posterior(PSC) & Horizontal Semicircular Canals(HSC)

2003. 6. 25

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Anatomy of Vestibular organ

Vestibule ()

Crista ampullaris ()

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Historical aspects(I)
- Barany(1921); first description of positioning nystagmus - Dix & Hallpike(1952); the provocative positioning maneuver and defining the syndrome - Schuknecht(1969); basophilic deposits on the cupula of the posterior SCC(PSC) in postmortem 2 BPPV patients(cupulolithiasis) - Hall, Ruby, & McClure(1979); something moving inside the canal rather than adhering to the cupula of the PSC(canalolithiasis) - Parnes & McClure(1992); free-floating endolymph particles-PSC occlusion

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Wellington et al., Larygoscope 1997;107:90-4.

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Historical aspects(II)
- Cipparone et al.(1985); the existence of a BPPV due to involvement of the HSC - McClure(1985); first reported come clinical features of BPPV originating from the HSC in 7 patients(the particles penetrate onto the non-ampullary arm(long arm or posterior part) of the HSC - Pagnini et al.(1989); clinical features of HSC BPPV in 15 patients(geotropic nystagmus) canalolithiasis type - Baloh(1995); ageotropic or apogeotropic nystagmus cupulolithiasis type - Bertholon(2002); Possible ASC BPPV

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Terminology
1.Nystagmus(fast component) (Rt., Lt., Up, Down.) 2. a.Canalolithiasis - Long arm(non-ampullary or post. portion) - Short arm(ampullary or ant. portion) b.Cupulolithiasis 3. Geotropic vs a(po)geotropic nystagmus 4. Ampullopetal(utriculopetal)(HSC) vs ampullofugal(utriculofugal)(PSC, ASC) 5. Ewalds law

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1.Nystagmus(fast component)
(Rt., Lt., Up, Down.) * => ; right beat ; up-beat

2.Canalolithiasis
a.Long arm(non-ampullary or post. portion)

b.Short arm(ampullary or ant.

portion) Cupulolithiasis
Cupulolithisais
Short arm

Canalolithiasis

; left beat ; down-beat

Long arm

) Right HSC

3. Geotropic vs a(po)geotropic 4. Ampullopetal(utriculopetal)

Nystagmus (HSC) excitation,
Ewald 2nd law

BPPV

Geotropic()

vs Right D-H test

Ageotropic()

Ampullofugal(utriculofugal) (PSC, ASC) excitation,

Ewald 3rd law

Right D-H test

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Actions of Extraocular muscles

HSC
Rt. Lt.

PSC

ASC

Slow phase

Fast phase

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Etiology of BPPV
1) 2) 3) 4) 5) 6) 7) 8) idiopathic(M/C) post-trauma Neurolabyrinthitis SNHL URI COM Postoperation(ear, general) Ototoxicity

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Occurrences of positional vertigo(Hx.)

1. PSC BPPV; , , , 2. HSC BPPV; (), ,
*

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Diagnosis of PSC-BPPV
* Dix-Hallpike Maneuver

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Criteria for Classic Dix-Hallpike Response

1)subjective vertigo 2)transient torsional(rotary) nystagmus 3)fatigability 4)nystagmus following a latency period of one or more seconds (duration less than 1 min) 5)reversibility in sitting position * non-classic; 1 or more of the above criteria are absent.

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Clinical Features of HSC-BPPV

624% of all patients with BPPV M;F = equal Mean age; 58.1 Etiology; idiopathic(M/C), post-traumatic, neurolabyrinthitis, SNHL, URI, COM, postoperative, ototoxicity - Horizontal direction changing positional nystagmus -> all CNS lesion in the past - Criteria of HSC-BPPV 1) pure horizontal nystagmus 2) >6 degree/sec 3) No CNS lesion -

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Diagnosis of HSC-BPPV
1. Lateral head turning test(Roll test); supine position with head tilted 30 upward -> 90 lateral head rotation in the left or right side -> horizontal bilateral direction changing nystagmus(geotropic or ageotropic) 2. Determination of the lesion side (still controversial) 1) geotropic type; strong nystagmus side 2) ageotropic type; weak nystagmus side by the Ewalds the 2nd law (Baloh, Nuti)

Canalolithiasis type(geotropic nystagmus) of HSC-BPPV

BPPV

Cupulolithiasis type(ageotropic nystagmus) of HSC-BPPV

BPPV

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Treatments of PSC-BPPV
I.Non-surgical
a) Brandt-Daroff habituation exercise(1980) b) Liberatory maneuver(Semont, 1988) c) Canalith Repositioning Procedure(Epley, 1992)

II. Surgical
a) Singular neurectomy(Gacek, 1974) b) PSC occlusion(Parnes, 1990)

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Brandt-Daroff Habituation Exercise(1980)

1.
2. 3.

