lecture outline comprehensive review of benign paroxysmal ... · benign paroxysmal positional...
TRANSCRIPT
10/24/17
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Katherine Heidenreich, MDClinical Associate ProfessorDirector, Michigan BalanceDivision of Otology-NeurotologyDept. of Otolaryngology-Head & Neck Surgery
Disclosure: I have no biomedical industry relationships, including no industry-sponsored research projects.
Comprehensive Review of Benign Paroxysmal Positional Vertigo
for the Audiologist
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Lecture Outline
§ Nystagmus conventions§ Relevant anatomy and physiology§ BPPV by semicircular canal subtype§ Unresolved issues
Learning objectives§ Describe semicircular canal anatomy and how the canal is
stimulated. § List the different nystagmus patterns associated with each
semicircular canal variant of BPPV.§ Discuss which eye (ipsilateral or contralateral) is more likely to
exhibit torsional nystagmus in posterior canal BPPV? What about for superior canal BPPV?
§ Be able to discuss the limitations of relying on strip recordings of nystagmus for diagnosis of BPPV.
§ Demonstrate how to perform a particle repositioning maneuver to treat posterior semicircular canal BPPV.
§ Describe 3 lateralizing signs to identify the affected ear in horizontal semicircular canal BPPV.
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Nystagmus
§ Definition = repetitive oscillation of the eyes
§ Jerk nystagmus has a slow phase that alternates with a corrective fast phase. It is named after the fast phase.
right-beating down-beating upbeating torsional4
RR L R L
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How can you improve your ability to detect nystagmus on exam?
Suppress the patient’s ability to visually fixate
Frenzel lenses Video-oculography (VOG) goggles
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Definitions
discordant = disagreeing§ I may use this to describe a scenario where
nystagmus seen on video disagrees with the eye movement documented by strip recording.
disconjugate = not paired in action§ I may use this to describe nystagmus where
the right and left eye movements differ
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Videonystagmography (VNG) and Electronystagmography (ENG)
§ Neither system can document torsional eye movements on strip recordings.
§ VNG has the advantage of allowing the eye movement to be directly viewed. Strip recordings can be inaccurate.
§ A binocular VNG system is better than a monocular system as vertical semicircular canal stimulation can manifest with disconjugate nystagmus (ie right and left eye movements may differ).
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2-D Videonystagmography (VNG) conventions
General:§ The recording runs left to right.§ 2 channels: H = horizontal; & V =
vertical.§ No torsional channel.
Vertical channel: § Upwards deflection = upwards eye
movement§ down = down.
Horizontal channel:§ Think “people walk upright”.
Upward deflection = rightwards eye movement.
§ downward deflection = leftwards eye movement.
fast up
slow down
slow to left
fast to right
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Pay attention to the patients’ eyes during static positional and Dix-Hallpike testing.
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Do not focus exclusively on the VNG strip recordings as they:§ only provide a graphic representation of
nystagmus§ cannot measure torsional component of
nystagmus which is present with vertical canal BPPV.
Relevant Anatomy and Physiology
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Source of figure: Herdman SJ. Vestibular rehabilitation, 3rd ed. © 2007 by F.A. Davis and Co.
Hair cells are oriented to respond to angular acceleration. § Key structures: ampulla, crista ampullaris, cupula
Semicircular Canals
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Angular acceleration causes endolymph movement which deflects cupula à this bends stereocilia on hair cells à canal nerve endings get stimulated
Cristaampullaris
Source of figure: Furman JM, Cass SP. Vestibular Disorders: A Case Study Approach, 2nd ed., © 2003 by Oxford Press.
