各型BPPV 的诊断手法及复位技巧打印稿课件

各型BPPV的诊断手法及复位技巧DrXiaofengMeiFushanhospitaloftraditionalchinesemedicine,Departmentofotorhinolaryngology—headandnecksurgeryOverview发病率约1/10000,占外周性眩晕的50%属周围性旋晕多为自限性，能自行缓解，故称为良性三个月不愈或丧失劳动力者为顽固性男:女=1:2～3BackgroundBarany(1921)[1]:首次描述benignparoxysmalpositionalvertigo(BPPV):Theattacksonlyappearedwhenshelayonherrightside.Whenshedidthis,thereappearedastrongrotatorynystagmustotheright.Theattacklastedaboutthirtysecondsandwasaccompaniedbyviolentvertigoandnausea.If,immediatelyafterthecessationofthesesymptoms,theheadwasagainturnedtotheright,noattackoccurred,andinordertoevokeanewattackinthisway,thepatienthadtolieforsometimeonherbackoronherleftside.DixM.R.&HallpikeC.S.(1952)[2]:介绍了BPPV特点和Dix—HallpikeTestSchuknechtH.F.(1969)[3]:病人颞骨病理见后半规管壶腹嵴致密颗粒cupulolithiasisHallSF，RubyRRF，McClureJA.(1979)[4]:根据重复刺激疲劳性提出半规管结石症canalithiasisBrandtT，DaroffRB(1980)[5]:首推体位治疗SemontA，FreyssG，VitteE(1988)[6]：耳石解脱法liberatorymaneuverEpleyJM(1992)[7]:耳石复位法canalrepositionprocedures(CRP)ParnesLS，McClureJA.(1990)[8]:描述后半规管阻塞术治疗难治性BPPVParnesLS，McClureJA.(1992)[9]:难治性BPPV手术中发现后半规管中嗜碱性颗粒GacekRR(1995):singularneurectomy[*]

MoriartyB，RutkaJ，HawkeM.(1992)[10]:大量颞骨病理发现其他半规管也见嗜碱性颗粒ThecupulolithiasisandThecanalithiasisBPPV病理生理正常耳石代谢：耳石膜含许多碳酸钙结晶，耳石含大量钙离子，酷似骨组织，是一动态结构，维持迷路内离子动态平衡，正常情况下耳石也会少量脱落，为吞噬细胞所消灭，这种情况多发生在囊斑、胶状壶腹嵴[11][12]和内淋巴囊[13]。BPPV病理生理：耳石脱落过多或吸收障碍时,异位进入半规管，当达到或超出临界状态时“criticalmass”[图1]

[图2]

？BPPV后半规管开窗所见耳石团块ThevestibularsystemBPPV分类原发性：占34～68％.继发性：以头部外伤为多见，约17%，其他可见发生于梅尼挨病、迷路炎、偏头痛、中耳术后、头颅外伤等.按解剖部位分类:PC—BPPV,HC—BPPV,SC—BPPV,NC—BPPV.Schuknecht分类:自限性、复发性和顽固性.Dix—HallpikeTest[2]

取坐位,观察有无自发性眼震,头转向一侧45°,迅速仰卧,与水平面呈30°角，观察有无眩晕及眼震.HC-BPPVtestMcClureJA(1985)[14][图5]

:Rolltest:Thepatientlyingsupineandtheheadmovedtobothsides.RahkoT(2001)[15][图6]

:WRWtest:thepatientwalksforwardandrotatesbrisklyontherotationdirectionfootandreturnsback.RolltestRahkonWRWtestHC-BPPV诊断标准在床上向左右翻身时发作，当头转向患侧时眩晕或眼震变剧烈，做头部的垂直运动如抬头或弯腰矢状面运动则不引起眩晕.潜伏期稍短，约2～3秒.持续时间略长,可达1分钟.疲劳性不明显.Rolltest阳性,两侧均出现向地性水平性眼震,以患侧更强烈(canalithiasis)或背地性水平性眼震,但以健侧更强烈(cupulolithiasis).眼震方向与头转动方向一致，称为向地性水平性眼震,否则为背地性水平性眼震SC-BPPVtestRAHKOTmanoeuvre[16][图7]

:Whentheposteriorandhorizontalcanalswerefreeofotoconia,thepatientswereinstructedtobowforward60°andstraightenbackwithclosedeyesquickly.Theobserverrecordedthepossiblemovementofthepatientsidewaysduringstraightening.Dix—Hallpiketest[2].SC-BPPV诊断标准典型病史及症状：特殊体位出现旋晕、恶心、呕吐排除PC-BPPV和HC-BPPV.SC-BPPVtest阳性oraDix—Hallpiketest.有下跳性、扭转性眼震管石复位原理示意图PC-BPPV手法复位示意图Brandt-DaroffExercises

HC-BPPV手法复位Lempertmanoeuvre(1996)[17]orBarbecuemanoeuvre:Thepatientislyingsupine.Herotatestheheadtothehealthysideby90°,thenturnstotheproneposition,theheadisturnednose-downandagaintheheadisturnedwiththeaffectedeardown,eachphase30s.Finally,thepatientsitsup.Gufoni’sliberatorymanoeuvre(1998)[18]:(A)Thepatientisseated.(B)Thepatientisquicklybroughttotheside-lyingpositionontheaffectedside.(C)Theheadofthepatientisquicklyturned45degreesupward.(D)Thepatientreturnstothesittingposition.PositionsBandCaremaintainedfor2minutes.LempertmanoeuvreSC-BPPV手法复位Honrubiamanoeuvre(1999)[19]:ThetreatmentwasareverseEpleymanoeuvreorareverseSemontmanoeuvre.RahkoTmanoeuvre[16]:thepatientliesonthehealthyside,theheadistilteddownwards45°,thenhorizontally,upwards45°for30seach,andfinallythepatientsitsupandstaystherewellsupportedforatleast3min.RahkoTmanoeuvreBPPV疗效判定症状消失Dix—Hallpiketest、HC-BPPVtest或SC-BPPVtest阴性416例BPPV临床资料自1997至2007年间，共收集416例BPPV病人，其中男136例，女280例，平均年龄