.
. ; a.

.
30 . b. 30 .

Liberatory maneuver
(Semont, 1988)

BPPV

1. (1).

2.
a. . b. 2-3

. 5
c. .

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Canalith Repositioning Procedure(CRP) (Epley, 1992)

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Baloh(1994), Epley(1995), Lempert(1996); 360 barbecue rotation

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Treatment of HSC-BPPV
* Canalolithisis type; 1. Baloh(1994), Epley(1995), Lempert(1996); 360 rotation of the supine patient toward the unaffected ear; displace the debris more effectively from the non-ampullary arm of the HSC toward utricle

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Treatment of HSC-BPPV
2. Vannuchi et al.(1994); Forced prolonged position(FPP)- on the basis of the canalolithiasis theory for geotropic HSC BPPV -> The patient lies on the healthy side for 12 hours. Under the effect of gravity the particle gradually slip into the vestibule from the nonampullary arm of the HSC

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Treatment of HSC-BPPV
* Cupulolithiasis type; 1. Nuti et al.(1998): change from ageotropic to geotropic type(ex; head-shaking -> 360 barbecue method) 2. Jo et al.(2000); cupulolith repositioning maneuver(CuRM) 3. Casani et al.(2002); modified fourth step of Semont maneuver (canalolithiasis type; combination of 360

barbecue method and followed by FPP)

Jo et al.(2000); cupulolith repositioning maneuver(CuRM)

BPPV

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Features the differentiate PSC and HSC BPPV(Baloh,1993)

PSC
Incidence Inducing maneuver Nystagmus 91% sitting to head hanging torsional, upbeating (geotropic)

HSC
6% supine to head lateral horizontal (geotropic, ageotropic) direction changing >30sec <3sec no*

Duration Latency Fatigability

<30sec 2-20 sec yes

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Failures of Therapeutic Maneuver

1)Too big particles(Nuti, 1998) 2)Incorrect affected site 3)Severe adhered to the cupula 4)Inappropriate Tx.(Fife, 1998) 5)Central origin vertigo 6)Cervical spondylosis 7)Obesity

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Vertigo clinic 300 48 BPPV

(2002 6-2003 5)

1-10 11-20 21-30 31-40 41-50 51-60 61-70 71

1 1 6 7 8 9 4 37

1 1 11 9 10 11 4 48

5 2 2 2 11

* Canal
1. PSC canalolithiasis; 28 cupulolithiasis; 3 2. HSC canalolithiasis; 14 cupulolithiasis; 2 3. ASC canalolithiasis; 1 4. Combined type 2 (PSC + HSC) 5. Change of SCC after Tx.(1) (PSC canalolithiasis -> HSC canalolithiasis)

BPPV

* Associated ds. or Causative primary ds.

48 idiopathic(29) post-traumatic(8) viral neuronitis or neurolabyrinthitis(3) VBI(2) Menieres disease(0) COM(2) Post surgery(Ear)(1) Post surgery(General)(2) Sudden hearing loss(0) Ototoxicity(1)

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* Recurrence
PSC canalolithiasis 28 3 Case 1 + Case 2 Case 3 + +

20 19 30

Idiopathi c Head trauma VBI

HSC canalolithiasis 14 2 Case 1 Case 2

+ +

7 40

Head trauma Idiopathic

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Conclusions
BPPV
. , canalolithiasis cupulolithiasis . 2 . *

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Crista ampullaris

cupula

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(macule)

(otoconia or otolith)

BPPV

BPPV Rt. HSC - geotropic type

Rt. HSC - ageotropic type

* Ewald the 2nd law