Benign Paroxysmal Positional Vertigo - Essay Example

Benign Paroxysmal Positional Vertigo Introduction: Vertigo and dizziness are not disease entities, but rather unspecific syndromes consisting of various disorders with different causes. The main symptoms of benign paroxysmal positioning vertigo (BPPV) include brief, sometimes severe attacks of rotatory vertigo with and without nausea, which are caused by rapid changes in head position relative to gravity. Typical triggers include lying down or sitting up in bed, turning around in bed, and also bending over to tie the shoelaces, or extending the head in order to look up or do something above the head. If BPPV is elicited while the patient is upright, he is in danger of falling. Attacks of vertigo frequently occur in the morning and are most pronounced during the first change in position after sleep; repeated changes in position cause a transient lessening of the symptoms. The complaints are so typical that a diagnosis can often be made solely on the basis of the patient history; occasionally even the affected ear can be identified, since the patients will complain "rotatory vertigo only occurs when I lie on my right side". Symptomatology and Epidemiology: Benign paroxysmal positioning vertigo is the most common cause of vertigo. It is so frequent that about one-third of all over 70-years old have experienced BPPV at least once. This condition is characterised by brief attacks of rotatory vertigo and simultaneous positioning rotatory-linear nystagmus toward the undermost ear. It can be accompanied by nausea. Benign paroxysmal positioning vertigo can appear at any time from childhood to senility, but the idiopathic form is typically a disease of old age, peaking in the sixth to seventh decades. More than 90% of all cases are classified as degenerative or idiopathic, with preponderance in women. Sometimes it can be secondary to other causes such as post head injury or vestibular neuritis. BPPV also occurs strikingly often in cases of extensive bed rest in connection with other illnesses or after operations. About 10% of the spontaneous cases and 20% of the trauma cases show a bilateral, generally asymmetrically pronounced BPPV. Signs: BPPV is elicited by extending the head or positioning the head or body toward the affected ear. Rotatory vertigo and nystagmus occur after such positioning with a short latency of seconds in the form of a crescendo/decrescendo course of maximally 30-60 seconds. The beating direction of the nystagmus depends on the direction of gaze; it is primarily rotating when gaze is to the undermost ear and mostly vertical to the forehead during gaze to the uppermost ear. The nystagmus corresponds to an excitation of the posterior canal of the undermost ear. Pathophysiology: The current hypothesis of pathophysiology of BPPV has been proposed by McClure (1991) and Epley (1992) and proven by Brandt and Steddin (1993). Heavy, inorganic particles or otoconia of specific weight, which become detached as a result of trauma or spontaneous degeneration from the utricular otoliths of the cupula. These particles float freely within the endolymph of the canal instead of being firmly attached to the cupula, and the "heavy conglomerate", which almost fills the canal, is assumed to be the cause of the positioning vertigo. The movement of the conglomerate causes either an ampullofugal or an ampullopetal deflection of the endolymph depending on the direction of the sedimentation. A valid model of the pathophysiology of BPPV must be able to predict the direction, latency, duration and fatigability of the typical nystagmus, as well as changes in these parameters due to other head manoeuvres. Liberatory Manoeuvre: The efficacy of positioning or liberatory manoeuvres of the head can only be explained by canalolithiasis, that is , the clot moves freely within the canal. As a result of these manoeuvres, the plug is washed out of the canal and then cannot cause any positioning vertigo. Proceeding from the explanations of cupulolithiasis or canalolithiasis, effective exercise programme can be devised, which, by means of the simple physical measure of head positioning, loosens the heavy degenerative otolithic material and distributes it into other areas of the labyrinth, where it comes to rest and no longer impairs canal function. In 1992, Epley proposed another liberatory manoeuvre that involved turning the patient from a supine position into a headhanging position. Only in very rare cases that are refractory to these manoeuvres should surgery, such as, the obliteration of the canal, may be considered. When correctly performed, all three physical liberatory manoeuvres are successful in almost all patients. Epley's alternative liberatory manoeuvre (Epley JM, 1992) requires that the patient's head and trunk be rotated after being tilted backward into a slightly head-hanging position. If, however, the plug is not dislodged during the outpatient visit, the patient can be quickly instructed how to proceed on his own at home. Series of these exercises should be performed five to ten times per day, preferably three times during the early morning and three times at noon. The manoeuvres seem to be most effective then, since the clot, which develops during rest, can be more easily removed from the canal than single otoconia. As a rule almost all patients are free of complaints after several days or sometimes a few weeks. Hypothesis: Practically this author has performed 400 Epley maneuvers in patients, and this research is designed to estimate the effective of this maneuver in these patients. Method: The patient data will be collected from clinic records. A form will be designed where the demographic data will be recorded. Since the maneuver is practiced by the patients themselves at home, it will be worthwhile to design a questionnaire to determine adherence, progression, or alleviation of the symptoms. Since from the previous discussion, it is clear that most of the patients are elderly, a telephone interview can be designed. The patients would not be able to comment on the signs that can be elicited in the clinic, but they would be definitely able to comment on the signs. Questionnaire: The patients will be explained about this study, and if they are willing to participate, then their interview will be conducted. The questions will be based on a 7-point Likert scale that has 0 to 6 scores with 0 indicating absence of symptoms and 6 maximum intensity, and each item will be assigned a scoring system. To be able to gather fairly accurate data, the patients will be explained the scoring system, and then they will be requested to answer on each question. The questions will be as follows 1. When did the symptom start 2. For what duration the patient is having this treatment 3. Frequency of maneuver that the patient is currently having 4. Whether the patient has stopped the treatment 5. If so why Likert Scale 1. Rate your current vertigo from 0 to 6. 2. Rate your pre-maneuver vertigo from 0 to 6. 3. Rate your current dizziness from 0 to 6. 4. Rate your pre-maneuver dizziness from 0 to 6. 5. Frequency of symptoms related to erect posture 0 to 6. 6. Frequency of symptom related to lying posture. 7. Timing of attack during morning or evening. 8. Associated nausea or vomiting. 9. Any other associated disease in the interim. Conclusion: These questions have been designed from the description of the disease and in relation to the epidemiology and pathophysiology of the condition. Search of literature could not yield similar questionnaire in any other study. Therefore it needs validation with a pilot study. Reference Epley JM (1992) The canalith repositioning procedure: for treatment of benign paroxysmal positioning vertigo. Otolaryngol Head Neck Surg 10:299-304 Read More