BPPV-마산, 창원 신경과
Transcript of BPPV-마산, 창원 신경과
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Benign Paroxysmal Positional Benign Paroxysmal Positional Vertigo(BPPV) of the Vertigo(BPPV) of the
Posterior(PSC) & Horizontal Posterior(PSC) & Horizontal Semicircular Canals(HSC)Semicircular Canals(HSC)
2003. 6. 25경상대학교 의과대학
경상대학교병원 이비인후과학교실안 성기
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BPPV
Anatomy of Vestibular organAnatomy of Vestibular organ
Vestibule
( 전정 )
Crista ampullaris
( 팽대부릉 )
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BPPV
Historical aspects(I)Historical aspects(I)
- Barany(1921); first description of positioning nystagmus
- Dix & Hallpike(1952); the provocative positioning maneuver and defining the syndrome
- Schuknecht(1969); basophilic deposits on the cupula of the posterior SCC(PSC)
in postmortem 2 BPPV patients(cupulolithiasis)- Hall, Ruby, & McClure(1979); “something” moving
inside the canal rather than adhering to the cupula of the PSC(canalolithiasis)
- Parnes & McClure(1992); free-floating endolymph particles-PSC occlusion
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BPPV
Wellington et al., Larygoscope 1997;107:90-4.
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BPPV
Historical aspects(II)Historical aspects(II)
- Cipparone et al.(1985); the existence of a BPPV due to involvement of the HSC
- McClure(1985); first reported come clinical features of BPPV originating from the HSC in 7 patients(the particles penetrate onto the non-ampullary arm(long arm or posterior part) of the HSC
- Pagnini et al.(1989); clinical features of HSC BPPV in 15 patients(geotropic nystagmus) – canalolithiasis type
- Baloh(1995); ageotropic or apogeotropic nystagmus – cupulolithiasis type- Bertholon(2002); Possible ASC BPPV
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BPPV
TerminologyTerminology1.Nystagmus(fast component) (Rt., Lt., Up, Down.)2. a.Canalolithiasis - Long arm(non-ampullary or post. portion) - Short arm(ampullary or ant. portion) b.Cupulolithiasis 3. Geotropic vs a(po)geotropic nystagmus4. Ampullopetal(utriculopetal)(HSC) vs ampullofugal(utriculofugal)(PSC, ASC)5. Ewald’s law
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BPPV
1.Nystagmus(fast component)
(Rt., Lt., Up, Down.)
* 안진의 방향
=> 급속상의 성분
수평채널에서 위쪽 ; right beat
수직채널에서 위쪽 ; up-beat
수평채널에서 아래쪽 ; left beat
수직채널에서 아래쪽 ; down-beat
2.Canalolithiasis
a.Long arm(non-ampullary
or post. portion)
b.Short arm(ampullary or ant.
portion)
Cupulolithiasis
Canalolithiasis
Cupulolithisais
예 ) Right HSC
Long arm
Short arm
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BPPV3. Geotropic vs a(po)geotropic
Nystagmus
Geotropic( 향지성 )
Right D-H test
Ageotropic( 원지성 )
Right D-H test
4. Ampullopetal(utriculopetal) (HSC) – excitation, Ewald 2nd
law
vs
Ampullofugal(utriculofugal)
(PSC, ASC) – excitation, Ewald 3rd law
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BPPV
Actions of Extraocular musclesActions of Extraocular muscles
HSC PSC ASC
Rt.
Slow phase
Fastphase
Lt.
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BPPV
Etiology of BPPVEtiology of BPPV
1) idiopathic(M/C)2) post-trauma3) Neurolabyrinthitis4) SNHL5) URI6) COM7) Postoperation(ear, general)8) Ototoxicity
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BPPV
Occurrences of positional Occurrences of positional vertigo(Hx.)vertigo(Hx.)
