Benign Paroxysmal Positional Benign Paroxysmal Positional Vertigo(BPPV) of the Vertigo(BPPV) of the

Posterior(PSC) & Horizontal Posterior(PSC) & Horizontal Semicircular Canals(HSC)Semicircular Canals(HSC)

2003. 6. 25경상대학교 의과대학

경상대학교병원 이비인후과학교실안 성기

BPPV

Anatomy of Vestibular organAnatomy of Vestibular organ

Vestibule

( 전정 )

Crista ampullaris

( 팽대부릉 )

BPPV

Historical aspects(I)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

BPPV

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

BPPV

Historical aspects(II)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

BPPV

TerminologyTerminology1.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 nystagmus4. Ampullopetal(utriculopetal)(HSC) vs ampullofugal(utriculofugal)(PSC, ASC)5. Ewald’s law

BPPV

1.Nystagmus(fast component)

(Rt., Lt., Up, Down.)

* 안진의 방향

=> 급속상의 성분

수평채널에서 위쪽 ; right beat

수직채널에서 위쪽 ; up-beat

수평채널에서 아래쪽 ; left beat

수직채널에서 아래쪽 ; down-beat

2.Canalolithiasis

a.Long arm(non-ampullary

or post. portion)

b.Short arm(ampullary or ant.

portion)

Cupulolithiasis

Canalolithiasis

Cupulolithisais

예 ) Right HSC

Long arm

Short arm

BPPV3. Geotropic vs a(po)geotropic

Nystagmus

Geotropic( 향지성 )

Right D-H test

Ageotropic( 원지성 )

Right D-H test

4. Ampullopetal(utriculopetal) (HSC) – excitation, Ewald 2nd

law

vs

Ampullofugal(utriculofugal)

(PSC, ASC) – excitation, Ewald 3rd law

BPPV

Actions of Extraocular musclesActions of Extraocular muscles

HSC PSC ASC

Rt.

Slow phase

Fastphase

Lt.

BPPV

Etiology of BPPVEtiology of BPPV

1) idiopathic(M/C)2) post-trauma3) Neurolabyrinthitis4) SNHL5) URI6) COM7) Postoperation(ear, general)8) Ototoxicity

BPPV

Occurrences of positional Occurrences of positional vertigo(Hx.)vertigo(Hx.)

1. PSC BPPV; 앉았다 눕거나 , 누운 상태에서 일어날때 , 몸을 앞으로 굽히거나 펼때 , 위를 보기위해 머리를 들때 등 2. HSC BPPV; 누운상태 ( 잠자면서 ), 앉은 상태 , 보행시 머리를 돌리거나 몸을 회전할 때 * 각 반고리관의 평면을 따라 두부회전시 병변이 있는 반고리관이 흥분하거나 억제되어 어지러움 유발

BPPV

Diagnosis of PSC-BPPVDiagnosis of PSC-BPPV

* Dix-Hallpike Maneuver

BPPV

BPPV

Criteria for Classic Dix-Hallpike RespoCriteria for Classic Dix-Hallpike Responsense

1)subjective vertigo2)transient torsional(rotary) nystagmus3)fatigability4)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.

BPPV

Clinical Features of HSC-BPPVClinical Features of HSC-BPPV

- 6–24% of all patients with BPPV- M;F = equal- Mean age; 58.1- Etiology; idiopathic(M/C), post-traumatic, neurolabyrinthi

tis, 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

BPPV

Diagnosis of HSC-BPPVDiagnosis 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 Ewald’s the 2nd law (Baloh, Nuti)

BPPVCanalolithiasis type(geotropic nystagmus) of HSC-BPPV

BPPVCupulolithiasis type(ageotropic nystagmus) of HSC-BPPV

BPPV

Treatments of PSC-BPPVTreatments 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)

BPPV

Brandt-Daroff Habituation Exercise(1Brandt-Daroff Habituation Exercise(1980)980)

1. 환자가 한다 .

2. 하루 수차례 시행할 수 있다 .

3. 방법 ;

a. 앉은 자세에서 어지러움 유발되는 쪽으로

갑작스럽게 눕는다 . 어지러움이 없어진 후

30 초 정도 더 누워있다가 앉는다 .

b. 약 30 초 후 반대편으로 운동 반복한다 .

BPPV

Liberatory maneuverLiberatory maneuver(Semont, 1988)(Semont, 1988)

1. 검사자가 한다 (1 회 ).

2. 방법 a. 앉은 자세에서 갑자기 환측으로 눕힌다 .

b. 2-3 분 후에 반대쪽으로 빠르게 눕힌다 . 이 상태로 5 분 정도 유지 c. 이후 천천히 앉은 자세로 돌린다 .

BPPV

Canalith Repositioning Procedure(CRP)Canalith Repositioning Procedure(CRP)(Epley, 1992)(Epley, 1992)

BPPV

BPPV

Treatment of HSC-BPPVTreatment 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

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

BPPV

Treatment of HSC-BPPVTreatment 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

BPPV

BPPV

Treatment of HSC-BPPVTreatment 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 ◦ barbec

ue method and followed by FPP)

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

BPPV

BPPV

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

PSC HSCIncidence 91% 6%

Inducing maneuver sitting to head hanging supine to head lateralNystagmus torsional, upbeating horizontal (geotropic) (geotropic, ageotropic) direction changingDuration <30sec >30sec

Latency 2-20 sec <3sec

Fatigability yes no*

BPPV

Failures of Therapeutic Failures of Therapeutic ManeuverManeuver

1)Too big particles(Nuti, 1998)2)Incorrect affected site3)Severe adhered to the cupula4)Inappropriate Tx.(Fife, 1998)5)Central origin vertigo6)Cervical spondylosis7)Obesity

BPPV

남자 여자 총1-10 세 1 1

11-20 세21-30 세 1 1

31-40 세 5 6 11

41-50 세 2 7 9

51-60 세 2 8 10

61-70 세 2 9 11

71 세이상 4 411 37 48

경상대학교병원 이비인후과 Vertigo clinic

총 300 명중 48 명이 BPPV 진단 (2002 년 6 월 -2003 년 5 월 )

BPPV* Canal 별 발생 빈도1. PSC canalolithiasis; 28 명 cupulolithiasis; 3 명2. HSC canalolithiasis; 14 명 cupulolithiasis; 2 명3. ASC canalolithiasis; 1 명4. Combined type 2 예 (PSC + HSC)5. Change of SCC after Tx.(1 예 ) (PSC canalolithiasis -> HSC canalolithiasis)

* Associated ds. or Causative primary ds.

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

BPPV

* Recurrence

HSCcanalolithiasis 14

명중 2 명이 재발

동측의재발

재발까지의 기간

반대측발생

동반질환

Case 1 + 7 일 - Headtrauma

Case 2 + 40 일 - Idiopathic

PSCcanalolithiasis 28

명중 3 명이 재발

동측의 재발

재발까지의 기간

반대측 발생

동반질환

Case 1 + 20 일 - Idiopathic

Case 2 + 19 일 - Headtrauma

Case 3 + 30 일 - VBI

BPPV

ConclusionsConclusionsBPPV 와 같은 증상을 보이는 환자가 오면특징적인 문진을 하고 신체 검사 및 기타 검사를 통하여 중추성 어지러움배제시킨다 .그런 후에 말초성으로 인한 어지러움이라고 판단되면 세개의 반고리관에서 어느 부위인지 , 또한 부위가 결

정되면 canalolithiasis 또는 cupulolithiasis 알아야 한다 . 그리고 항상 2 개 이상의 반고리관에 병변이 있을 가능성을 염두해 두어야한다 .

* 적절한 재활 치료

BPPV

cupula

Crista ampullaris

BPPV

평형반 (macule) 의 기본 구조 이석 (otoconia or otolith)

BPPV

BPPV

억제 흥분

흥분 억제

* Ewald the 2nd law

Rt. HSC - geotropic type

Rt. HSC - ageotropic type