1. 17 2 2006 KISEPSpecial Article J Clinical Otolaryngol 2006;17:174-181 Diagnosis and Management of Benign Paroxysmal Positional Vertigo of Posterior Semicircular CanalWon-Ho Chung, MD and Kye Hoon Park, MD Department of Otorhinolaryngology-Head and Neck Surgery, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea BPPV BPPV (7~17%), , , , , . ( BPPV) . 1) , 18.3% . , , . . , BPPV 100,000 10.7 64 2)3), (History). BPPV . (free floating debris) . . . (idiopathic) , 50~70% . (secondary) . , 135-710 50 . (02) 3410-3579(02) 3410-3879 , E-mailwhchung@smc.samsung.co.kr 174

2. 45 30 ABFig. 1. Dix-Hallpike maneuver (right ear). The patient is seated and positioned so that the patients head will extendover the top edge of the table when supine. The head is turned 45toward the ear being tested (position A). Thepatient is quickly lowered into the supine position with the head extending about 30 below the horizontal (position B).The patient head is held in this position and the examiner observes the patients eyes for nystagmus. . Sagittal 30 1 Frontal . 45 . , , , . . (Diagnostic maneuvers) BPPV Dix-Hallpike 19524) . . 1) Fig. 2. Side-lying test (right ear). The subjects head is tur- ned with the nose pointing 45away from the side to be , . tested (The head is turned left). Then, the subject is briskly laid on the side being tested. The examiner is not shown, but supports the subjects head. Arms are crossed to pre- . 2) vent the patient from inadvertently stopping the motion. . 3) 30 30 . (B) . 45 (A) 1~5 30 175 3. J Clinical Otolaryngol 2006;17: 174-181. (Fig. 1).. Dix-Hallpike side- , , lying . 45 5)Rt.Slow Phase Lt. (Fig. 2). Excitability , IOSOSRIRInhibitory . IIIIII IV IV (Fig. 3). , SL MLF . MMLF (trochlea) X 51 I (Fig. 4A). , Fig. 3. Excitation of the right posterior semicircular canalcauses contraction of the ipsilateral superior oblique mus- (Fig. 4B) cle and the contralateral inferior rectus muscle. The result (Fig. 4C)will be left-rotatory and downward vertical movement ofeyes. To overcome this movement, right-rotatory and (Fig. 4D).upward vertical nystagmus is appeared. Ssuperior ves-tibular nucleus, Llateral vestibular nucleus, Iinferior vestibular nucleus, Mmedial vestibular nucleus, IIIocu- lomotor nucleus, IVtrochlear nucleus, MLFmedial lon-gitudinal fasciculus. SRsuperior rectus muscle, SO . (cupulolithiasis) Dix-superior oblique muscle, IRinferior rectus muscle, IO Hallpike inferior oblique muscle. The dotted lines mean excitatory,and the solid lines mean inhibitory. . X axis Action Rotational plane 5139axis SO Y axisLR SR A BCDFig. 4. Rotational axis and action plane of right superior oblique muscle and direction of nystagmus on eye positions. AThe eye movements by superior oblique muscle are internal rotatory and downward vertical through the influence ofthe trochlea. The axis of trochlea forms about 51 with X axis. When gaze is directed about 39laterally, only internal ro-tatory movement occurs because of the right angle between the rotational axis and the action plane of superior ob-lique muscle. But when gaze is directed to the nasal side, mainly downward movement occurs. The nystagums changesduring Dix-Hallpike maneuver for posterior canal BPPV depending on the eye position. BThe fast component nystag-mus is mainly rotatory when gaze is directed toward the lesion side. CThe fast component nystagmus is upward whengaze is directed to the normal side. DWhen the eyes are in the neutral position, the fast component nystagmus is bothupward vertical and rotatory toward the lesion side. SOsuperior oblique muscle, LRlateral rectus muscle, SRsuperior rectus muscle. 176 4. Dix-Hallpike Frenzel 6) . Frenzel . , , 7) . Frenzel . . , Fig. 5. Brandt-Daroff exercises. Start sitting upright. Then (Infraredmove into the side-lying position, with the head angledvideography) upward about half-way. Stay in the side-lying position for 30 seconds, or until the dizziness subsides, then go back to . the sitting position. Stay there for 30 seconds and then go to the opposite side and follow the same routine. Dix-Hallpike , , . 