BPPV 2 Flashcards
Semont Liberatory Manoeuvre (Canalithiasis/Cupulolithiasis)
For posterior canal canalithiasis or cupulolithiasis.
• 50-90% response (1-5 sessions)
Non-Amullary Arm – Posterior BPPV
• Be directed from torsion for the side to treat (towards side of rotation)
o Left Torsional DBN (usually in the right HPDix)
♣ Left Epley or Left Semount
o Right Torsional DBN (usually in the left HPDix)
♣ Right Epley or Right Semount
Anterior SCC
• Treatment is the same as for posterior SCC
o Epley
• Anterior canal specific treatment tools
o Deep head hand (don’t need to know side of crystals)
Modified Liberatory Manoeuvre for Anterior SCC
For anterior canal cupulolithiasis.
- The head is turned toward the involved side and the patient rapidly lies down on the involved side so the nose is pointed 45 to the floor
- After 2 minutes the patient is rapidly moved through sitting onto the other side (nose now pointing towards ceiling) – stay a further 2 minutes
Horizontal Canal BPPV
- Approx. 5-10% of patients
* Posterior canal BPPV can convert to horizontal canal
BPPV after the CRM treatment
HSCC Canalithiasis ¬ BBQ Roll ¬ Forced Prolonged Positioning ¬ Modified Brandt Daroff HSCC Cupulolithiasis ¬ Casani Manoeuvre (Semont manoeuvre modified by Casani) Short Arm Apogeotrophic Horizontal BPPV ¬ New Gufoni ¬ Deep BBQ Roll
Brandt-Daroff Exercises
¬ 95% success rate in 3-14 days
¬ 5-10 repetitions / 3x per day
Used when:
- CRT has failed/patient too anxious to consent to CRT, or if unsure of involved ear
- Continued until patient experiences 2 consecutive symptom-free days
BPPV: Outcomes
• 15-20% recurrence rate for BPPV
• Common to have multiple canal involvement
• Need to come back for re assessment
• Can only treat one canal at a time
To self-manage, have patient exercise at home:
A. Brandt – Daroff exercises (5 cycles, once a day)
B. CRM – Self-Epley (1 cycle, once a day)
When to Refer On
- If you are not sure of BPPV diagnosis
- If you have attempted to treat them for BPPV but the patient is not responding to treatment (3-4 sess.)
- Any neurological or audiology signs
- Refer on to appropriate person for full vestibular/medical/neurological assessment
Vestibular Clinical Reasoning Flow Chart
Habituation
HABITUATION TRAINING:
Commence with 2-3 movements that:
◦ cause mild - moderate dizziness
◦ Symptoms settle quickly when movement stops
E.g. rolling, bending, turning
Patient performs up to 5 reps, twice daily
Movements should be performed quickly enough and through sufficient range to produce mild to moderate symptoms
Brandt-Daroff exercises
Patient should rest between each movement until the symptoms stop (should be <1min)
May take 4 - 6weeks for the symptoms to settle
Vestibular Rehab Summary: How much / how long?
Aim 60 - 70 minutes / day including
30 minutes outdoor walk (NOT treadmill inside!)
x 5 reps of gaze stability
x 2 reps of balance exercises
Dynamic visual acuity should begin to improve within 3-4 weeks - most better/improved by 6-8 weeks
Semicircular canals (SCC)
• “Rate sensors”
• Provide sensory input about head velocity
• Enables the Vestibular ocular reflex (VOR) to
generate an eye movement that matches the velocity
of the head movement.. More information to follow
• Alignment of the SCC are characterised by three
important spatial arrangements
Co-planar pairing of SCCs
• “Push-pull” rhythm
– the endolymph of the co-planar pair is displaced
in opposite direction with respect to to the
ampulla
EXCITATION:
“ a canal is excited by head motion towards that
canal, in the appropriate plane”
– The right horizontal canal is excited by right head turns
– The right posterior canal is excited by right posterior head tilts
– The left anterior canal is excited by left anterior head tilts Head turns will cause excitation of one vestibular
nerve and inhibition of its paired canal
Otolith organs: Utricle and Saccule
Otolith organs: Utricle and Saccule • are arranged to enable them to respond to motion in all three dimensions in an upright individual – saccule = vertical – utricle = horizontal Sense linear acceleration of the head – occipito-caudal – antero-post – lateral • Sense orientation of the head with respect to gravity (tilt)
