Particle Repositioning for BPPV Philip Littlefield, MD Otology - PDF document

Particle Repositioning for BPPV Philip Littlefield, MD Otology & Neurotology Tripler Army Medical Center Honolulu, HI The views expressed in this presentation are those of the author and do not reflect the official policy of the Department of Army, Department of Defense, or U.S. Government. Objectives • Anatomy & Physiology • Findings & Treatment – Posterior Canal – Horizontal Canal – Anterior Canal • Mimickers • Coding & Reimbursement 1

Lateral Canal Crista Ampullaris Vestibule Excitation Ewald’s First Law: Eye movements are in the plane of the semicircular canal, and in the direction of the endolymph flow. 2

BPPV Exam Start seated –Neck mobility –Cervical-induced nystagmus –Rotational vertebral artery syndrome BPPV Exam • Right Dix-Hallpike – Roll test (if horizontal nystagmus) – Reverse Dix-Hallpike (it depends) • Left Dix-Hallpike • Supine head hanging (bring back up first) 3

Right Ear Lateral View Sitting g AC LC PC Right Ear Lateral View Dix-Hallpike 20 ° Head Hang g LC PC AC 4

BPPV Characteristics • Direction • Latency • Duration • Fatigability • Reversibility Directions of Nystagmus • Posterior – Upbeat with geotropic torsion • Anterior – Downbeat with torsion to bad ear • Lateral – Geotropic horizontal (common) – Apogeotropic horizontal (uncommon) 5

Right Ear Posterior Canal BPPV Geotropic & Upbeat VNG Goggles • Not necessary - torsional nystagmus not visually suppressed • But they sure help – Non-torsional nystagmus – Can see in awkward positions – Recordings give you time to think Dmitry Kostyukov/AFP/Getty Images 6

Right Posterior Canal Semont http://www.neurology.org/content/70/22/2067/F3.large.jpg (modified) Brandt-Daroff http://www.neurology.org/content/70/22/2067/F3.large.jpg (modified) 7

Right Ear Epley Maneuver http://hearingaidscentral.com/BPPV_Epley_Maneuver.asp Canalith Repositioning Maneuver Position A (Sitting) Right Ear Lateral View Posterior Canal BPPV 8

CRM Position B (Dix-Hallpike) Right Ear Lateral View Posterior Canal BPPV CRM Position C (Head Rotated To Opposite Side) Right Ear Lateral View Keep the head back as you rotate it. Posterior Canal BPPV The nystagmus should not reverse direction. 9

CRM Position D (On Side - Nose Down) Right Ear Lateral View Posterior Canal BPPV 10

CRM Position E (Back To Sitting) Right Ear Lateral View Posterior Canal BPPV Stabilize patient for at least a minute. http://www.vesticon.com/The_Epley_Omniax/Epley_Omniax_Gallery 11

Adjuncts • Vestibular suppressants – Hide findings – Useful for severe nausea • Mastoid vibration – no help 1-2 (except) – Multiple failures – Cupulolithiasis 1 Hain TC, Helminski JO, Reis IL, Uddin MK. Vibration does not improve results of the canalith repositioning procedure . Arch Otolaryngol Head Neck Surg 2000; 122(3):440-4. 2 Burton MJ, Eby TL, Rosenfeld RM. Extracts from the Cochrane Library: Modifications of the Epley maneuver for posterior canal BPPV. Otolaryngol Head Neck Surg 2012; 147(3):407-11. Post-Care • Post-treatment restrictions do not help 1-4 • Seat in waiting room for 20 min • No driving for remainder of day 1 Tusa RJ, Herdmann SJ. BPPV: Controlled trials, contraindications, post-manouvere instructions, complications, imbalance. Audiology Medicine 2005; 3(1):57-62. 2 Nuti D, Nati C, Passali D. Treatment of BPPV: No need for post maneuver restrictions. Otolaryngol Head Neck Surg 2000; 122(3):440-4. 3 Andreoli SM, Devaiah A. Posture restrictions in BPPV. Otolaryngol Head Neck Surg 2007; 137(2): 258. 4 Burton MJ, Eby TL, Rosenfeld RM. Extracts from the Cochrane Library: Modifications of the Epley maneuver for posterior canal BPPV. Otolaryngol Head Neck Surg 2012; 147(3):407-11. 12

Epley vs. Semont • Epley – 80 to 85% effective after one session 1 – Easier to do – Better tolerated by elderly • Semont – 90% effective after four sessions 2 – Better for cupulolithiasis? 1 Epley JM. The canalith repositioning procedure: For the treatment of BPPV. Otolaryngol Head Neck Surg 1992; 107(3); 399-404. 2 Levrat E, van Mell G, Monnier P, Maire R. Efficacy of the Semont maneuver in BPPV. Arch Otolaryngol Head Neck Surg 2003; 129(6): 629-33. Horizontal Canal AC LC PC 13

Geotropic Right Horizontal Canal Geotropic Debris Near Vestibule Supine Left Ear Down Right Ear Down Inhibition Stimulation 14

Apogeotropic Right Horizontal Canal Apogeotropic Debris Near Ampulla Supine Right Ear Down Left Ear Down Inhibition Stimulation 15

Right Horizontal Canal Lempert Roll http://www.neurology.org/content/70/22/2067/F5.expansion Right Horizontal Canal Lempert Roll 1 2 3 4 16

Horizontal Canal In The Office • Geotropic – roll away from the strongest nystagmus • Apogeotropic – roll toward the strongest nystagmus, convert to geotropic • Cannot tell which side – guess 17

Horizontal Canal At Home* • Log roll to one side daily for one week • Switch sides if that does not work • Sleep with bad ear up • Modified Brandt-Daroff (head straight) - to loosen up possible cupulolithiasis *Only necessary if office treatments fail. Right Ear Anterior Canal Lateral View Sitting g AC PC 18

Right Ear Anterior Canal BPPV Geotropic & DOWNBEAT Left Ear Anterior Canal BPPV APOGEOTROPIC & Downbeat 19

Anterior Canal Strategy Deep Head Hang Maneuver Head Midline – the effected side does NOT matter Mimickers • Horizontal – Positional alcohol nystagmus • Downbeat – Caudal midline cerebellar lesions • Upbeat – Dorsal central medullary lesions • Torsional – Syringomyelia and syringobulbia • Persistent – Somewhere central 20

Billing - 95992 • Medicare – 45.12 • Aetna – 64.29 • Cigna – 87.75 • Humana APP – 50.13 • First Health – 73.50 • BCBSA – 57.00 • DMG – E&M only Thank You 21