Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Neuro Dev/Control II > Evaluation & Treatment of Benign Paroxysmal Positional Vertigo (BPPV) > Flashcards

Evaluation & Treatment of Benign Paroxysmal Positional Vertigo (BPPV) Flashcards

1
Q

Describe the ampulla

A
  • Enlargement of semicircular canal
  • Hair cells contained in each ampulla & otolith organ convert displacement due to head motion into neural firing, the hair cells of the ampullae rest on the crista ampullaris
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Describe the cupula

A
  • Diaphragmatic membrane that overlies each crista & completely seals the ampulla from the adjunct vestibule
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Describe direction of cupular deflection

A
  • Deflection toward the kinocilla = excitation
  • Deflection away from the kinocilla = inhibition
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is VOR gain

A
  • During rapid head movement (VOR) keeps focused on target
  • Eye movement equal speed and opposite direction to head movement
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is responsible for the slow phase of nystagmus

A
  • Vestibular stimulation is responsible with asymmetric firing of vestibular nucleus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Describe direction of eyes based on canal

A
  • Anterior: Ipsi SR = ipsi eye elevation/intorsion; contra IO = contact eye elevation/extorsion
  • Horizontal: ipsi MR = ipsi eye adduction; contra LR = contra eye abduction
  • Posterior: ipsi SO = ipsi eye depression/intorsion; contra IR = contra eye depression/extorsion
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What type of nystagmus will BPPV not present with

A
  • Will not present as spontaneous or gaze evoked nystagmus
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Ture/False BPPV is caused by a peripheral vestibular hypofunction

A
  • False, it is NOT caused by peripheral vestibular hypofunction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How to differentiate between other triggered episodic vestibular syndrome

A
  • BPPV: positional related vertigo like rolling in bed, picking up an object from the floor
  • Postural hypotension: orthostatic vitals
  • Perilymph fistula: symptoms exacerbated by Valsalva
  • Superior canal dehiscence: auditory symptoms, autophony, Tullio phenomenon, Valsalva exacerbates symptoms
  • Vertibrobasilar Insufficiency: abnormal vertebra artery test -> positional tests are not unique to VBI
  • Central paroxysmal positional vertigo: doe snot respond to carnality repositioning maneuvers
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

BPPV testing based on age

A
  • Given prevalence of BPPV in the elderly, if pt’s >65 years old complain of dizziness, it’s a good idea to rule out BPPV, even if history does not sound like BPPB
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Classic symptoms of BPPV

A
  • Brief (typically <1 minute) episodes of vertigo associated with changes in head position relative to gravity
  • Lying down- rising from horizontal orientation (PC/AC)
  • Rolling over in bed (HC)
  • Bending over (AC)
  • Looking up (PC)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Describe difference between canalithiasis and cupulolithiasis

A
  • Canal: A theory for the pathogenesis of BPPV that proposes that there are free-floating particles (otoconia) that have moved from the utricle and collect near the cupula of the affected canal, causing forces in the canal leading to abnormal stimulation of the vestibular apparatus.
  • Cupulo: A theory for the pathogenesis of BPPV that proposes that otoconial debris attached to the cupula of the affected semicircular canal cause abnormal stimulation of the vestibular apparatus.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Canalithiasis process of causing nystagmus

A
  • Reorientation of the canals relative to gravity causes the otoconia to move to the lowest part of the canals
  • Increased drag on the endolymph
  • Increased fluid pressure on the cupula
  • Activating the ampullary organ
  • Nystagmus/vertigo
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Describe BPPV canalithiasis

A
  • Latency of nystagmus occurs as a result of the time needed for motion of the otoconia within the posterior canal to be initiated by gravity
  • Nystagmus duration is correlated with the length of time required for the otoconia to reach the lowest part of the canal
  • Vertical and torsional components of nystagmus are used to determine canal involvement
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Describe BPPV cupulolithiasis

A
  • Dislodged otoconia directly attach to the cupula, weighting this membrane.
  • Reorientation of the canal relative to gravity deflects the cupula, exciting or inhibiting the ampullary organ
  • Immediate onset of symptoms/nystagmus with provocative head position
  • Symptoms/Nystagmus will persist as long as patient is in the provocative position
  • More common with horizontal canal BPPV
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is the dizziness handicap inventory and what is included

A
  • 5 item BPPV sub scale that is a significant predictor of the likelihood of having BPPV
  • Does looking up increase your problem?
  • Because of your problem, do you have difficulty getting into or out of bed?
  • Do quick movements of your head increase your problem?
  • Does turning over in bed increase your problem?
  • Does bending over increase your problem?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is the gold standard for posterior canal BPPV

A
  • Dix-Hallpike Test
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What is the sidelying test for posterior canal BPPV

A
  • An alternative to the Dix-Hallpike Test for patients who are unable to tolerate the Dix-Hallpike position due to neck Orr back pain
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Describe fluid dynamics and nystagmus in posterior canal BPPV

A
  • Vertigo & nystagmus begin after a characteristic latency of about 5 sec
  • The delay in onset of Sx is caused by movement of detached otoconia through the ampulla
  • Pressure caused by moving otoconia is negligible until otoconia enter the narrow duct of the SCC (semicircular canal)
  • Under the influence of a full 1 g of gravity, typical otoconia move at a rate of 0.2 mm/sec, or only about 1% of the circumference of the canal each second.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What can you do during the Dix-Hallpike Test if you’re unsure of the direction the nystagmus is moving

A
  • Have patient look toward the downward ear will exsensuate the torsion
  • Have patient look toward their nose will insensuate the vertical beat
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Dix-Hallpike Test diagnostic accuracy

A
  • Sensitivity 82% & specificity 71% in posterior canal BPPV primarily among specialty clinicians
  • A negative Dix-Hallpike maneuver does not necessarily rule out a diagnosis of posterior canal BPPV
  • Dix-Hallpike maneuvrer may need to be repeated at a separate visit to confirm the diagnosis & to avoid a false-negative result
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Posterior canalithiasis BPPV diagnostic criteria

A
  • Vertigo associated with characteristic ocular nystagmus that is up-beating & torsional (toward the dependent ear)
  • Latency of 1-40 sec before the onset of vertigo & nystagmus
  • Vertigo & nystagmus with a duration of less than 60 sec
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Which canal is most frequently involved in BPPV

A
  • Posterior canal accounts for 80-90% of cases
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Posterior cupulolithiasis BPPV diagnostic criteria

A
  • No latency
  • Permanent nystagmus that persists as long as the head is positioned so that the canal being stimulated is not horizontal
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What should you be caution of for BPPV treatment

A
  • Patients with symptoms consistent with those of BPPV who do not show improvement or resolution after undergoing the CRP, especially after 2 or 3 attempted maneuvers, or those who describe associated auditory or neurologic symptoms should be evaluated with a thorough neurologic examination, additional CNS testing, and/or magnetic resonance imaging of the brain and posterior fossa to identify possible intracranial pathologic conditions.
26
Q

Describe how to perform Epley maneuver for PC-BPPV treatment

A
  • Patient is placed in the upright position with the head turned 45º toward the affected ear (ear that was positive on the Dix Hallpike test)
  • Patient is rapidly laid back to the supine head-hanging 20º position which is then maintained for 20-30 sec (Dr. Minor says at least twice as long as the nystagmus)
  • Head is then turned 90º toward the other (unaffected) side & held for 20 sec
  • Head is then turned again 90º such that the patient’s head is nearly in the facedown position which is held for 20-30 sec
  • Patient is then brought into the upright sitting position completing the maneuver
27
Q

