Positional and Positioning Tests 2

Question 1

What is an example of positioning?

Answer 1

Dix hallpike

Question 2

What do positioning and positional tests assess?

Answer 2

BPPV
Looks for any tonic asymmetry in the vestibular system (manifested by positional nystagmus)

Question 3

What is canalithiasis?

Answer 3

Otoconia freely moving in the endolymph within the SCC
This type generally has a delayed onset after placing patient in provoking position and fatigue-ability

Question 4

What is cupulolithiasis?

Answer 4

Otoconia adhered to cupula within the SCC OR on opposite side of cupula (debated)
BPPV of this type has immediate onset after placing patient in provoking position and little to no fatigue over time

Question 5

What is it for horizontal canal BPPV?

Answer 5

Canalithiasis is geotropic (nystagmus beats toward the ground, will change w/ head position) - beats to right when laying to the right and cupulolithiasis is ageotropic (nystagmus beats away from the ground, will change with head position)

Question 6

What is the incidence of BPPV?

Answer 6

Posterior canal BPPV is the most common most likely representing 90-95% cases
Horizontal canal variant next most common most likely representing 2-10% cases
Anterior canal variant is rare with about 1-3% of cases

Question 7

What are the treatments for BPPV?

Answer 7

Habituation techniques / exercises
Particle repositioning maneuvers
Surgical intervention (in rare cases)

Question 8

What are habituation therapies?

Answer 8

Techniques designed to disperse displaced otoconia within the involved SCC without moving the otoliths out of the canal
Used prior to advent of particle repositioning
Patient moved into provocative position several times a day for multiple days til symptoms no longer present
Based upon principle of repeat exposure to noxious stimulus until abnormal signal is “ignored” by the CNS

Question 9

What are brandt-daroff exercises?

Answer 9

Performed initially on involved side
Move into offending position, allow symptoms to subside, return to sitting position, then move to uninvolved side
Performed over a period of 3-14 days, up to 5 times a day
98% efficacy reported by authors; home program

Question 10

What is particle repositioning?

Answer 10

Best way to treat BPPV with outcomes reported at 80-95% with only 1-2 treatments (multiple studies)
Goal is not just to disperse otoconia but to move it out of the canal, back into the utricle where it is probably dissolved by endolymph or dark cells

Question 11

What are the two types of particle repositioning treatments?

Answer 11

AC/PC BPPV Treatment = Epley (aka CRM), Semont, Half-somersault (Foster maneuver), Gans repositioning maneuver
HC-BPPV BPPV Treatment: Multiple depending upon canalithiasis or cupulolithiasis variant, see other slides

Question 12

What is the epley or canalith repositioning maneuver?

Answer 12

Most common treatment for AC-PC canalithiasis BPPV
Start with involved side down and roll away from vertigo
Each position held for 30-60 seconds

Question 13

What is the semont?

Answer 13

Performed initially on involved side, patient is held for 1-3 minutes then moved in one motion to final position
Reportedly as effective as Epley maneuver per lit review (AAN 2008)
Good for certain patient populations
Most commonly used for PC-BPPV and cupulolithiasis variants
Can also treat AC
Same effectiveness as epley

Question 14

What are the treatments for geotropic (canalithiasis) HC BPPV?

Answer 14

Otoconia located in the posterior portion of canal, mobile
Treatments: Lempert (aka BBQ or 360) Roll, Gufoni-Asprella (Appiani) geotropic maneuver, Forced prolonged positioning (Vanucchi)

Question 15

What are the treatments for ageotropic (cupulolithiasis) HC BPPV?

Answer 15

Otoconia located in the anterior portion of canal, immobile
Treatments: Gufoni (aka Appiani) ageotropic maneuver (note: incomplete maneuver*), Casani maneuver, Vanucchi maneuver

Question 16

What is the lemport?

Answer 16

BBQ or 360 roll
Performed initially on involved side, roll away from affected ear
Performed in 90 degree steps, held 30-60 sec in each
Sometimes also used for ageotropic variant but less effective
Difficult for some patients to perform, variations on final position
Used to treat HC canalithiasis

Question 17

What things do you typically see when there is canalithiasis?

Answer 17

Fatigue
Reversal
Latency (delayed onset of nystagmus)

Question 18

What does upward torsional nystagmus indicate?

Answer 18

Posterior canal BPPV

Question 19

What indicates abnormal positional testing?

Answer 19

Present in 3 positions
Changes direction
Greater then or equal to 4 or 6
Intermittent in all positions