Benign positional vertigo recognition and treatment

Transkript

1 Benign positional vertigo recognition and treatment

2 Vertigo

3 Svimmelhed BPV Benign Positionel Vertigo (40 %) NV Neuritis Vestibularis (40 %) Tumorer og apoplexi! Morbus Meniere, Vestibulær migræne, og andre

4 Diagnose Anamnese: Er svimmelheden som når man står af en karrusel? Er der andre symptomer? Objektiv Undersøgelse: Head-Thrust-Test Hjernenerver Hallpike

5 Head-Thrust-Test Med patienten siddende lige op beder man ham fiksere blikket, på f.eks sin næse. Med en hurtig bevægelse drejes patientens hoved ca. 15 grader til først den ene og derefter den anden side. Normalt vil øjnene forblive fikseret ved bevægelsen, men hvis labyrinten til den side hovedet drejes er læderet vil refleksen være ophævet øjnene vil følge med hovedet mens det drejes og først bagefter finde næsen igen. Testen er altid positiv ved NV, men sjældent ved affektion af centrale strukturer, hvor den vestibulo-okulære refleks er bevaret.

6 Head-Thrust-test, BMJ2009;339:749-52

7 Differentialdiagnoser Episodisk stillingsafhængig svimmelhed, der svækkes indenfor sekunder og med positiv Hallpike, taler for BPV; denne tilstand kan behandles med Epleys manøvre. Konstant svimmelhed uafhængig af stilling, med unidirektionel horizontal nystagmus og positiv Head- Thrust-Test taler for Neuritis Vestibularis. Røde flag: Persisterende svimmelhed med negativ Head-thrust-test, ledsagende neurologiske udfald, ataxi, nyopstået hovedpine samt vertikal nystagmus. Ved forbigående døvhed og tinnitus kan Menieres sygdom overvejes. Ledsagende hovedpine og fotofobi taler for vestibulær migræne, men bør konfirmeres ved neurologisk vurdering.

8 Benign positional vertigo incidence of benign positional vertigo is conservatively estimated to be 6,4 per population per year Most patients report attacks of rotational vertigo of between 10 and 20 seconds that are provoked by turning over in bed, lying down or sitting up

9 Pathophysiology Benign positional vertigo results from an inappropriate activation of the ipsilateral posterior semicircular canal of the labyrinth are consistent with the hypothesis that the posterior canal contains free floating particles that are heavier than the surrounding endolymph Agglomerated masses within the posterior canal have been observed both at necropsy and during labyrinthine surgery

10 DIAGNOSIS: Hallpike manoeuvre The diagnosis is confirmed by positional testing as described by Dix and Hallpike The classic nystagmus of benign positional vertigo occurs when the head is reclined and turned to the affected side

11 Hallpike positional manoeuvre Begin with patient sitting upright with head turned 45 to left to test left posterior canal

12 With head in this position, lie patient down rapidly until head is dependent

13 The classic nystagmus of benign positional vertigo occurs when the head is reclined and turned to the affected side. For example, when the left ear is affected the nystagmus occurs when the head is hanging to the left.

14 The examiner will see alternating quick eye rotations around the line of sight towards the left (undermost) ear and slow rotations in the opposite direction

15 Return patient to upright position

16 Approach patient from other side and rotate head to right to test right posterior canal

17 Lie patient down into opposite head hanging position

18 Treatment Epley has introduced a procedure in which the posterior canal is rotated backwards close to its planar orientation, thus directing foreign material out of the canal into the utricle.

19 Epley's manoeuvre The manoeuvre consists of successive head positionings each of about 90 angular displacement Premedication with a vestibular sedative such as dimenhydrinate or prochlorperazine one hour before treatment is advisable in severely affected patients.. Head movements are guided from behind and each is executed rapidly, within 1 second. Each position is maintained for at least 30 seconds

20 Sit patient upright with head turned 45 to affected side.

21 Lie patient down with head dependent as if performing Hallpike manoeuvre

22 Rotate head through 90 with face upwards, maintaining dependent position

23 Ask patient to roll on to side while head is held in this position

24 Rotate head so that patient is facing obliquely downward, with nose 45 below horizontal

25 Raise patient to a sitting position while maintaining head rotation

26 Finally, simultaneously rotate head to central position and move 45 forward

27 Epley's manoeuvre If no nystagmus is visible the latency and duration of nystagmus observed during Hallpike testing may serve as a guideline Head movements are guided from behind and each is executed rapidly, within 1 second. Each position is maintained for at least 30 seconds The manoeuvre should be repeated up to three or four times during one session if nystagmus can still be elicited by Hallpike positioning

28 Epley's manoeuvre Usually patients are advised to keep their head fairly upright for 48 hours after treatment The usefulness of this measure, however, has not been investigated. Epley showed effective relief from positional vertigo in 77% of patients after just one treatment session.and in another 20% after a second trial a week later

29 Self guided positional exercises If patients have symptoms after the first treatment they may perform the positional exercises of Brandt and Daroff: Sit on a bed with head turned 45 to one side Quickly lie down to opposite side with head still turned

30 Self guided positional exercises