Video Demonstration of Positional Test of BPPV and Repositioning for "Halo" Strategies Issue 5

The "Halo" column has been launched since May 2019, and within one year, nearly 50 articles have been published
.

Mr.
Chen Ganggang, combined with actual clinical cases and diagnosis and treatment experience, analyzes the key points of vertigo disease knowledge in simple language, which is well received by clinicians! In order to facilitate everyone to read past articles (you can read "Hao's Strategy · Season 1", you can scan the QR code below), this year, we will continue to push the content of ""Halo' Strategy · Season 2" to learn from everyone.
And discuss vertigo disease! This article is published by the author with the authorization of Yimaitong, please do not reprint without authorization
.

Review ""Halo" Planning Strategy Season 1", for more information, scan the QR code below ↓↓↓ Benign Paroxysmal Positional Vertigo (BPPV), commonly known as "otolithiasis"
.

It is the most common peripheral vestibular disorder characterized by recurrent transient vertigo and characteristic nystagmus, induced by changes in head position relative to the direction of gravity
.

Has certain self-healing properties
.

Overview It is more common in women, with a lifetime prevalence of 3.
2% and 1.
6% for men and women, respectively.
The annual incidence rate varies from country to country, about (10.
7-600)/100,000.
It can occur in any age group and increases with age.
increased, and the incidence increased by 38% for every 10 years of age
.

Children are less common
.

The etiology of approximately BPPV is unknown
.

The latest meta-analysis shows that women, urban dwellers, sleep disorders, vitamin D deficiency, osteoporosis, migraine, head trauma, and high total cholesterol levels are common triggers of BPPV
.

Among older women, those who were physically inactive were 2.
6 times more likely to develop BPPV than those who were regularly physically active
.

The short-term recurrence rate of BPPV patients is about 20%, and the recurrence rate of more than 18 months can reach 30-50%.
The recurrence rate of female patients is significantly higher than that of males
.

Patients ≥65 years of age had a 1.
5-fold increased risk of recurrence compared with patients <65 years of age
.

In addition, other ear diseases (such as Meniere's disease, vestibular neuritis, idiopathic sudden deafness, otitis media, etc.
), various types of surgery (otology, oral and maxillofacial surgery, orthopedic surgery, etc.
), application of ear Toxic drugs can also induce BPPV
.

The clinical classification criteria in the literature are not uniform
.

They are often classified according to etiology, involved semicircular canals, and pathophysiological mechanisms
.

Classification according to involved semicircular canals: 1) Posterior semicircular canal BPPV: the most common, about 70-90%
.

2) External (horizontal) semicircular canal BPPV: about 10-30%
.

3) Anterior (superior) semicircular canal BPPV: rare
.

4) Multiple semicircular canals BPPV: simultaneous involvement of multiple semicircular canals on the same side or both sides, which is rare
.

Classification by pathophysiological mechanism: 1) Canal calculi: Free otoliths are located in the semicircular canal canal arms.
According to the different positions of the otoliths in the canal arms, they can be divided into forearm type and posterior brachial type
.

2) Crest calculi: otoliths adhere to the crista cap of the semicircular canal
.

 Positional testing should be performed first when a patient is considered to have BPPV
.

Before the examination, it is necessary to comprehensively consider the patient's physical and mental state, inform the patient of the examination method and the discomfort that may be induced, evaluate whether it can tolerate it, and win the active cooperation of the patient and family members
.

Before the examination, it is necessary to observe whether the patient has spontaneous nystagmus, and special attention should be paid to the possibility of pseudo-spontaneous nystagmus
.

Commonly used position tests include Dix-Hallpike test, Roll test,
etc.

1.
Dix-Hallpike test This test is the preferred method for judging the BPPV of the posterior and anterior semicircular canals
.

The patient is in a sitting position, the examiner turns his head to one side 45°, keeps his head still and quickly lies on his back, with his head tilted back and 30° from the horizontal plane, to observe the presence or absence of positional vertigo and nystagmus (see Video 1).

.

 Video 1: Right Dix-Hallpike test If the patient has posterior semicircular canal BPPV, bilateral vertical torsional nystagmus occurs when the affected ear is turned to the ground (see Video 2) (the vertical component goes up to the pole, and the torsion component goes to the ground), with fatigue, And the torsional component of low nystagmus is more prominent, and the vertical component of high nystagmus is more obvious
.

  Video 2: Bilateral Posterior Semicircular Canalolithosis Nystagmus (0-20S: Left Posterior Semicircular Canalolithosis Nystagmus, 21-56S: Right Posterior Semicircular Canalolithosis Nystagmus) Note: Left and right sides of all nystagmus videos There is a mirror image relationship with our readers' left and right hands, that is, when facing the video, our left direction is the right side of the video patient
.

The same below
.

If the patient has anterior semicircular canal BPPV, vertical torsional nystagmus can also be seen in the unilateral/bilateral Dix-Hallpike test or supine hanging head examination, but the vertical component is down to the pole, the torsion component is weak, and the direction is difficult to determine
.

Occasionally, it may only manifest as vertical jump nystagmus
.

If the positional nystagmus disappears after reduction, the diagnosis of BPPV in the anterior semicircular canal can be confirmed
.

On the contrary, central positional nystagmus, vestibular migraine, and contralateral posterior semicircular canal BPPV should be excluded
.

 When the patient has severe cervical spinal stenosis, cervical spine mobility limitation, kyphosis, rheumatoid arthritis, ankylosing spondylitis, severe obesity, etc.
, the Dix-Hallpike test should be performed with caution [16]
.

