BPPV良性发作性位置性眩晕

会计学1BPPV良性发作性位置性眩晕BasicAnatomy第1页/共37页BPPVBarany1921Dix-Hallpike1952–importantfeaturesofnystagmusAbnormalsensationofmotionelicitedbycertaincriticalpositionsProvocativepositionnystagmusAtleast20%ofvertigoUnderestimated第2页/共37页BPPV…Subclassification:sccpost/lat/ant/bilatPathophysiology:Canalithiasiscupulolithiasis第3页/共37页Pathophysiology第4页/共37页Pathophysiology(cont.)Cupulolithiasis:HaroldSchuknecht1962Densities(otocania)adherenttocupulaofcristaampullarisBasophilicparticles-1969第5页/共37页Canalithiasis:JohnEpley–1980DensitiesfreefloatingincanalportionParnes,McClure–1991foundparticlesinpostSCC第6页/共37页BPPV...Frequency:10-64/100000Sex:64%womenAge:olderpopulation(51-57)youngerthan35–headtrauma.History: suddendays-weeksoccassionallymonths-years episodes. 第7页/共37页Physical:neurologicalexamination–normalexcept–Dix-Hallpikepathognomonic第8页/共37页BPPV…Nystagmus:characterizationandtypesRT/LT,vertical/horizontal,changingTortional=Rotational–clockwise/counterclockwiseGeotropic-towardtheearthAgeotropic–opposite第9页/共37页BPPV…ClassicpostSCC–geotropicrotatorynystagmusHorizontalSCC–purelyhorizontalnystagmusNon-fatiguingnystagmus–cupulolithiasis>canalithiasis第10页/共37页ClassicBPPVInvolvedthePOSTSCCGeotropicNGwithaffectedeardownRotatory,fastphasetowardtheundermostearLatency–fewsecondsDuration–limited<20secondsReversaluponreturnuprightpositionResponsedeclineuponrepetitiveprovocation第11页/共37页Lat.SCCPPVMostcommonatypicalBPPV3-9%ofcasesConsequenceofEpleymaneuverHorizontalpurelynystagmusCupulolithiasisratherthancanalithiasisModifiedEpley/lampertmaneuver…第12页/共37页Lat.SCCPPV第13页/共37页Ant.SCCPPVRare–2%Down-beating/torsionalNGfortheoppositeearonDix-Hallpikemaneuver第14页/共37页BPPV-CausesPredisposingfactors:InactivityAcutealcoholismMajorsurgeryCNSdisease第15页/共37页Causes(cont.)Idiopathic–39%Eardisease–29%OM–9%Vestibularneuritis–7%Menier’sdis–7%Otosclerosis–4%SuddenSNHL–2%Trauma–21%第16页/共37页Causes(cont.)Trauma–21%CNSdiseases–11%Acusticneuroma–2%Cervicalvertigo–2%第17页/共37页BPPV-D.DMenier’sdiseaseInnerearconcussionAlcoholintoxicationLabyrinthitisVascularloopsyndromePost.Fossalesions:acusticneuroma,meningiomaCentralorigion:stroke,MS,cerebellardegenerationVertibralarteryinsuffeciencyCervicalvertigo第18页/共37页BPPV-TreatmentWatchfulwaitingVestibularsuppressantmedicationsVestibularrehabilitationCanalithrepositioningSurgerycareLabyrinthectomyPost.CanalocclusionSingulaneurectomyTranstympanicaminpglycosideapplication第19页/共37页TrialsaboutBPPV第20页/共37页GeneralLabeledbenignparoxysmalpositionalvertigoisnotalwaysbenignEvaluationoftheeffectivenessofcanalithreepositioningprocedurs–CRPSeveralstudies…第21页/共37页Trials…Blakely–1994:50%improvementinthecontrolandCRPgroup!!(2-3months)Lynn–1995:Randomized-controlled:89%negativeDHinCRPgroup,27%inthecontrolgroupJohnLi(1995):第22页/共37页Trials…JohnLi(1995):ComparisonCRP/CRP+mastoidoscillationandcontrolModifiedEpleymaneuverUseofcolarandheadelevationafterCRPNospontaneousresolutionwithinaweek60%symptomsimprovementinCRPgroup92%symptomsimprovementinCRP+mastoidoscilationand70%negativeDH第23页/共37页Trials…R.steenerson–1996:ComparisonofCRPandvestibularhabituationtrainingTowapproachesareeffectiveinsymptomaticrelief(3months)CRPfasterreliefandfewertreatments第24页/共37页Trials…K.Yimatae(2003)Randomized-controoledModifiedEpleymaneuver,nomastoidoscillatorandnoinstructionsafterthemaneuverSubjectiveandobjectiveweeklyfollow-upCRPgroup–76%negativeDH,48%controlgroupCRPgroup–96%symptomsimprovement,90%controlgroupNon-curedpatientsneed>6proceduresin2weeks,shouldconsideringliberatorymaneuver第25页/共37页ElderlypopulationandBPPVS.Angeli–2003:EffectivenessofCRPandVRModifiedEpley:Elderlycomorbidities:degenerativeosteoarthritisdisease,CVA,peripheralneuropathy,cognitiveandautonomicdysfunctionsS/EofCRP–necktorsionandextensionresultinvertibrobasilararteryinsufficiency,strainonthespinecolumn,dislodgedcarotida.emboliAvoidliberatorymaneuver64%CRPgroup–negativeDHafteramonthOverall77%withCRPandVR第26页/共37页CRPMeta-Analysis

B.Woodworth-2004CRP-FirstlineoftreatmentNon-invasiveEasytoperformintheofficeNoneedtoexpensiveinstrumentationsRepeatmaneuverifneededPotentialtoproviderapidreliefofvertigo

第27页/共37页Meta-Analysis9randomized-controlledtrialsSymptomsresolutionandeliminationofpositiveDix-HallpiketestCRPmoreeffectivethancontrol(x5)Untreatedpatients-symptomsimprovementswithtimebutpositiveDHSoResolutionofvertigo–avoidanceofprovocativepositions第28页/共37页CRP–Epleymaneuver第29页/共37页CRP–Semontmaneuver第30页/共37页Mastoidoscillator第31页/共37页Brandt-DaroffEx