El vértigo posicional paroxístico benigno (VPPB) es una de las patologías vestibulares más frecuentes. El desarrollo de las terapias de reposición de partículas. El vértigo posicional paroxístico benigno (VPPB) es una enfermedad crónica recurrente y la discapacidad asociada es habitualmente subestimada. El objetivo . Download scientific diagram | Maniobra de Pagnini-McClure o Roll Test. Paciente en Manejo del vértigo posicional paroxístico benigno en atención primaria.
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Download scientific diagram | Maniobra de Pagnini-McClure o roll-test. de reposicionamiento canalicular en el vértigo posicional paroxístico benigno: revisión. El vértigo posicional paroxístico benigno es el trastorno vestibular más Document downloaded from raudone.info, day 07/07/ This copy is for. Download PDF Vértigo posicional paroxístico benigno: revisión de casos El vértigo posicional paroxístico benigno es uno de los trastornos vestibulares .
Again, the value of post-maneuver restrictions is probably small, and it is also OK to just go about your life but we think a little riskier. At one week after treatment, put yourself in the position that usually makes you dizzy.
VÉRTIGO POSICIONAL PAROXÍSTICO BENIGNO
Position yourself cautiously and under conditions in which you can't fall or hurt yourself. Let your doctor know how you did. Variant office maneuvers for PC BPPV: While some authors advocate use of vibration in the Epley maneuver, we have not found this useful in a study of our patients Hain et al, There is some rationale for its use in cupulolithasis or refractory BPPV. Use of an antiemetic prior to the maneuver may be helpful if nausea is anticipated.
Some authors suggest that position 'D' in the figure is not necessary e. Cohen et al. In our opinion, this is a mistake as mathematical modeling of BPPV suggests that position 'D' is the most important position Squires et al, Mathematical modeling also suggests that position 'C' is probably not needed. In our opinion, position 'C' has utility as it gives patients a chance to regroup between position 'B' and 'D'.
The "Gans" maneuver. This is a little used treatment maneuver, called the "Gans maneuver" by its inventor R. Gans, Ph. It incorporates the head orientations to gravity of "B" and "D" in the Epley figure above, using the body positions of the Semont maneuver. It leaves out position 'C' in the figure above.
Many patients have been reported in controlled studies. A metanalysis published in indicated that there is very good evidence that the Epley maneuver CRP is effective Helminski et al, See here for the details. For this reason, in persons who have continued dizziness, a follow-up visit is scheduled and another nystagmus test with video-Frenzel goggles is done.
Acta Otorrinolaringologica Española
There are several possible reasons for continued dizziness after a physical treatment for BPPV: Maneuver didn't work should keep treating for a reasonable number -- about 4 is usually reasonable-- attempts Canal conversion should change treatment to the new canal Another problem in addition to BPPV e.
This insurance company logic is seriously flawed. Just imagine -- what if insurance companies tried to save money by limiting the number of EKG's that can be done in a person with a heart attack? Insurance would pay less but more people would die. With BPPV, one needs to see the results of the last treatment, and be sure that things haven't changed.
Similarly, it would be ridiculous to prevent a cardiologist from checking an EKG on a patient who had sustained a heart attack, but was not in chest pain. You can see how this logic applies to follow-up testing for BPPV. When all maneuvers have been tried, the diagnosis is clear, and symptoms are still intolerable, surgical management posterior canal plugging may be offered.
This is exceedingly rare. Occasional patients travel to a facility where a device is available to position the head and body to make the maneuvers more effective.
Acta Otorrinolaringologica Española
See this page for more information about this option. As one can usually get to any position through moving the head and body around, unless you are very unwieldy, these devices are likely an "overkill". BPPV often recurs. If BPPV recurs, in our practice we usually re-treat with one of the maneuvers above. While daily use of exercises would seem sensible, we did not find it to prevent recurrence Helminski et al, ; Helminski and Hain, In some persons, the positional vertigo can be eliminated but imbalance persists.
This may be related to utricular damag e Hong et al, See this page for some other ideas. In these persons it may be reasonable to undertake a course of generic vestibular rehabilitation, as they may still need to compensate for a changed utricular mass or a component of persistent vertigo caused by cupulolithiasis. Conventional vestibular rehabilitation has some efficacy, even without specific maneuvers.
Angeli, Hawley et al. There are so many home maneuvers that we wrote a separate page to describe them. We have not had any patients go for surgery for at least 5 years.
Surgical treatment of BPPV is not easy -- your local ear doctor will probably have had no experience at all with this operation. Of course, it is always advisable when planning surgery to select a surgeon who has had as wide an experience as possible. Canal plugging blocks most of the posterior canal's function without affecting the functions of the other canals or parts of the ear. The risk of the surgery to hearing derives from inadvertent breaking into the endolymphatic compartment while attempting to open the bony labyrinth with a drill.
Sensibly, canal plugging for BPPV note the first letter stands for "benign" is rarely undertaken these days due to the risk to hearing. Alternatives to plugging. Singular nerve section is the main alternative. Interestingly, Dr.
Gacek is the only surgeon who has published any results with this procedure post Leveque et al, Singular nerve section is very difficult because it can be hard to find the singular nerve. Anthony Houston, Texas , advocates laser assisted posterior canal plugging. It seems to us that these procedures, which require unusual amounts of surgical skill, have little advantage over a conventional canal plugging procedure.
Vestibular nerve section , while effective, eliminates more of the normal vestibular system than is necessary. Similarly, transtympanic gentamicin treatment is generally inappropriate. Labyrinthectomy and sacculotomy are also both inappropriate because of reduction or loss of hearing expected with these procedures. Singular nerve section appears to be too difficult for most otologic surgeons.
They are mainly thought to be caused by migration of otoconial debris into canals other than the posterior canal, such as the anterior or lateral canal. Debris may also migrate into or out of the short arm of the PC on diagram, where arrow says "vestibulolithiasis".
It is also possible that some are due to other conditions such as brainstem or cerebellar damage, but clinical experience suggests that this is very rare. There is presently no data reported as to the frequency and extent of these syndromes following treatment procedures.
In nearly all instances, with the exception of cupulolithiasis, these variants of BPPV following maneuvers resolve within a week without any special treatment, but when they do not, there are procedures available to treat them. It is especially common to have supine downbeating nystagmus after a successful Epley maneuver Cambi et al, This should not be of any concern as long as it is unaccompanied by upbeating nystagmus on sitting which suggests anterior canal BPP V.
In clinical practice, atypical BPPV arising spontaneously is first treated with maneuvers as is typical BPPV, and the special treatments as outlined below are entered into only after treatment failure.
When atypical BPPV follows the Epley, Semont or Brandt-Daroff maneuvers, specific exercises are generally begun as soon as the diagnosis is ascertained. In patients in whom the exercise treatment of atypical BPPV fails, especially in situations where onset is spontaneous, additional diagnostic testing such as MRI scanning may be indicated.
The reason for this is to look for other types of positional vertigo. Many cases are seen as a consequence of an Epley maneuver. It is diagnosed by a horizontal nystagmus that changes direction according to the ear that is down. It is diagnosed by a positional nystagmus with components of downbeating and sometimes torsional movement on taking up the Dix-Hallpike position. More detail about anterior canal BPPV as well as an illustration of a home exercise can be found here Cupulolithiasis is a condition in which debris is stuck to the cupula of a semicircular canal, rather than being loose within the canal.
Cupulolithiasis should result in a constant nystagmus. This pattern is sometimes seen Smouha et al. Cupulolithiasis might theoretically occur in any canal -- horizontal, anterior or vertical, each of which might have it's own pattern of positional nystagmus. If cupulolithiasis of the posterior canal is suspected, it seems logical to treat with either the Epley with vibration, or alternatively, use the Semont maneuver.
Other maneuvers have been proposed for lateral canal cupulolithiasis. There are no controlled studies of cupulolithiasis to indicate which strategy is the most effective. Vestibulolithiasis is a hypothetical condition in which debris is present on the vestibule-side of the cupula, rather than being on the canal side.
For this theory, there is loose debris, close to but unattached to the cupula of the posterior canal, possibly in the vestibule or short arm of the semicircular canal. This mechanism would be expected to resemble cupulolithiasis, having a persistent upbeating nystagmus, but with intermittency because the debris is movable. Very little data is available as to the frequency of this pattern, and no data is available regarding treatment. Multicanal BPPV.
If debris can get into one canal, why shouldn't it be able to get into more than one? It is common to find small amounts of horizontal nystagmus or contralateral downbeating nystagmus in a person with classic posterior canal BPPV. While other explanations are possible, the most likely one is that there is debris in multiple canals. Gradually a literature is developing about these situations Bertholon et al, This is one way to a local treating health care provider interested in treating this condition.
We think it is best to select someone who treats BPPV at least on a weekly basis, or if this is not possible, someone who has attended a course on vestibular rehabilitation AND who has the equipment in their office to visualize BPPV i. Such theory states that otolithic fragments detach from the utricle macula and stick to the semicircular cupule, which stops working as angular acceleration transducer and starts working as linear acceleration transducer.
The canalithiasis theory explains that the fragments do not remain adhered to the semicircular canal cupula, but rather they float in the endolymph. Thus, the patient's head movement causes these fragments to move and thus an inadequate stimulation of the canal cupula, generating vertigo symptoms. Anterior canal involvement is characterized by rotatory and downbeat vertical positional nystagmus counterclockwise in right labyrinth lesions and clockwise in left labyrinth lesions.
Exclusively counterclockwise or clockwise rotatory positional nystagmus suggests involvement of the vertical canal, although not defining which vertical canal is affected. In vertical canal involvement, canalithiasis is characterized by nystagmus lasting up to 1min, and cupulolithiasis is evidenced by nystagmus lasting more than 1min. Horizontal positional nystagmus is geotropic when tilting the head to the right causes right horizontal nystagmus and tilting the head to the left causes left horizontal nystagmus.
It is ageotropic when tilting the head to the right causes left horizontal nystagmus and tilting the head to the left causes right horizontal nystagmus. According to them, the success rate after one session was The test became negative in Improvement was reported in In a study by Froehling et al.
All 50 patients wore the neck collar on the first two nights and were asked not to sleep over the affected side for 5 days, and avoid head movements for one week. Angeli et al. Post-maneuver recommendations were given, such as to avoid vertigo-provoking movements, avoid sleeping with the head high for 48 hours and, if necessary, use anti-vertigo drugs. A neck collar was used during this period. Similarly, Yimtae et al.
No other recommendation was given after Epley's maneuver, not even the neck collar. No mastoid vibration was used. The groups were compared after one, two, three and four weeks, with results favoring the maneuver group, specially after one week Sridhar et al. Here, neither mastoid vibration nor medication was used as well, but only sleeping tips such as to elevate bead head for 48 hours.
Thus, it was possible to group them according to: Dix-Hallpike test cure one week after Epley's maneuver; and patient reported subjective improvement one week after the same maneuver. Results are depicted on Figure 1 graphs.
Figure 1. There is a lack of phases II, III and IV clinical trials, and even multicentric studies, made up of large samples over individuals and with longer follow up over 1 year.
There are very few publications either describing or proposing interventions for anterior and horizontal semi-circular canal dysfunctions, and the few studies found were not adequate according to the adopted criteria or Jadad's scale.
We did not find any study on the Semont's maneuver efficacy of enough methodological quality to meet the criteria of this review. Therefore, we see a broad research field about Semont's maneuver efficacy. As to the studies found that met the minimum quality requirements to be grouped in our review, we see that only Epley's maneuver was deeply investigated. Notwithstanding, there still remain details and variations as to that author's originally described technique, curiously obtaining similar results.
Froehling et al.Male patient, 57 years of age, see for 4 episodes of acute onset of vertigo, lasting several seconds, are triggered by abrupt movements of the head and body position changes, are followed by nausea, vomiting and sweating deep concerns disequilibrium during walking. A modified Epley's procedure for self-treatment of benign paroxysmal positional vertigo. For at least one week, avoid provoking head positions that might bring BPPV on again.
We also did not see methodological relevant papers that described or proposed a proper handling of anterior and horizontal canal dysfunction. Similarly, Yimtae et al. In two papers the authors advised patients to wear neck collar after the maneuver for 48 hours 28, This is exceedingly rare. Steenerson contributes showing in his study the physical therapists usual modus operandi, with many weekly sessions for patients treated by canal repositioning maneuvers and for patients treated by vestibular rehabilitation.
We also recommend that the study should not involve only otolaryngologists and neurologists, but all the other health care professionals involved in BPPV patient treatment such as general practitioners 1 , emergency physicians 4 , psychiatrists 41 and physical therapists 2 , we must be attentive to identify BPPV early on, know its main differential diagnosis and its treatment.
Just imagine -- what if insurance companies tried to save money by limiting the number of EKG's that can be done in a person with a heart attack?