Orrthotropic nystagmus in predicting the efficacy of Epley treatment

A
  • Orthotropic nystagmus occurring during the repositioning of the Epley maneuver especially in the third position (nose down) has certain value for predicting the successful repositioning of posterior canal BPPV
28
Q

What is canal conversion

A
  • When you perform the Epley maneuver incorrectly and dump the otolith crystals from the posterior canal into the horizontal canal
29
Q

Precautions for canalith repositioning

A
  • Most common complications include nausea, vomiting, fainting, & conversion to lateral canal BPPV during the course of treatment (canal switch/conversion)
  • Another potential side effect after the CRP is postural instability that can last 24 hours with a tendency to fall backward or forward
30
Q

Relative contraindications for canalith repositioning (CRP) meaning apply cautiously

A
  • Occipitoatlantal or atlantoaxial instability
  • Cervical myelopathy or radiculopathy
  • Severe carotid stenosis
  • Orthopnea
  • Unstable cardiac conditions
  • Retinal detachment
  • Glaucoma
31
Q

Describe how to perform the Semont-Libertory maneuver

A
  • Start with the patient sitting on a table or flat surface with the head turned away from the affected side
  • Quickly put the pt into the sidelying position toward the affected side with the head turned up, hold position for at least 20 sec after all nystagmus has ceased
  • Quickly move the pt back up & through the sitting position so that they are in the opposite sidelying position with the head facing down, hold position for about 30 sec (Dr. Minor says at least 1 min but 2 min if they can handle it)
  • At a normal or slow rate bring the patient back up to the sitting position
32
Q

What is the best method for treatment of cupulolithiasis

A
  • Semont-Libertory Maneuver but can also be used for treatment of canalithiasis
33
Q

The occurrence of a _________________ at the end of Epley and Semont maneuvers for PC-BPPV may be linked with treatment success.

A
  • Tumarkin-like phenomenon (severe feeling of falling retropulsion)
34
Q

Describe a Semont Plus maneuver

A
  • Instead of go to the table the head goes off the table past 90º
35
Q

Describe the importance of re-examination

A
  • Repeated positioning may cause a fatigue response that can mimic successful treatment
  • To separate the effects of active treatment from a fatigue response, outcome should be assessed 24 hours or more after treatment.
  • Dix-Hallpike Test is critical for determining the outcome of particle repositioning maneuvers.
  • The absence of the characteristic nystagmus indicates the resolution of PC BPPV.
  • The patient’s report of vertigo is more variable than the observation of the characteristic nystagmus on positional testing
  • Patients with positive findings on the DHT may report no vertigo at the time of follow-up if provoking positions are avoided or if they have unrecognized BPPV (imbalance with no vertigo)
36
Q

Describe anterior canal BPPV

A
  • Uncommon accounting for 1-3% of cases
  • Most prominent characteristic, positional down-beating nystagmus, which also occurs as central positional nystagmus associated with various brainstem & cerebellar lesions, & may indicate a sinister pathology
  • Down-beating nystagmus in AC-BPPV is often accompanied by a less pronounced torsional component, which is thought to indicate the affected side
37
Q

Treatment of anterior canal BPPV

A
  • Overall success rate of 85.6% for AC-BPPV, which is in the same range as for the posterior- and horizontal-canal variants.
  • Most case series applied the Epley (or reverse Epley) maneuver
  • Some authors used self-invented maneuvers, and others applied the Yacovino maneuver.
38
Q

How to answer the patient’s question for “is my vertigo going to come back?”

A
  • 5-13.5% report recurrent BPPV at 6 month follow-up
  • At 1 year after treatment 10-18% report recurrent BPPV
  • Recurrence rate increases over time & may be as high as 36%
  • Pts with BPPV after trauma are likely to demonstrate an even higher recurrence rate of their BPPV
39
Q

Describe how to perform Yacovino maneuver (AKA Deep Head Hanging maneuver)

A
  • Deep cervical extension
  • Deep cervical flexion
  • Once seated return head/neck to neutral
40
Q

Describe the supine roll test for horizontal canal BPPV

A
  • Direction changing positional nystagmus (DCPN) during supine head turning (Roll test)
  • Canalithiasis: geotropic (beats toward the ground) DCPN that is typically transient & fatiguable
  • Cupulolithiasis: Apogeotropic (beats away from the ground) DCPN is persistent & lacks latency or fatiguability
  • The above doesn’t tell you which ear is affected
  • Lateral semicircular canal BPPV is the 2nd most common type
  • Several studies have cited an incidence of approximately 5-22% in populations referred for evaluation & treatment of BPPV
  • Put the pt’s head in about 20º of flexion before rolling
  • Roll left first, then neutral, then to the right, should see the same tropic on both rolls, have to wait for nystagmus to fatigue/slow down to confirm canalithiasis
41
Q

Dix Hallpike test all 3 semicircular canals on that side so what determines the type of BPPV

A
  • The direction of the nystagmus
42
Q

Slide 65

A
43
Q

Describe the Bow and Lean test

A
  • Used to differentiate which side is involved in horizontal canal BPPV
  • From a seated position the pt’s head is bent forward to 90º (bowing), then tilted backward to 60º (leaning)
  • Canalithiasis: transient bowing nystagmus beating toward the affected side & a leaning nystagmus beating toward the healthy side are observed
  • Cupulolithiasis: bowing nystagmus beating toward the healthy side & leaning nystagmus beating toward the affected side are persistently observed
44
Q

How to tell in a supine roll test which ear is affected

A
  • The side with the more vigorous nystagmus is generally the one affected
  • The direction of nystagmus in supine in canalithiasis beating toward the unaffected side
  • Cupulolithiasis follows the opposite of the two above statements
45
Q

Slide 67

A
46
Q

Describe how to perform the BBQ Roll Maneuver (treatment for horizontal canal BPPV canalithiasis)

A
  • Start with the patient in supine OR some recommend rolling to start on the involved side
  • Roll the patient’s head to the unaffected side
  • Keep rolling in the same direction until their head is completely nose down or prone OR some recommend ending the maneuver here & returning to sit (270º roll) as anatomically the debris is repositioned
  • As originally published, complete the final roll (full 360º) and return to sitting
  • Each position is held for 15-30 sec or until nystagmus stops
47
Q

Describe how to perform the Gufoni geotropic Maneuver

A
  • Tx for horizontal canal canalithiasis BPPV
  • *May help to have pt lean back towards affected side before side-lying to make sure the otoconia are in the posterior portion of the horizontal canal
  • Initial sidelying position is towards the unaffected side for 2 minutes
  • Rapidly turn 45 degrees down, hold position for 2 minutes
  • Slowly return to sitting, cervical spine returned to neutral
  • This maneuver is sometimes referred to as the Modified Gufoni maneuver for canalithiasis
48
Q

Describe how to perform the Gufoni apogeotropic Maneuver

A
  • Tx for horizontal canal cupulolithiasis BPPV
  • AKA Casani Maneuver or modified Semont maneuver for horizontal canal cupulolithiasis
  • Initial sidelying should be towards “affected side” for 2 minutes
  • Turn head up 45 degrees for 2 minutes
  • Slowly return to sitting, return to neutral cervical rotation
  • Casani et al (2002) report 75% effectiveness with one maneuver
  • Proposed to dislodge otoconia from the cupula
  • May need to follow with BBQ Roll Maneuver
49
Q

Describe how to perform the Zuma Maneuver apogeotropic

A
50
Q

Describe how to perform the modified Zuma Maneuver geotropic

A
51
Q

Describe how to perform forced prolonged positioning for geotropic variant (canalithiasis)

A
  • Sidelying on affected side for 30-60 sec
  • Roll towards the healthy ear until sidelying with healthy ear down
  • Remain in this position all night
  • If the patient needs to get up during the night, repeat the maneuver as above
52
Q