1. PSC BPPV; 앉았다 눕거나 , 누운 상태에서 일어날때 , 몸을 앞으로 굽히거나 펼때 , 위를 보기위해 머리를 들때 등 2. HSC BPPV; 누운상태 ( 잠자면서 ), 앉은 상태 , 보행시 머리를 돌리거나 몸을 회전할 때 * 각 반고리관의 평면을 따라 두부회전시 병변이 있는 반고리관이 흥분하거나 억제되어 어지러움 유발
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BPPV
Diagnosis of PSC-BPPVDiagnosis of PSC-BPPV
* Dix-Hallpike Maneuver
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BPPV
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BPPV
Criteria for Classic Dix-Hallpike RespoCriteria for Classic Dix-Hallpike Responsense
1)subjective vertigo2)transient torsional(rotary) nystagmus3)fatigability4)nystagmus following a latency period of one or
more seconds (duration less than 1 min)5)reversibility in sitting position* non-classic; 1 or more of the above criteria are absent.
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BPPV
Clinical Features of HSC-BPPVClinical Features of HSC-BPPV
- 6–24% of all patients with BPPV- M;F = equal- Mean age; 58.1- Etiology; idiopathic(M/C), post-traumatic, neurolabyrinthi
tis, SNHL, URI, COM, postoperative, ototoxicity- Horizontal direction changing positional nystagmus -> all
CNS lesion in the past- Criteria of HSC-BPPV 1) pure horizontal nystagmus 2) >6 degree/sec 3) No CNS lesion
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BPPV
Diagnosis of HSC-BPPVDiagnosis of HSC-BPPV 1. Lateral head turning test(Roll test); supine position with head tilted 30 ◦ upward -> 90◦ lateral head rotation in the left or right side -> horizontal bilateral direction changing nystagmus(geotropic or ageotropic)
2. Determination of the lesion side (still controversial) 1) geotropic type; strong nystagmus side 2) ageotropic type; weak nystagmus side by the Ewald’s the 2nd law (Baloh, Nuti)
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BPPVCanalolithiasis type(geotropic nystagmus) of HSC-BPPV
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BPPVCupulolithiasis type(ageotropic nystagmus) of HSC-BPPV
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BPPV
Treatments of PSC-BPPVTreatments of PSC-BPPV
I.Non-surgical a) Brandt-Daroff habituation exercise(1980) b) Liberatory maneuver(Semont, 1988) c) Canalith Repositioning Procedure(Epley, 1992)
II. Surgical a) Singular neurectomy(Gacek, 1974) b) PSC occlusion(Parnes, 1990)
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BPPV
Brandt-Daroff Habituation Exercise(1Brandt-Daroff Habituation Exercise(1980)980)
1. 환자가 한다 .
2. 하루 수차례 시행할 수 있다 .
3. 방법 ;
a. 앉은 자세에서 어지러움 유발되는 쪽으로
갑작스럽게 눕는다 . 어지러움이 없어진 후
30 초 정도 더 누워있다가 앉는다 .
b. 약 30 초 후 반대편으로 운동 반복한다 .
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BPPV
Liberatory maneuverLiberatory maneuver(Semont, 1988)(Semont, 1988)
1. 검사자가 한다 (1 회 ).
2. 방법 a. 앉은 자세에서 갑자기 환측으로 눕힌다 .
b. 2-3 분 후에 반대쪽으로 빠르게 눕힌다 . 이 상태로 5 분 정도 유지 c. 이후 천천히 앉은 자세로 돌린다 .
