4/9/2014

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Essam Saleh,MD

Prof of Otolaryngology,

Alex. University, Egypt

Lateral Canal BPPV:Our Experience in 58 cases

Current Trend in Vertigo Management

Vertigo

History + C/O

Lab investigationsENG, VNGCTMRI, MRA

Possibly Peripheral

Medications e.g(Cinnarzine, Betahistine, Aspirin)

MedicationsMedications

UnknownPossibly Central

Definite diagnosis Treatment

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BPPV

Vertigo

History + Examination

Definite Diagnosis

CURE

Treatment

Incidence of BPPV

20-30% of causes of vertigo & 50% of causes of peripheral vertigo.

64 per 100,000 population with a lifetime prevalence of 2.4 percent.

Females > males

More in the elderly > 60 yrs

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Benign Paroxysmal Positional Vertigo

Characteristics: Very severe spinning sensation lasting < 1

minute.

Ppt by changing position or turning in bed.

No hearing loss or tinnitus.

Vertigo may be accompanied by vegetative symptoms (nausea, & rarely vomiting)

Other Variants of BPPV

Our series of 723 cases

PSC commonest: 651 cases (91%)

LSC 58 cases (8.0%)

Geotropic 38

Apogeotropic 20

SSC 14 cases (1.9%)

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Basic Physiology

In lateral canal cupuladeflection

Towards utricle

Away from utricle

Stimulation of a canal produces more Ny. than inhibition.

Lateral Canal BPPV

Less common

Severe vertigo mainly in turning in bed.

Vertigo worse than SC

More vomiting

Its latency is short

Can last up to or longer than a minute

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Lateral Canal BPPV

Lateral Roll test

Body supine

Head inclined 30º

Turn head to either side

2 variants

Geotropic

Apogeotropic

Geotropic LSC BPPV

Free particles in the long arm of the LSC (Canalithiasis)

Horizontal Ny. towards lowermost ear

Stronger Ny. on turning towardsside of lesion.

+

-

Lt LSC BPPV Geotropic

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Geotropic LSC BPPV

Ageotropic LSC BPPV

Pathogensis

Cupulolithiasis(particles adherent to cupula)

Free particles in short arm of the canal

Cupulolithiasis

Canalithiasis short arm

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Apogeotropic LSC BPPV

Horizontal Ny. awayfrom lowermost ear

Stronger Ny. on turning away from side of lesion. +

-

Lt LSC BPPV Apogeotropic

Ageotropic LSC BPPV

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Practical Problems

Cervical spondylosis or disc prolapse

Lateral Roll will be difficult to perform

Turn the patient whole body to either side

Practical Problems

Side Determination

In 10%, Ny. is symmetric; so side is difficult to determine.

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Side Determination

Sit to supine test

Geotropic Ny. away

Ageotropic Ny. Towards

Null Point

Geotropic Ny away

Ageotropic NyTowards

Side Determination

Spontaneous (pseudo) Nystagmus Geo away

Ageo Towards

Head pitch test (bow & lean)Bow:

Geo Ny. away

Ageo Ny. towards

Lean:

Reverse

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Type Positional Test Nystagmus Direction

Geotropic Sit to Supine Away from affected

Spontaneous (Pseudo) Nyst Away from affected

Null Point Away from Affected

Bow & Lean-Lean (up)-Bow (down)

AwayTowards affected side

Ageotropic Sit to Supine Towards affected side

Spontaneous (Pseudo) Nyst Towards affected side

Null Point Towards affected side

Bow & Lean-Lean (up)-Bow (down)

Towards affected sideAway from affected

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Treatment of LSC BPPV

Geotropic Variant

Log roll (barbecue maneuver & variants) towards the healthy ear

Forced prolonged position patient sleeps towards healthy ear for 12 hours

Other maneuvers:

Vannuchi –Asprella maneuver.

Guffoni maneuver.

Common Maneuvers for LSC BPPV

Lempert (Barbecue) Maneuver

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Common Maneuvers for LSC BPPV

Gufoni Maneuver (Rt Geotropic)

Common Maneuvers for LSC BPPV

Vanucchi AsprellaManeuver (Rt Geotropic)

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Our treatment of LSC BPPVGeotropic variant (Rt)

Barbecue to the healthy side.

Forced Prolonged Position (FPP) to the healthy side

Our Treatment of LSC BPPVAgeotropic variant (Rt)

Trial to convert to geotropic 180⁰ rotations

Or Barbecue to Lt

FPP to Rt

Next day reassessment

Converted Geotropic

Not converted Barbecue to Lt

FPP to Lt

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Treatment of LSC BPPVAgeotropic variant (Rt)

Forced Prolonged Position (FPP) to Lt

Cupulolithisasis towards utricular side cured

Our Treatment of LSC BPPVFollow-up

All cases are assessed one day post treatment.

Remaneuver if not cured.

Reassessment after 1 week.

Follow-up for a minimum of 2 weeks

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Lateral Canal Cases

58 cases

Males 30, Females 28.

Age 10-80 (mean 44.9 yrs).

Mean duration before diagnosis 12.5 days.

Rt 36, Lt 19 and 3 difficult to determine(5.2%)

Lateral Canal Cases

Geotropic 38 (65.5%), Ageotropic 20 (34.5%)

vomiting in 7 cases.

7 cases were admitted to hospital (3 had atrial fibrillation)

Aetiology: 52 Idiopathic.

3 cases conversions from PSC during Epley.

3 cases were post-traumatic.

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Lateral Canal CasesResults Geotropic

25 (83.3%) cured

5 (16.7%) improved

Ageotropic

16 (80%) cured

2 (10CC%) improved

2(10%) No improvement

Lateral Canal Cases Results

4 cases converted to PSC and treated with Epley

2 cases Barbecue could not be performed and only FPP was used.

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Lateral Canal Cases Results

Ageotropic(20 cases)

6 persisted

Head Shaking180 RotationBarbecue to Healthy Side FPP to Affected Side

2cured2 persisted

8 converted to geotropic4 cured

Barbecue to Healthy Side FPP to Healthy Side

2 Improved

Barbecue to Healthy Side FPP to Healthy Side

8cured

Lateral Canal Cases Results

Follow-up 2 weeks to 3 years

5 cases recurred having new LSC BPPV

10 other cases had PSC BPPV

Overall, 15 cases had recurrence of BPPV (25.9%)

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Conclusions

LSC BPPV is less common 8-12% of cases of BPPV.

Symptoms are more severe

2 Variants geotropic and ageotropic

Treatment Maneuvers are effective

Geotropic variant shows more favorable results.