8) 9) 14)subjective BPPV . Haynes , Tirelli 1992 Epley . 10) Weider subjective BPPV 76~93% BPPV . Dix- . Hallpike . . , , Brandt-Daroff 8) . 30 BPPV . 30 (Fig. 5). BPPV . 20 . , 11) . cupulolithiasis canalolithiasis . 12)15). Brandt Daroff 1980 BPPV , , 12)13). 1988 Semont . 177 5. J Clinical Otolaryngol 2006;17: 174-181 AParticles Utricle Bin posterior canal CCupula A B C Fig. 6. Semont liberatory maneuver (right ear). AThe patient is sitting with the head turned horizontally 45 the healthy (left) ear. BMo- to ving to right side-lying position. C Moving to left side-lying position.14)(Semont liberatory maneuver) . (mechanical . 5 skull vibrator) . Par-20)21). 5~10 nes (Fig. 6). 3 Semont 84% Epley (modified Epley maneuver) , 1 93% , . 13) . 52~90% Hain 8)16-18) 18) 22) 29% . Herdman 19) Cohen . (Fig. 7) Dix-Hallpike (B). . 90 (C). (Modified Epley maneuver) 90 (D), 1992 Epley 5 ( ) . 178 6. 135 90Superior45canal D D Utricle Cupula Particles in posterior canal A B 45 135 D D C DFig. 7. Modified Epley maneuver (right ear). AThe patient is seated on a table as viewed from the right side. BPatient in normal Dix-Hallpike head-hanging position. The patients head is then rotated toward the opposite side withthe neck in full extension through position (C) and into position (D) in a steady motion by rolling the patient onto theopposite lateral side and then the patient sits back up to position (A). (common crus) (reverse nystagmus) 3) . . . 1~2 , , 8) 30~100% . ( 30). BPPV 5 , 1 , 1 24~48 82.2% 24) . . 17)23) BPPV . 1 . BPPV 22). , . . 1 (Singular neurectomy) 179 7. J Clinical Otolaryngol 2006;17: 174-181 (posterior ampullary nerve) 4) Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular sys-25) 1970 Gacek tem. Ann Otol Rhinol Laryngol 1952;61:987-1016. 5) Cohen HS. Side-lying as an alternative to the Dix-Hallpike test of the posterior canal. Otol Neurotol 2004;25:130-4. 6) Bronstein AM. Vestibular reflexes and positional manoeuvres. .J Neurol Neurosurg Psychiatry 2003;74:289-93.7) Straumann D, Suzuki M, Henn V, Hess BJ, Haslwanter T. Visual suppression of torsional vestibular nystagmus in rhe- (Posterior semicircular canal occlusion)sus monkeys. Vision Res 1992;32:1067-74. 26-28)8) Haynes DS, Resser JR, Labadie RF, Girasole CR, Kovach BT,Parnes 1990 Scheker LE, et al. Treatment of benign positional vertigo using the semont maneuver: efficacy in patients presenting without nystagmus. Laryngoscope 2002;112:796-801. 9) Tirelli G, DOrlando E, Giacomarra V, Russolo M. Benign positional vertigo without detectable nystagmus. Laryngo- scope 2001;111:1053-6. 10) Weider DJ, Ryder CJ, Stram JR. Benign paroxysmal posi- . tional vertigo: analysis of 44 cases treated by the canalith repositioning procedure of Epley. Am J Otol 1994;15:321-6. 11) McClure JA, Willett JM. Lorazepam and diazepam in the .treatment of benign paroxysmal vertigo. J Otolaryngol 1980; 9:472-7. 2~3 . 5~6 cm 12) Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol 1980;106:484-5. 13) Semont A, Freyss G, Vitte E. Curing the BPPV with a libera- . tory maneuver. Adv Otorhinolaryngol 1988;42:290-3. 13 mm bone dust fibrinogen 14) Epley JM. The canalith repositioning procedure: for treat- ment of benign paroxysmal positional vertigo. Otolaryngolglue plug . Head Neck Surg 1992;107:399-404. 2~3 . 15) Banfield GK, Wood C, Knight J. Does vestibular habitua- tion still have a place in the treatment of benign paroxysmal positional vertigo? J Laryngol Otol 2000;114:501-5. 16) Norre ME, Beckers A. Comparative study of two types of exercise treatment for paroxysmal positioning vertigo. Adv. .Otorhinolaryngol 1988;42:287-9. 29)Agrawal 44 17) Nuti D, Nati C, Passali D. Treatment of benign paroxysmal positional vertigo: no need for postmaneuver restrictions. 1 Otolaryngol Head Neck Surg 2000;122:440-4. 3 18) Herdman SJ, Tusa RJ, Zee DS, Proctor LR, Mattox DE. Single treatment approaches to benign paroxysmal positio-. nal vertigo. Arch Otolaryngol Head Neck Surg 1993;119:30-34) 450-4. . 19) Cohen HS, Jerabek J. 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