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BPPV
Canalith Repositioning Procedure(CRP)Canalith Repositioning Procedure(CRP)(Epley, 1992)(Epley, 1992)
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BPPV
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BPPV
Treatment of HSC-BPPVTreatment of HSC-BPPV* Canalolithisis type;1. Baloh(1994), Epley(1995), Lempert(1996); 360 ◦ rotation of the supine patient toward the unaffected ear; displace the debris more effectively from the non-ampullary arm of the HSC toward utricle
Baloh(1994), Epley(1995), Lempert(1996); 360 ◦ barbecue rotation
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BPPV
Treatment of HSC-BPPVTreatment of HSC-BPPV
2. Vannuchi et al.(1994); “Forced prolonged position”(FPP)- on the
basis of the canalolithiasis theory for geotropic HSC BPPV
-> The patient lies on the healthy side for 12 hours. Under the effect of gravity the particle gradually slip into the vestibule from the nonampullary arm of the HSC
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BPPV
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BPPV
Treatment of HSC-BPPVTreatment of HSC-BPPV* Cupulolithiasis type;1. Nuti et al.(1998): change from ageotropic to geotropic type(ex; head-shaking -> 360◦ barbecue method)2. Jo et al.(2000); cupulolith repositioning maneuver(CuRM)3. Casani et al.(2002); modified fourth step of Semont maneuver (canalolithiasis type; combination of 360 ◦ barbec
ue method and followed by FPP)
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BPPVJo et al.(2000); cupulolith repositioning maneuver(CuRM)
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BPPV
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BPPV
Features the differentiate PSC anFeatures the differentiate PSC and HSC BPPV(Baloh,1993)d HSC BPPV(Baloh,1993)
PSC HSCIncidence 91% 6%
Inducing maneuver sitting to head hanging supine to head lateralNystagmus torsional, upbeating horizontal (geotropic) (geotropic, ageotropic) direction changingDuration <30sec >30sec
Latency 2-20 sec <3sec
Fatigability yes no*
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BPPV
Failures of Therapeutic Failures of Therapeutic ManeuverManeuver
1)Too big particles(Nuti, 1998)2)Incorrect affected site3)Severe adhered to the cupula4)Inappropriate Tx.(Fife, 1998)5)Central origin vertigo6)Cervical spondylosis7)Obesity
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BPPV
남자 여자 총1-10 세 1 1
11-20 세21-30 세 1 1
31-40 세 5 6 11
41-50 세 2 7 9
51-60 세 2 8 10
61-70 세 2 9 11
71 세이상 4 411 37 48
경상대학교병원 이비인후과 Vertigo clinic
총 300 명중 48 명이 BPPV 진단 (2002 년 6 월 -2003 년 5 월 )
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BPPV* Canal 별 발생 빈도1. PSC canalolithiasis; 28 명 cupulolithiasis; 3 명2. HSC canalolithiasis; 14 명 cupulolithiasis; 2 명3. ASC canalolithiasis; 1 명4. Combined type 2 예 (PSC + HSC)5. Change of SCC after Tx.(1 예 ) (PSC canalolithiasis -> HSC canalolithiasis)
* Associated ds. or Causative primary ds.
총 48 예 중 idiopathic(29 예 ) post-traumatic(8 예 ) viral neuronitis or neurolabyrinthitis(3 예 ) VBI(2 예 ) Meniere’s disease(0 예 ) COM(2 예 ) Post surgery(Ear)(1 예 ) Post surgery(General)(2 예 ) Sudden hearing loss(0 예 ) Ototoxicity(1 예 )
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BPPV
* Recurrence
HSCcanalolithiasis 14
명중 2 명이 재발
동측의재발
재발까지의 기간
반대측발생
동반질환
Case 1 + 7 일 - Headtrauma
Case 2 + 40 일 - Idiopathic
PSCcanalolithiasis 28
명중 3 명이 재발
동측의 재발
재발까지의 기간
반대측 발생
동반질환
Case 1 + 20 일 - Idiopathic
Case 2 + 19 일 - Headtrauma
Case 3 + 30 일 - VBI
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BPPV
ConclusionsConclusionsBPPV 와 같은 증상을 보이는 환자가 오면특징적인 문진을 하고 신체 검사 및 기타 검사를 통하여 중추성 어지러움배제시킨다 .그런 후에 말초성으로 인한 어지러움이라고 판단되면 세개의 반고리관에서 어느 부위인지 , 또한 부위가 결
정되면 canalolithiasis 또는 cupulolithiasis 알아야 한다 . 그리고 항상 2 개 이상의 반고리관에 병변이 있을 가능성을 염두해 두어야한다 .
* 적절한 재활 치료
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BPPV
cupula
Crista ampullaris
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BPPV
평형반 (macule) 의 기본 구조 이석 (otoconia or otolith)
BPPV
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BPPV
억제 흥분
흥분 억제
* Ewald the 2nd law
Rt. HSC - geotropic type
Rt. HSC - ageotropic type