Ans. d (BPPV) (Ref. PL Dhingra ENT, 4th ed, 58)Epley Maneuver for Rx of BPPV: The patient is taken through 4 moves, starting in the sitting position with the head turned at a 45-degree angle toward the affected side. (1) The patient is placed into the Dix-Hallpike position (supine with the affected ear down) until the vertigo and nystagmus subside.(2) The patient's head is then turned to the opposite side, causing the affected ear to be up and the unaffected ear to be down.(3) The whole body and head is then turned away from the affected side to a lateral decubitus position, with the head in a face down position.(4) The last step is to bring the patient back to a sitting position with the head turned toward the unaffected shoulder.BPPV (BENIGN PAROXYSMAL POSITIONAL VERTIGO)It is characterized by vertigo when head is placed in a certain critical position.# Cause:- Disorder of posterior semicircular canal.- Otoconial debris, consisting of calcium carbonate, is released from the degenerating macula of utricle and floats freely in endolymph. When it settles on the cupula of posterior semicircular canal in critical head position, it causes displacement of cupula and vertigo.# H/o: Deafness, Vomiting, Tinnitus# Positional vertigo is precipitated by a recumbent head position, either to the right or to the left.# Benign paroxysmal positional (or positioning) vertigo (BPPV) of the posterior semicircular canal is particularly common. Although the condition may be due to head trauma, usually no precipitating factors are identified. It generally abates spontaneously after weeks or months. The vertigo and accompanying nystagmus have a distinct pattern of latency, fatigability, and habituation that differs from the less common central positional vertigo due to lesions in and around the fourth ventricle. Moreover, the pattern of nystagmus in posterior canal BPPV is distinctive.# When supine, with the head turned to the side of the offending ear (bad ear down), the lower eye displays a large- amplitude torsional nystagmus, and the upper eye has a lesser degree of torsion combined with upbeating nystagmus. If the eyes are directed to the upper ear, the vertical nystagmus in the upper eye increases in amplitude. Mild dysequilibrium when upright may also be present.FeaturesBPPVCentralLatency3-40 sNone: immediate vertigo and nystagmusFatigabilityYesNoHabituationYesNoIntensity of vertigoSevereMildReproducibilityVariableGood# Treatment:a) Epley's Maneuverb) Intra-labyrinthine Streptomycin / Gentamycin.# BPPV is caused by dislodged otoconia that move with changes in head position. Single applications of the Epley procedure or the Semont maneuver have been reported to relieve symptoms in the majority of patients. Repeated treatment sessions may be necessary before symptoms resolve. Sign or symptomPeripheral (Labyrinth)Central (Brainstem or Cerebellum)1. Direction of associated nystagmusUnidirectional; fast phase oppositeBidirectional or unidirectional2. Purely horizontal nystagmus without torsional componentUncommonCommon3. Vertical/purely torsional nystagmusNever presentMay be present4. Visual fixationInhibits nystagmus and vertigoNo inhibition5. Severity of vertigoMarkedOften mild6. Direction of spinToward fast phaseVariable7. Direction of fallToward slow phaseVariable8. Duration of symptomsFinite (minutes, days, weeks) but recurrentMay be chronic9. Tinnitus and/or deafnessOften presentUsually absent10. Associated CNS abnormalitiesNoneExtremely common (e.g., diplopia, hiccups, cranial neuropathies, dysarthria)11. Common causesBPPV, infection (labyrinthitis),Meniere's, neuronitis, ischemia, trauma, toxinVascularAdditional Educational Points: