Particle Repositioning for BPPV. Objectives
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1 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
2 Lateral Canal Crista Ampullaris Excitation Vestibule Ewald s First Law: Eye movements are in the plane of the semicircular canal, and in the direction of the endolymph flow. 2
3 BPPV Exam Start seated Neck mobility Cervical-induced nystagmus Rotational vertebral artery syndrome Right Dix-Hallpike BPPV Exam Roll test (if horizontal nystagmus) Reverse Dix-Hallpike (it depends) Left Dix-Hallpike Supine head hanging (bring back up first) 3
4 Right Ear Lateral View Sitting AC g PC LC Right Ear Lateral View Dix-Hallpike 20 Head Hang LC g AC PC 4
5 Direction Latency Duration Fatigability Reversibility BPPV Characteristics Directions of Nystagmus Posterior Upbeat with geotropic torsion Anterior Downbeat with torsion to bad ear Lateral Geotropic horizontal (common) Apogeotropic horizontal (uncommon) 5
6 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
7 Right Posterior Canal Semont (modified) Brandt-Daroff (modified) 7
8 Right Ear Epley Maneuver Canalith Repositioning Maneuver Position A (Sitting) Right Ear Lateral View Posterior Canal BPPV 8
9 CRM Position B (Dix-Hallpike) Right Ear Lateral View Posterior Canal BPPV CRM Position C (Head Rotated To Opposite Side) Right Ear Lateral View Posterior Canal BPPV Keep the head back as you rotate it. The nystagmus should not reverse direction. 9
10 CRM Position D (On Side - Nose Down) Right Ear Lateral View Posterior Canal BPPV 10
11 CRM Position E (Back To Sitting) Right Ear Lateral View Posterior Canal BPPV Stabilize patient for at least a minute. 11
12 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): 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): 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): Nuti D, Nati C, Passali D. Treatment of BPPV: No need for post maneuver restrictions. Otolaryngol Head Neck Surg 2000; 122(3): Andreoli SM, Devaiah A. Posture restrictions in BPPV. Otolaryngol Head Neck Surg 2007; 137(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):
13 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); Levrat E, van Mell G, Monnier P, Maire R. Efficacy of the Semont maneuver in BPPV. Arch Otolaryngol Head Neck Surg 2003; 129(6): Horizontal Canal AC PC LC 13
14 Geotropic Right Horizontal Canal Debris Near Vestibule Geotropic Left Ear Down Inhibition Supine Right Ear Down Stimulation 14
15 Apogeotropic Right Horizontal Canal Debris Near Ampulla Apogeotropic Left Ear Down Stimulation Supine Right Ear Down Inhibition 15
16 Right Horizontal Canal Lempert Roll Right Horizontal Canal Lempert Roll
17 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
18 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 Lateral View Sitting Anterior Canal AC g PC 18
19 Right Ear Anterior Canal BPPV Geotropic & DOWNBEAT Left Ear Anterior Canal BPPV APOGEOTROPIC & Downbeat 19
20 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
21 Billing Medicare Aetna Cigna Humana APP First Health BCBSA DMG E&M only Thank You 21
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