What Is Benign Paroxysmal Positional Vertigo?

Benign paroxysmal positional vertigo (BPPV) is a clinically common peripheral vestibular disease and is the most common vertigo caused by the inner ear. When the head moves to a specific position, it can induce short-term dizziness, accompanied by nystagmus and autonomic symptoms. Can be seen in all ages, more common in the elderly. The disease is self-limiting. The most commonly involved semi-regulatory is the latter semi-regulatory (80% -90%), followed by the outer semi-regulatory (10%), and the least affected is the upper semi-regulatory (2%).

Basic Information

English name: benign paroxysmal positional vertigo
Visiting department: ENT
Common causes: It is more common in clinics. Secondary after head trauma, Meniere's disease, vestibular neuritis, sudden deafness, or inner ear surgery

Common symptoms: Patient suffers a short dizziness when in a specific position, such as lying down, sitting up, lifting his head, lowering his head, turning his head or turning
Contagious: no

Causes of benign paroxysmal positional vertigo

The cause of the disease can be primary or secondary, which is more common clinically. Secondary cases are common after head trauma, Meniere's disease, vestibular neuritis, sudden deafness, or inner ear surgery.

Benign paroxysmal positional vertigo classification

1. Classified according to where otoliths fall off

(1) The second half regulates BPPV;

(2) Horizontal semi-regular BPPV;

(3) The upper half regulates BPPV;

(4) Hybrid BPPV.

Later semicircular canal BPPV is the most common clinically, followed by horizontal semicircular canal BPPV, and upper semicircular canal BPPV and mixed BPPV are rare in clinical practice.

2. Classification by pathogenesis

BPPV is divided into tube calculi and ampullate calculi. Tube stones are the most common type of BPPV.

Clinical manifestations of benign paroxysmal positional vertigo

The patient experienced a short dizziness when he was in a particular position, such as lying down, sitting up, picking up, lowering his head, turning his head, or turning over.

1. Clinical characteristics of tube stones

(1) When the head position is in the excited position, there is a latency period of 1 to 40 seconds, and then dizziness occurs;

(2) The incubation period of nystagmus and dizziness is the same;

(3) The intensity of vertigo and nystagmus fluctuates, first and then light, and the duration does not exceed 60 seconds;

2. Clinical features of ampullate apical stones

(1) Dizziness occurs immediately when the head position is in the excited position;

(2) Vertigo and nystagmus will persist if the position of the stimulus does not change.

This type of BPPV is relatively rare and can occur in the latter semicircular canal as well as in the horizontal semicircular canal.

Benign paroxysmal positional vertigo

If necessary, a displacement test is performed. In conditional hospitals, the displacement test is best observed on the video nystagmus. The displacement test is the gold standard for diagnosing BPPV, especially the semicircular canal BPPV after diagnosis. The displacement tests used to diagnose BPPV are:

1.Dix-Hallpike test

It is a commonly used method to determine the BPPV of the second or upper half. The appearance of vertigo and nystagmus has a latency period and fatigue. The specific steps are as follows (take the right side as an example):

The patient sits on the examination bed. The examiner is located behind or in front of the patient, holding his head with both hands, turning 45 degrees to the right, keeping this position unchanged, quickly changing the posture to the supine position, with the head hanging back out of the bed and horizontal. At 30 degrees, the head position was always maintained at 45 degrees, and the dizziness and nystagmus were observed. Due to the incubation period of vertigo and nystagmus, the proprioception position should be maintained for 30 seconds. Patients with posterior semicircular canal BPPV often experience dizziness and nystagmus when the affected ear is down. The nystagmus is vertical torsion, and the fast phase of the nystagmus is perpendicular to the top of the head (upbeat nystagmus). At the same time, the nystagmus is tested against the ear, that is, the nystagmus. The upper semicircular canal BPPV can induce dizziness and nystagmus when the patient's ears are up. The nystagmus is vertical torsion, the nystagmus is fast downward (toward the foot, and the nystagmus), and at the same time, it is seen facing the opposite side (dorsal). Nystagmus or nystagmus).

2. Roll test

It is a commonly used method for determining horizontal semicircular canal BPPV. The specific operation steps are as follows: The patient lies on the examination table with his head tilted 30 degrees forward. According to the patient's condition and the habits of the examiner, he can quickly turn his head to the left or right first. Pay attention to nystagmus at each location, and record the direction and duration of nystagmus. Horizontal semicircular canal BPPV is nystagmus in the horizontal direction. Taking the right horizontal semicircular canal calculi as an example, a nystagmus can occur when you turn your head to both sides, but the dizziness and nystagmus are more obvious when you turn your head to the right. In patients with horizontal semicircular canal sacral calculi, when the affected ear is up or down, the direction of the nystagmus is dorsal nystagmus (off-ground nystagmus).

Diagnosis of benign paroxysmal positional vertigo

The main points of diagnosis include the following four points: recurrent vertigo, vertigo is usually induced when the position changes, the duration of vertigo is generally less than 1 minute, and other vertigo diseases should be excluded.

Treatment of benign paroxysmal positional vertigo

The treatment of benign paroxysmal positional vertigo includes manual reduction, drug-assisted treatment, vestibular rehabilitation and surgical treatment.

Manual reset

Otolith reduction is currently the preferred method for the treatment of benign paroxysmal positional vertigo, and it can also be combined with necessary medications. Most patients with manual reduction can be cured at one time (the effective rate can reach 75% to 90%). Successful treatment depends on the correct identification of which semicircular canal is involved, and whether the otolith fragments float in the endolymph or adhere to the pot. Belly . The goal of manual reduction is to reset the otoliths that had fallen off to their original location-the vestibular part, to relieve vertigo. The most commonly used otolith reduction in clinical practice:

(1) EPLEY otolith reduction method This treatment is developed based on the theory of calculi. After a series of head position changes, the patient's otolith fragments suspended in the posterior semicircular canal or upper semicircular canal eventually fall back to the oval through the semicircular canal. bag. Taking the right side as an example, the specific steps are as follows: the patient takes a seated position and turns the head 45 degrees to the right. Keeping the head position makes the patient lie down and the head is suspended 30 degrees. After that, the patient stretches the head moderately, and the head slowly moves to the left. Rotate 45 degrees, then the patient is lying to the left while the head continues to rotate 45 degrees to the left, maintaining the position for 1 to 3 minutes, and finally slowly returning to the sitting position with the head tilted forward 30 degrees.

(2) Barbecue Rolling Otolith Reduction Method According to the theory of semicircular canal otolith, and the anatomical relationship between the horizontal semicircular canal and the vestibule, Baloh et al. First tried to treat the benign array of the horizontal semicircular canal by using a rapid 180-degree roll from the supine position to the healthy side. Locational vertigo, but did not achieve the desired results. Based on this, Lempert and others improved the head rotation range to three consecutive 90-degree rolls (Barbecue roll otolith reduction method), and believed that adding a 90-degree turn may be more conducive to the restoration of otoliths from the horizontal semicircular canal. To the oval capsule, and clinical practice has proven to achieve good results.

(3) Semont Oscillation for benign paroxysmal positional vertigo in the posterior semicircular canal to treat Semont et al. Designed a treatment method. After judging the lesion side (taking the right posterior semicircular canal BPPV as an example), the patient sat on the examination table and turned 45 degrees to the healthy side, and the patient quickly lay down on the affected side (parallel to the affected posterior semicircular canal), with the head suspended 20 At this time, the head is turned to the level of the posterior semicircular canal and held for 2 to 3 minutes, and then the patient moves quickly to the sitting position and falls to the contralateral lying position, keeping the head 45 degrees to the healthy side (the nose is 45 degrees to the ground). The treatment The teacher keeps the patient's head and neck in a straight line with the body. Generally, the patient will experience nystagmus and dizziness. The patient stays in this position for 1 minute and then slowly returns to the sitting position.

(4) Brant-Daroff adaptive therapy for posterior semicircular canker calculi. This treatment requires the patient to exercise repeatedly to the excited position several times a day. The patient first sits, and then quickly enters the position that causes dizziness. The degree of dizziness is directly related to the speed at which the patient moves to the excited position. The patient stayed in the vertigo position until the vertigo disappeared, then sat up again. Vertigo is usually returned to the sitting position, but the intensity and duration of vertigo are reduced. The patient stayed in the sitting position for 30 seconds, then fell back to the opposite side and stayed for 30 seconds. The patient repeats this motion process until the dizziness disappears. The entire process was repeated every three hours until the patient had no dizziness for two consecutive days. Brant-Daroff adjuvant therapy after treatment of semicircular canaliculi calculi can also be used to treat external semicircular canaliculi calculi, allowing patients to repetitive exercise in the horizontal plane. It is speculated that the treatment mechanism may mainly be the removal of otolith fragments from the ampulla .

2. Drug treatment

Drug treatment is mainly to suppress the vestibular response and reduce vomiting caused by dizziness. Medication is not a cure. Commonly used drugs are vestibular inhibitors such as diazepam, theophylline and betahistine mesylate. For patients with extreme sensitivity and anxiety, diazepam can be considered before manual reduction.

3. Surgical treatment

For a very small number of patients with refractory BPPV, semicircular canal tamponade and single foramen (retroampillary nerve) amputation can be considered. It has been reported that the effectiveness of posterior ampulla neurotomy can be as high as 96%. Severe single-hole neurotomy can reduce or alleviate the occurrence of vertigo. However, this operation can cause sensorineural hearing loss and is rarely used today. The surgery is only used in a very small number of patients with refractory vertigo attacks and manual reduction. Semicircular canal tamponade attempts to pack bone fragments, fibrous tissue, and fascia into the semicircular canal to cut the otolith fragments into the sensitive area of the semicircular canal.

References:

[1] Editorial Board of Journal of Otolaryngology Head and Neck Surgery, Chinese Medical Association, Otolaryngology Branch of Chinese Medical Association. Diagnostic basis and efficacy evaluation of benign paroxysmal positional vertigo: Chinese Journal of Otorhinolaryngology, 2007: 42: 163-164.

[2] Snow editor. Compiled by Li Daqing. Meniere's disease, vestibular neuritis, benign paroxysmal positional vertigo, upper semicircular canal fissure, and vestibular migraine. Ballenger Otorhinolaryngology Head and Neck Surgery. Beijing: People's Medical Publishing House, 2012: 356-361.