 2.
Roll test is the preferred method for judging lateral semicircular canal otolithiasis
.

Take the supine position, raise the head 30°, turn the head 90° to one side and observe until the vertigo or nystagmus disappears and return to the original position 30 seconds later, and then turn 90° to the other side to observe (see Video 3)
.

If both sides evoked horizontal gravitational nystagmus or horizontal dorsal nystagmus (with a slight torsional component), it was considered as BPPV of the lateral semicircular canal
.

Video 3: Roll test nystagmus classification: ①Horizontal geotropic nystagmus: when the time is less than 1 minute, it is considered as the lateral semicircular canal and posterior brachial canal calculi.
And the intensity ratio of nystagmus induced by left and right lateral positions is about 2:1; when the time is greater than 1 minute, it is considered as a light crest cap
.

(See Video 4) Video 4: 0-21S: Geotropic nystagmus (rightward) in right lateral decubitus, 22S-1 minutes 02S: Geotropic nystagmus (leftward) in left lateral decubitus, It can be seen that the left side is strong and the right side is weak, and the patient has left horizontal semicircular canal lithiasis
.

 ②Horizontal dorsal nystagmus: when the time is less than 1 minute, it is considered as lateral semicircular canal forearm canal calculi; when the time is greater than 1 min, it is considered as lateral semicircular canal crest calculi
.

At this time, the side with low eyeball intensity and short duration is the affected side
.

(See Videos 5 and 6, the time is less than 1min.
) When the judgment of the affected side is difficult, pseudo-spontaneous nystagmus, null plane, and head down-up test ( bowand lean test), sitting-supine test (lying-downtest), etc.
to assist judgment
.

The latent period of nystagmus in capstone lithiasis is short or non-latent, and the intensity of nystagmus changes gradually
.

 Manipulative reduction therapy Manipulative reduction therapy should be performed when a patient presents with characteristic nystagmus on position testing
.

The commonly used reduction methods for posterior semicircular canal BPPV include Epley's method and Semont's method, and the commonly used reduction methods for lateral semicircular canal BPPV include Barbecue's method and Gufoni's method
.

(1) Epley's method This reduction method was first reported by Professor Epley in 1992.
The method: from the Dix-Hallpike test-induced position to the opposite side (the healthy side), turn 2 consecutive 90°, and finally sit up
.

After each 90° rotation, you need to stay until the nystagmus disappears for 30 seconds before the next rotation
.

When the nystagmus pattern in the two 90° rotation positions is consistent with the evoked position, the possibility of successful reduction is high
.

During the reduction process, the patient may experience discomfort such as dizziness, nausea, vomiting, and feeling of falling
.

(See Video 7) Video 7: Epley reduction for canallithiasis in the left posterior semicircular canal (2) Semont's method The reduction method was first proposed by Professor Semont in 1988
.

METHODS: The patient sits in a sitting position, turns his head 45° to the unaffected side, and quickly falls from the sitting position to the affected side in a lateral recumbent position.
After 30 seconds of nystagmus disappears, he sits up, and then turns 180° to the unaffected side in a coronal position.
After the nystagmus disappeared for 30 seconds, resume sitting
.

(See Video 8) Video 8: Semont reduction for right posterior semicircular canal lithiasis (3) Barbecue method was first proposed by Professor Lempert in 1996.
Lie on the affected side - sit up, roll continuously at 90°, wait for the nystagmus and vertigo to disappear for 30 seconds in each position, then turn to the next position, and finally sit up and lower your head to rest
.

(See Video 9) Video 9: The patient has left lateral semicircular canal lithiasis, and the patient is directly treated with Barbecue reduction (omitting the lying position on the affected side) (4) Gufoni method: according to the characteristics of nystagmus when lying on both sides of the roll test , firstly lie on the side with the weaker nystagmus, wait for 30 seconds after the nystagmus disappears, and then quickly turn the head 45° to the fast side of the nystagmus
.

(See Video 10) Video 10: Gufoni's Method (0-25S: Assume the patient has geotropic nystagmus, left lateral semicircular canal lithiasis; 26-49S: Assume the patient has dorsal nystagmus, right lateral semicircular canal lithiasis (5) vestibular rehabilitation training vestibular rehabilitation training can be used as an adjuvant therapy for otolith reduction in patients with BPPV
.

It is suitable for: ① patients with a clear diagnosis but ineffective reduction; ② patients with residual dizziness after reduction; ③ patients who cannot tolerate manual reduction; sex
.

The most commonly used rehabilitation training method for otolithiasis is the Brandt-Daroff home practice method
.

Method: Lie on the dizzy side for 30 seconds, sit up and lie on the opposite side for 30 seconds, alternately and repeatedly, several times a day, until the symptoms of dizziness disappear
.

For the posterior semicircular canal BPPV, some scholars believe that its reduction efficiency is lower than that of the Epley method and the Semont method
.

However, there are also studies that this method has good curative effect on canallithiasis and crest calculi in posterior semicircular canal BPPV, and the effective rate of 1-week follow-up is comparable to the Epley method
.

(See Figure 1) Figure 1: Home Repositioning Method: Lie on the dizzy side for 30 seconds, sit up and lie on the opposite side for 30 seconds, alternately and repeatedly
.

Acknowledgments: Thanks to Yang Jie and Wu Jiaxin from the Department of Otolaryngology and Head and Neck Surgery of the First Hospital of Shanxi Medical University for their friendship
.

Note: For more details, please refer to the entry "benign paroxysmal positional vertigo" in the "Yizhiyuan Disease Knowledge Base - Vestibular Medicine"
.

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