Describe how to perform forced prolonged positioning for apogeotropic variant (cupulolithiasis)

A
  • The first step needs a prolonged position on the affected side to cause the displacement of otoliths from the ampullary arm to the non ampullary arm of the lateral canal.
  • After the conversion in the geotropic form, the patient will lie on the healthy side for about other 12 hours, to complete the otoliths movement toward the utricle.
  • Or, you could potentially treat with the BBQ Roll Maneuver
53
Q

What forced prolonged positioning

A
  • A home treatment for horizontal canal BPPV that does not respond to head maneuvers can be recommended
54
Q

Describe Brandt-Daroff exercises and posterior canal BPPV

A
  • A daily routine of Brandt-Droff exercises does not significantly affect the time of recurrence or rate of recurrence of BPPV-PC (posterior canal)
55
Q

Describe use of vestibular suppressant medications & anti-emetics for BPPV

A
  • Vestibular suppressants are not routinely recommended for treatment of BPPV
  • But they may be appropriate for short-term management of autonomic Sx such as nausea or vomiting in a severely symptomatic patient
  • Anti-emetics may be considered for prophylaxis for pts who have previously manifested severe nausea and/or vomiting with the Dix-Hallpike maneuvers& in whom a CRP is planned
  • Zofran improves nausea but doesn’t suppress nystagmus
56
Q

Describe coexisting vestibular system dysfunction (CVSD)

A
  • A BPPV treatment failure may be subsequently found to be a case manifesting vertiginous symptoms that are provoked by one of the following: Head and body movements in general (ie, not primarily provoked by positional changes relative to gravity), Unprovoked (ie, spontaneous) episodes of vertigo occurring while not moving, Constant unsteadiness
  • Vestibular neuritis and head trauma are both frequently associated with vestibular dysfunction, the cause of persistent symptoms following treatment of BPPV is likely related to widespread dysfunction within the vestibular system in this setting
  • When CVSD is suspected, additional testing should be considered
57
Q

CNS disorders that masquerade as BPPV

A
  • Rarely CNS disorders can masquerade as BPPV due to symptoms of gait, speech, & autonomic dysfunctions
  • Likelihood of CNS diagnosis increases in the face of initial Tx failure for BPPV
  • Whenever the s/s of BPPV are atypical or refractory to Tx, additional Hx & physical exam should be obtained to address the possibility of undiagnosed CNS disease
58
Q

Patients with symptoms consistent with those of BPPV who do not show improvement or resolution after undergoing the CRP, especially after 2 or 3 attempted maneuvers, or those who describe associated auditory or neurologic symptoms should be evaluated with

A
  • A thorough neurologic examination
  • Additional CNS testing
  • And/or magnetic resonance imaging of the brain and posterior fossa to identify possible intracranial pathologic conditions.
59
Q

What if the nystagmus is geotropic and persistent in a roll test?

A
  • It is NOT BPPV
  • It is light cupula; nothing we can do the patient is just going to have to ride it out
60
Q

Considerations for cervical spine dysfunction

A
  • In the case of orthopedic limitations (mainly cervical), because the maneuvers only utilize gravitational force to move the otoconia through the canals, the only real requirement is that the head is in the correct plane.
  • Therefore, rolling the patient instead of rotating the cervical spine may be used to achieve 45 degrees of cervical rotation.
  • Pillows or a wedge under the thoracic spine, or a reverse tilt table may be used as ways to modify the maneuver in order to achieve 30 degrees of cervical extension
61
Q

What is the null plane for light cupula

A
  • It’s the rotation of the head/plane that causes the nystagmus to cease
  • Rotate head slowly and wait for the nystagmus to stop in order to find the null phase
62
Q

BPPV type dizziness

A
  • Rotatory/rotational type dizziness

Neuro Dev/Control II (19 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions