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Bppv and particle repositioning maneuvers
1. BPPV AND PARTICLE REPOSITIONING
MANEUVERS
DR.ANITA BHANDARI
CONSULTANT NEUROTOLOGIST
VERTIGO AND EAR CLINIC
JAIPUR
2. The ampulla contains the cupula – a gelatinous mass with the same
density as the endolymph. Cupula forms an impermeable barrier across
the lumen of the ampulla. Hence the particles in scc may only exit via
the end with no ampulla.
3. SECONDARY CAUSES OF BPPVSECONDARY CAUSES OF BPPV
Head injury
Prolonged bed rest
Vestibular neuritis
Meniere’s disease – hydropically induced damage to
macula of utricle
Migraine
Ear surgery
4.
5. BPPV by canal typeBPPV by canal type
Posterior Horizontal Anterior
Estimated
frequency
81-89% 8-17% 1-3%
Provocative
maneuver
Dix Hallpike Supine Roll Test
(Pagnini-McClure)
Dix Hallpike
Nystagmus Upbeat,
torsional
Horizontal
Direction Changing
Downbeat,
torsional
6. POSTERIOR CANAL BPPVPOSTERIOR CANAL BPPV
Most common– posterior canal is most gravity
dependant in upright and supine position
Once debris enter the post. canal ,the cupula at the
shorter most dependant arm trap the debris.
Debris can exit only through the longer arm through the
crus commune [non-ampullary]
20. BRANDT – DAROFF EXERCISESBRANDT – DAROFF EXERCISES
Used as a home program
Indications
o Posterior canal cupulolithiasis
o Persistant posterior canal canalithiasis
Mechanism
o Dislodge debris attached to cupula
o Habituation through central compensation
22. BRANDT – DAROFF EXERCISESBRANDT – DAROFF EXERCISES
Things to remember
o The exercises may dislodge more otoconia from the
utricle causing an increase in symptoms.
o May cause multiple canal involvement.
o Important to hold for 30 seconds in each position.
23. HORIZONTAL SCC BPPVHORIZONTAL SCC BPPV
Pagnini-McClure maneuvre
Geotropic nystagmus – debris are away from
ampulla , side showing stronger nystagmus is the
side involved
Apogeotropic nystagmus – indicates cupulolithiasis
34. CUPULOLITHIASISCUPULOLITHIASIS
Coined by Schuknetch
Rare , more common in horizontal canal
Caused by otoliths attached to cupula of scc
When cupula is horizontal no vertigo
When non-horizontal constant input persistant
dizziness
Nystagmus : persistant non-fatiguable as long as patient is
in the same position
38. ANTERIOR CANAL BPPVANTERIOR CANAL BPPV
Anterior canal BPPV is usually transitory and
most often the result of “canal switch” that
occurs in the course of treatment more
common forms of BPPV
39. SUBJECTIVE BPPVSUBJECTIVE BPPV
No nystagmus is detected but patient feels dizzy on
provocative tests
PRP beneficial
Reasons
o Subtle nystagmus
o Fatigued nystagmus
o Inadequate neural signal to stimulate the VOR
41. OTHER CAUSES OFOTHER CAUSES OF
POSITIONAL NYSTAGMUSPOSITIONAL NYSTAGMUS
Direction changing nystagmus – central
Down beating positional nystagmus – nodulus
Down beating nystagmus on Dix-Hallpike – anterior
canal BPPV . Treated by Epley’s maneuvre