Endolymph flow and cupular deflection can be characterized as either:
§ ampullopetal (towards ampulla)§ ampullofugal (away from ampulla; think f=flee)
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30◦
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Stimulation of semicircular canals differs between the horizontal and vertical canals
Canal Excitation Inhibition
Horizontal Ampullopetal deflectionof cupula
Ampullofugal deflection of cupula
Superior Ampullofugal deflectionof cupula
Ampullopetal deflection of cupula
Posterior Ampullofugal deflection of cupula
Ampullopetal deflectionof cupula
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Vestibulo-Ocular Reflex (VOR)
The VOR generates an automatic slow-phase eye movement equal and opposite to angular acceleration to stabilize vision
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Nystagmus can occur with sustained semicircular canal stimulation due to VOR activation. The slow phase is from the VOR.
Source of figure: Herdman SJ. Vestibular rehabilitation, 3rd ed. © 2007 by F.A. Davis and Co.15
§ Head down & rotated towards that ear
§ VOR: slow phase eye movement up and rotated away from the side
§ Downbeatingtorsional nystagmus
§ Head up & rotated towards that ear
§ VOR: slow phase eye movement down & rotated away from the side
§ Upbeating torsional nystagmus
§ Head rotated towards that ear
§ VOR: slow phase eye movement in opposite direction
§ Horizontal nystagmusbeating towards direction of angular acceleration
Disorders that stimulate a semicircular canal will be interpreted by the brain as angular acceleration in the plane
of that canal and cause pathologic nystagmus
horizontal canal superior canal posterior canal
Extraocular muscles
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right eye
Rectus muscles move the globe in a linear direction.
Oblique muscles cause torsion/rotation of the globe.
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17Figure source: what-when-how.com
Excitatory neural connections that give rise to VOR
SC
Superior Posterior Horizontalsemicircular canal semicircular canal semicircular canal
Benign Paroxysmal Positional Vertigo (BPPV)
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Most common cause of dizziness from the ear§ Overall prevalence = 11-64 per 100,000§ female:male = ~1.5:1
Easy to diagnose§ Classic history: brief spells of rotary vertigo
triggered by changes in head position.§ elderly patients may report vague symptoms
Readily treatable with particle repositioning maneuvers (PRM)
Why learn about BPPV ?
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Did Shakespeare know about BPPV ?
“He that is giddy, thinks the world turns round”. - The Taming of the Shrew (Act V, Scene 2)
“…turn giddy, and be [helped] by backwards turning…”- Romeo and Juliet (Act I, Scene 2)
References: (1) Hornibrook J. BPPV: History, pathophysiology, office treatment, and future directions. International J Otolaryngol 2011:1-13. (2) Heaton KW. Body-conscious Shakespeare: Sensory disturbances in troubled characters. Med Humanit 2011;37:97-102 20
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Mechanism
Source of figure: Imhofmeyr.co.za. 21
Canalithiasis§ Otoconia float freely§ Latency in onset of vertigo &
nystagmus§ Nystagmus has crescendo –
decrescendo intensity & disappears within 60 seconds.
§ common
Cupulolithiasis§ Otoconia adhere to cupula§ Immediate onset of vertigo &
nystagmus§ Nystagmus persists as long as
patient remains in provoking position (> 60 seconds)
§ rare
latencyfatigueabilityreversibility
trajectorydisconjugacy
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BPPV by semicircular canal type
Posterior Horizontal Superior
Frequency 81-89% 8-17% 1-3%
Provocative maneuver used to diagnose it
Dix-Hallpike Supine roll test Dix-Hallpike• ipsilateral• contralateral• or with both
Nystagmus trajectory
Upbeat torsional Horizontal bidirectional (geo vs apogeo)
Downbeat torsional
Table adapted from: Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidenced-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70(22):2067-2074. 23
The posterior semicircular canal (PSC) is most commonly affected in BPPV because it is the most dependent (ie lowest) canal.
Posterior Semicircular Canal (PSC) BPPVThe Dix-Hallpike Test
Dix-Hallpike test for the right ear: (A) Patient’s head is rotated 45°to their right, (B) patient is rapidly brought into the head-hanging position. Observe for nystagmus.
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The nystagmus of PSC BPPV is upbeatingtorsional
R L
R L
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How can we explain this pattern of nystagmus ?
Source of figures: Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of BPPV. CMAJ 2003;169(7): 681-693. Herdman SJ. Vestibular rehabilitation, 3rd ed. © 2007 by F.A. Davis and Co. 26
R
Stimulation of canal afferents is interpreted as angular acceleration in the plane of the affected canal.
The nystagmus is disconjugate
Torsion is more evident in ipsilateral eye for PSC BPPV
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Right PSC
superior oblique
inferior rectus
Figure source: what-when-how.com
RVNG tracings are often inaccurate when compared
to the eye video in PSC BPPV.
§ Retrospective case series with chart review of patients diagnosed with PSC BPPV who had VNG testing.
§ 3 clinicians (MD, AuD, PT) independently reviewed videos and were blinded to each others interpretation
§ 100 videos of PSC BPPV with accompanying VNG tracings included in final analysis
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65% 29% 6%
§ Our VNG system is binocular and defaults to left eye to determine nystagmus trajectory.
§ There was no association between ear of involvement and tracing accuracy when considered alone or when accounting for globe position.
Works by drawing the otoconia back to the utricle in an ampullofugal direction.
Epley Maneuver
Right Epley
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Success rate in randomized controlled trials is 66-89%.§ Otolaryngol Head Neck Surg 2008;139:S47-S81
Source of figure: Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of BPPV. CMAJ 2003;169(7): 681-693.
Semont’s Liberatory Maneuver
Figure source: neurochangers.com31
Per Cochrane Review (Hilton et al 2014), the Semont maneuver is equally effective as Epley maneuver for treatment of posterior canal BPPV.
Semont maneuver for right PSC BPPV
Pay attention to the patient’s eyes during PRM
§ Some patients may develop a “liberatory” or ”secondary” nystagmus during PRM.
§ During Epley, an ipsitorsional secondary nystagmus may be a favorable sign that suggests ampullofugal mobilization of the otoconia through the PSC#.
#Oh HJ et al. Neurology 2007;68:1219-1222Source of figure: Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of BPPV. CMAJ 2003;169(7): 681-693.
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Brandt-Daroff Exercises
Unclear mechanism
Not as effective as Epleyor Semont maneuver for PSC BPPV.§ A single PRM is >10 times
as effective as 1 week of Brandt-Daroff exercises done three times a day.#
33#Hinton MP, Pinder DK. Cochran Database Syst Rev. 2014
Figure source: Google images
Mastoid oscillation/vibration
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§ Has primarily been studied in cases of posterior canal BPPV. Most studies do not distinguish between canalithiasis vs cupulolithiasis.
§ Cochrane Review (2012) found no added benefit with mastoid oscillation in posterior canal BPPV.
Postmaneuver restrictions do not confer clear benefit
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§ Many studies differ on the type of postural and/or activity restriction used following repositioning therapy.
§ 9 of 11 RCT showed no benefit with postmaneuverrestrictions.§ Bhattacharyya N. et al. Clinical practice guideline: BPPV (update)
Otolaryngol Head Neck Surg 2017;156(3S):S1-S47.
Recurrence
Once successfully treated, BPPV often recurs.§ For posterior canal BPPV, the rate of recurrence is ~12%
- 15% per year.
A daily routine of either Brandt-Daroff exercises or self-PRM does not affect (1) the time to recurrence, or (2) the rate of recurrence.
§ Helminski JO, Jannsen I, et al. Arch Otol Head Neck Surg 2005;131-344-348.§ Helminski JO, Janssen I, Hain TC. Otol & Neurotol 2008;29:976-981.
Recurrent BPPV often responds to additional repositioning maneuvers.
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Surgical Treatment for Refractory BPPVSemicircular Canal Occlusion
Has been described primarily for refractory posterior semicircular canalithiasis
Technical goal:§ Occlude the membranous canal
lumen without violating it
How does it work?§ Endolymph flow is restricted
thereby preventing cupulardeflection & stimulation of canal afferents
Source of figures: (1) Coker NJ, Jenkins HA. Atlas of Otologic Surgery. ©2001 by W.B. Saunders Co. (2) Beyea JA, Agrawal SK, Parnes LS. Laryngoscope 2012;122:1862-1866.
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Sample Case
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Which video depicts correct PRM for left PSC BPPV?
A B
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Any questions on PSC BPPV ?
Posterior Horizontal Superior
Frequency 81-89% 8-17% 1-3%
Provocative maneuver used to diagnose it
Dix-Hallpike Supine roll test Dix-Hallpike• ipsilateral• contralateral• or with both
Nystagmus trajectory
Upbeat torsional Horizontal bidirectional (geotropic vs apogeotropic)
Downbeat torsional
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Horizontal Semicircular Canal BPPV
Table adapted from: Fife TD, Iverson DJ, Lempert T, et al. Neurology 2008;70(22):2067-2074.
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41from Charles Darwin’s The Power of Movement in Plants (1869)
AlbertB.Frank(1839-1900) CharlesDarwin(1809-1882)
These terms have a botanical origin Horizontal Semicircular Canal (HSC) BPPV
§ Characterized by horizontal, bidirectional nystagmus provoked by the supine roll test.
§ Two subtypes exist:
Geotropic Apogeotropic
Head center supine Right ear down Left ear down
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Video of Geotropic HSC BPPV
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The dilemma with horizontal canal BPPV
If nystagmus is present in both the right and left ear down positions, then which ear is affected?
There are several lateralizing signs that can be used to identify the affected side#.
1) Nystagmus intensity during supine roll test2) Sit-to-supine test3) Pseudo-spontaneous nystagmus
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#Asprella-Libonati G. Acta Otorhinolaryngologica Ital 2008;28:73-78.
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Lateralizing sign #1Compare nystagmus intensity during supine roll test
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When nystagmus intensity is the greatest it beats towards the affected side.
With geotropic HSC BPPV, the affected ear is undermost when nystagmus intensity is greatest.
With apogeotropic variant, the affected ear will be up when nystagmus intensity is the greatest.
What is the basis for this lateralizing sign ?
Ewald’’s 2nd LawThe response to an excitatory stimulus is always more intense than that of an inhibitory stimulus. - J.R. Ewald, 1892
Geotropic HSC BPPV is due to canalithiasis where the otoconial debris resides far away from the ampullated end of the canal.
Head center supine left ear down right ear down
ampullopetal ampullofugalexcitatory LB inhibitory RB
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Sample case: What does this patient have?
Figure source: J.A. White, MD, PhD. Used with permission. 47
Apogeotropic HSC BPPV
Can be due to two possible mechanisms: (1) cupulolothiasis, or (2) canalithiasis, where the otoconia reside close to the ampullated end of the canal.
Head center supine left ear down right ear down
ampullofugal ampulopetalinhibitory RB excitatory LB
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What do you think is going on with this
patient?
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Lateralizing sign #2: Sit-to-supine test
When the patient is brought from a seated to supine position, they often develop a horizontal nystagmus which beats…
§ towards the affected ear in apogeotropic HSC BPPV§ away from the affected ear in geotropic HSC BPPV
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What are the expected lateralizing signs for left apogeotropic HSC BPPV ?
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Lateralizing sign #3Pseudo-spontaneous nystagmus
Source of figures: +Asprella-Libonati G. Acta Otorhinolaryngologica Ital 2008;28:73-78.
In a series of 293 pts with HSC BPPV, 76% exhibited a pseudo-spontaneous nystagmus+. This beats:§ towards the affected ear in apogeotropic HSC
BPPV§ towards healthy ear in geotropic HSC BPPV
It is a pseudo-spontaneous nystagmus b/c it can be extinguished by tilting head forward 30º which brings HSC into neutral plane.§ It’s direction can be inverted with bending
head forward >30º (B).§ It will be restored back to its initial direction
with leaning head backwards (C)
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Video of Pseudo-spontaneous nystagmus for right apogeotropic HSC BPPV
Video courtesy of G. Asprella-Libonati, MD
My philosophy for eliciting lateralizing signs for HSC BPPV
To be efficient with my time, I look for the 2 most sensitive lateralizing signs:1st: Sit-to-supine test, then go straight into the…2nd: Supine roll test
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Treatment of HSC BPPV
The key is to correctly identify the affected side.
Treat with repositioning maneuvers. § These differ from those used to address PSC BPPV.§ Confusing nomenclature
If patient fails to improve consider other potential causes (central).
Surgery is controversial given the potential to operate on the wrong side.
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BBQ Rollfor geotropic HSC BPPV
The literature for BBQ roll varies regarding whether this should be a 270º or 360º roll.
For right geotropic HSC BPPV, roll the patient to their left.
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Gufoni Manuever for geotropic HSC BPPV
Figure source: Kim JS, et al. Randomized clinical trial for geotropic horizontal canal BPPV. Neurology 2012;79:700-707.
Treatment of left ear is shown.Each position is maintained for 2 min.
In the sitting position, the otoconial debris is located in the posterior arm of the HSC.
How to do it:§ Bring the patient to a side-
lying position on the healthyside. This moves the otoconia posteriorly in the canal.
§ Head is rotated to the ground, causing otoconia to fall into the utricle.
§ Patient is returned to upright position.
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Modified Gufoni Maneuver for apogeotropic HSC BPPV
Treatment of left ear is shown. Positions (b) through (d) are
maintained for 2 minutes.
Figure source: Kim J-S et al. Randomized clinical trial for apogeotropic horizontal canal benign BPPV. Neurology 2012;78-159-166.
In the sitting position, the otoconial debris is adherent to the cupula or in the anterior portion of the HSC.
How to do it:§ Bring the patient to a side-
lying position on the affectedside. This moves the otoconia posteriorly in the canal.
§ Head is rotated to the ceiling, causing otoconia to move posteriorly through the canal & into the vestibule.
§ Patient is returned to upright position. 58
Vannucci-Asprella Maneuver for geotropic or apogeotropic HSC BPPV
Source of figure & text: Asprella-Libonati G. Acta Otorhinolaryngologica Italica 2008;28:73-78.59
Sample Case
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R L
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initial right Dix-Hallpike
post-Epley right Dix-Hallpike
left lateral position
R
R
L
What happened?
R L
Canal Switch: A potential complication of repositioning therapy
The risk of converting posterior to horizontal or superior canal BPPV following Epley is 6-16%.§ Herdman SJ, Tusa RJ. Complications of canalith repositioning
procedure. Arch Otolaryngol Head Neck Surg 1996;122:281-286.§ Foster CA, et al. Canal conversion & reentry: A risk of Dix-
Hallpike during canalith repositioning procedures. Otol Neuotol2012;33:199-203.
Figure source: Judith A. White, MD PhD 62
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Any questions on HSC BPPV?
Superior Semicircular Canal BPPV
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Posterior Horizontal Superior
Frequency 81-89% 8-17% 1-3%
Provocative maneuver used to diagnose it
Dix-Hallpike Supine roll test Dix-Hallpike• ipsilateral• contralateral• or with both
Nystagmus trajectory
Upbeat torsional Horizontal bidirectional (geo vs apogeo)
Downbeat torsional
Table adapted from: Fife TD, Iverson DJ, Lempert T, et al. Neurology 2008;70(22):2067-2074.
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Can you differentiate the nystagmus of superior vs. posterior canal BPPV?
