Before anything , a small souvenir Anatomical
Moreover, the saccule and utricle are specialized in linear acceleration position static head. The displacement of the otoliths in the macula of the saccule and utricle is interpreted as linear motion in space. The utricle responds to movements in the horizontal plane while the saccule responds to movements in the vertical plane.
The vestibular system works as accelerometer and inertial guidance device in miniature, which continually gives information regarding the movements of the head to integrative centers located in the brain stem, cerebellum and somatosensory cortex. If the system is damaged alters the balance, stabilization of the look and sense of direction in space.
- So, what do I have?
- Called Benign paroxysmal Positional Vertigo.
- ... Well, Benigno sounds good.
- Exactly, that's very interesting to know.
I think the word should Apostilles Benigno more pathologies:
- Oh, my god, do not tell me I have arthritis. Just what I needed ...
- No, no, mild osteoarthritis.
- Ah, well ...
BPPV was first described in 1921 by Barany. At that time, nystagmus and vertigo related to position changes were attributed to the otolith organs (saccule and utricle).
In 1952, Hallpike and Dix devised provocative positional test.
In 1962, Harold Schuknecht proposed the theory of cupulolithiasis after a study of 3 bodies BPPV diagnosed before his death. The otoliths cupulolithiasis sonstiene that occupy the top of the blister at the base of each semicircular canal.
In 1979, Hall suggested canalithiasis theory. The otoliths canalithiasis argues that occupy the semicircular canal
In 1980, Epley published canalithiasis theory produced exclusively in the posterior semicircular canal.
In 1985, McClure introduced the idea of the horizontal semicircular canal involvement in VBBP.
currently considered that 90% of those responding to a canalithiasis BPPV of posterior semicircular canal, but this is still controversial.
In this study, 110 of 122 were affected semicircular canal and of those 110 postertior repositioning was effective at 106.
The remaining 10% is attributable to the semicircular canal horizontal. The involvement of the anterior semicircular canal has been proposed by some authors and contradicted by others.
Clinic
BPPV is the most common cause of vertigo. It affects more women (64%)
Suerle accompanied by rotary geotropic nystagmus (quick phase eye goes to the floor) if it affects the posterior canal (90%) or horizontal ageotrópico (fast phase eye goes up) if it affects the channel horizontal.
vertigo is usually triggered by movements of the head with latency period between 2 and 10 seconds, a duration of 30 seconds to 1 minute and a box length of days to weeks with a spontaneous and often , recurrence. The average length of the table is about 3 weeks.
Diagnosis
Hallpike-Dix maneuver
The sensitivity and specificity vary according to some studies, but are encrypted at:
sensitivity of 79%
specificity of 75%
in this study.
With a positive predictive value of 83.3%
and a negative predictive value 52%
rotary geotropic nystagmus (toward the ground) with the affected ear down indicates involvement of the semicircular canal later, and this occurs in 90% of cases.
The finding of rotary nystagmus to perform the Hallpike-Dix maneuver is considered pathognomonic of BPPV, but nystagmus is not unique rear channel in the Hallpike maneuver.
The anterior semicircular canal BPPV is extremely rare. It has a vertical nystagmus, so you should have a central differential vesibular disease. Hallpike maneuver stimulates the anterior semicircular canal of both ears at once, so it does not help to discriminate affected side.
Pagnini-McClure maneuver or Head Roll Test.
is a provocative maneuver horizontal semicircular canal.
The patient is supine with the head elevated about 30 ° to the horizontal plane.
head is rotated 90 ° left and then right fairly quickly.
By turning his head toward the involved side causes a horizontal nystagmus directed toward that side and its direction is reversed with the change in head position.
Nystagmus geotropic in both positions (fast phase toward the ground) indicates canalithiasis.
ageotrópico nystagmus in both positions (fast phase toward the ceiling) indicates cupulolithiasis.
Cupulolithiasis of the horizontal semicircular canal.
This study, published last month suggests that the vertical and rotary nystagmus may also result from a horizontal canal involvement.