A B66
The torsional component is more pronounced in the contralateral eye in superior canal BPPV
Superior rectus
MLF
SC
PC
Left superior canal BPPV(torsion is more evident in the right eye)
v
Inferior oblique
Treatment of Superior Canal BPPV
No large series exist
These maneuvers have been described:§ Epley§ Yacovino
If tx of SSC BPPV fails, referral to neurology should be considered to exclude central pathology.
Figure source: Yacovino DA, Hain TC, Gualtieri F. new therapeutic maneuver for anterior canal BPPV. J Neurol 2009; 256:1851-1855.
Yacovino maneuver
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Any questions on SSC BPPV?
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BPPV by semicircular canal type
Posterior Horizontal Superior
Frequency 81-89% 8-17% 1-3%
Provocative maneuver used to diagnose it
Dix-Hallpike Supine roll test Dix-Hallpike• ipsilateral• contralateral• or with both
Nystagmus trajectory
Upbeat torsional Horizontal bidirectional (geotropic vs apogeotropic)
Downbeat torsional
Table adapted from: Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidenced-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70(22):2067-2074. 69
Posterior canal BPPV may be more complex than we initially thought …
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Posterior(geotropic)
Posterior(apogeotropic)
Horizontal Superior
Diagnosticmaneuver
Dix-Hallpike Dix-Hallpike (ipsi-or contra-)Head hanging supine
Supine roll test
Head hanging supine or Dix-Hallpike
Nystagmus pattern
Upbeatingtorsional rotating towards ear (ie geotropic)
Downbeatingtorsional rotating away from ear (ie apogeo)
Horizontal(geotropic vs apogeotropic)
Downbeating(may see torsional towards ear)
Other features of apogeotropic posterior canal BPPV *:§ Nystagmus often last > 2-minutes§ Does not fatigue§ Does not reverse with sitting up.
*References: Vannucchi P et al. Apogeotropic posterior semicircular canal BPPV: some clinical and therapeutic considerations. AudiolResearch 2015;5:130.
Apogeotropic Posterior Semicircular Canal BPPV
Figure source: Califano L, et al. Anterior canal BPPV and apogeotropic posterior canal BPPV: two rare forms of vertical canalolithiais. ActaOtorhinolaryngologica Italica 2014;34:189-197.
Background: § Some patients with presumed superior canal BPPV exhibit nystagmus
associated with contralateral posterior canal BPPV following repositioning therapy.
Inhibition of the posterior canal manifests with the same nystagmus as excitation of its co-planar pair (contralateral superior canal): § Downbeating torsional rotating away from affected ear (apogeotropic)
Mechanism: § otoconia present in the non-
ampullated arm of posterior canal§ Dix-Hallpike position causes
ampullopetal migration & triggers an inhibitory nystagmus.
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Repositioning maneuvers for apogeotropicposterior canal BPPV
§ Tx for left apogeo PSC BPPV shown.
§ Move from a → b in 1-sec, and remain in 45º nose down healthy side for 3-minutes.
Source of left figure: Califano L, et al. Acta Otorhinolaryngologica Italica 2014;34:189-197. Source of middle and right figures: Vannucchi P et al. Audiology Research 2015;5:130.
Quick Liberatory Maneuver demi Semont45º Forced Prolong
Positioning
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Unresolved Issues
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Residual Dizziness after successful repositioning maneuvers
Prospective, controlled study:§ control = normal volunteer§ 82 pts with PSC-BPPV; 53 with HSC-BPPV (Apogeo:Geo = 19:34).§ Seen 5-7 days after successful repositioning maneuver
Results:§ Improvement in DHI seen with tx of BPPV, but post-Epley scores
do not reach level of controls.
Residual Dizziness (continued)
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§ N=49patients§ MeanRD
duration:16days
§ Prospectivecohortstudy(N=86).
§ IfRDwaspresent3daysaftersuccessfultx,ptsweremonitoredevery3daysuntilitresolved.
§ 83%hadRD.Thisresolvedin55%by6days.