These following two articles pose an alternative to the head roll test with the bow and lean test. I have not managed to figure out how to perform this test, so if anyone knows and wants to provide the information would be appreciated:
Efficacy of the "bow and lean test" for the management of horizontal canal benign paroxysmal positional vertigo .'Bow and lean test' to determine the Affected ear of horizontal canal benign paroxysmal positional vertigo.
Treatment
Epley maneuver
In 1992 Epley maneuver described canalithiasis replacement for the posterior semicircular canal. It consists of a rotating collar 90 º in the opposite direction causing the dizziness from the position of Hallpike and then another 45 degrees to the ground after having rotated the trunk, with the aim of merge all otoliths .
Epley maneuver has proven to eliminate symptoms in 72-78% of patients with BPPV with complete resolution in 91% after 2 treatments in some studies.
However, a Cochrane systematic review in 2003 concluded that evidence is lacking for the Epley maneuver: Although we are firmly convinced that the Epley maneuver is superior to simple clinical observation or vestibular suppressant that treatment, we accept that better studies are needed. The Epley maneuver or anything similar, usually does not provide long-term resolution of symptoms, but still better than other alternatives.
Hilton M, Pinder, D, Cochrane Ear, Nose and Throat Disorders Group. The Epley (canalith Repositioning) maneuver for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews. 1, 2003.
Epley also proposes to place a serious pitch (125 Hz) on the mastoid, to take off the otoliths of the semicircular canal wall.
Semont maneuver
Semont in 1988 described the move to release and although it Cupulolithiasis demonstrated as effective Epley as is often used with positive results.
For the treatment of horizontal canal BPPV.
The replacement described by Lempert and Tiel-Wilck and modified by Baloh is a 360 º in phases: the head is rotated 90 º and 180 º body each time.
Brandt-Daroff exercises
Exercises Brandt-Daroff home are held 3 times day for two weeks. In each series the maneuver is repeated 5-10 times.
the exercises are not recommended at the beginning of treatment. Only recommended in refractory cases.
No evidence exists that would advise the limitation of head movements after recanalization maneuvers for the treatment of BPPV.
However, several studies support the use of pillows to sleep in an inclined position after the maneuvers.
Efficacy of postural restriction in treating benign paroxysmal positional vertigo.
In this paper, the restriction of the position with a collar 2 days after the modified Epley maneuver increased the therapeutic effect of repositioning in the treatment of canalicular Posterior semicircular canal BPPV.
Clinical practice guideline: benign paroxysmal positional vertigo.
Finally, the 2008 provides a review of clinical guidelines on VBBP:
1. The clinician should diagnose posterior semicircular canal VBBP when the vertigo associated with nystagmus causes the Hallpike-Dix maneuver.
2. Not recommended radiographs or vestibular tests patients with BPPV, unless the diagnosis is uncertain, or any signs or symptoms not related to BPPV.
3. Not recommended for treatment with vestibular suppressant drugs such as antihistamines or benzodiazepines.
4. It is recommended if the patient has a history compatible with BPPV and the Hallpike-Dix maneuver is negative, perform supine roll test to evaluate the lateral semicircular canal.
5. The clinician should distinguish BPPV from other causes of imbalance, dizziness and vertigo,
6. The clinician should ask patients with BPPV of the factors that influence: as decreased mobility or balance, CNS disorders, lack of support at home, and an increased risk of falling,
7. Clinicians should treat posterior canal BPPV with the repositioning maneuver,
8. Clinicians should reassess patients a month after the initial period of observation or treatment to confirm the resolution of symptoms.
9. Clinicians should evaluate patients who did not work the initial treatment and there remains an underlying VBBP or trastono peripheral vestibular or CNS disorder.
10. Clinicians should counsel patients about the impact of BPPV on safety, the possibility of recurrence, and the importance of monitoring.
11. It is offered as vestibular rehabilitation options guided by the clinical or home exercise.
12. Hearing tests are not recommended in patients diagnosed with VBBP s.
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