Otolaryngology Update

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Otolaryngology Update

• Chuck Reese, CAPT MC USN
• Naval Aerospace Medical Institute
• 850-452-3256
• Charles.reese_at_med.navy.mil

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Benign Paroxysmal Positional Vertigo

• Sudden onset of vertigo related to change in head
  position
• Often begins on arising from bed in morning
• Etiology uncertainpostviral? post-head trauma?
  following prolonged static head positioning (root
  canal)?
• Establish diagnosis on basis of history and
  positive Dix-Hallpike test.

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Benign Paroxysmal Positional Vertigo

• Theory
• Somehow, otoliths travel from utricle to the
  posterior semicircular canal and stimulate the
  wrong hair cells upon head movement
• Treatment
• Epley maneuver (repositions errant otoliths)

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First, a little anatomy
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1934 Sketch of membranous labyrinth, Brodel, M,
in Schuknecht, Pathology of the Ear, 2nd Edition
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Schematic of Inner Ear Demonstrating
Interconnectivity of Labyrinths.
Picture from Otolaryngology Head and Neck
Surgery, 3rd Edition, 1998, Cummings, et al page
2587
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Schematic diagram of SacculeLindeman, 1969, in
Schuknecht, 2nd Edition, Pathology of the Ear
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Orientation of Maculae of Utricle and Saccule
Picture from Otolaryngology Head and Neck
Surgery, 3rd Edition, 1998, Cummings, et al page
2570
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Otoconia in Schuknecht, 2nd Edition Pathology of
the Ear
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Benign Paroxysmal Positional Vertigo
Cupula of Posterior Semicircular Canal
Movement of otoliths, or other debris, trapped in
the posterior semicircular canal causes a current
within the endolymph which results in stimulation
of the cupula
From the Ear Info Web site http//www.earinfosit
e.org
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Orientation of the Semicircular Canals
ACAnterior (or Superior) Canal PCPosterior
Canal LCLateral Canal
Picture from Otolaryngology Head and Neck
Surgery, 3rd Edition, 1998, Cummings, et al page
2563
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Crista Ampullaris Cupula
Picture from Otolaryngology Head and Neck
Surgery, 3rd Edition, 1998, Cummings, et al page
2569
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Benign Paroxysmal Positional Vertigo

• Characteristics of Positive Dix-Hallpike
• brief latent period before onset
• Mixed tortional and vertical nystagmus (the
  superior pole of the eyes rotates toward the ear
  that is down in the fast component. There is
  also usually a vertical fast component toward the
  forehead)
• builds in intensity over several seconds
• lasts for less than a minute
• becomes less severe with successive repetitions
  of the provocative head movement(that is, it
  fatigues)

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The Dix-Hallpike Maneuver
From Otolaryngology-Head and Neck Surgery, Vol
139, No. 5S4, Nov 2008
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Epley Maneuver (or Canalith Repositioning
Procedure)
From Otolaryngology-Head and Neck Surgery, Vol
139, No. 5S4, Nov 2008
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Semont Maneuver (Alternative PRM)
From Otolaryngology-Head and Neck Surgery, Vol
139, No. 5S4, Nov 2008
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Benign Paroxysmal Positional Vertigo

• Aeromedical disposition
• There has been an increased number of cases in
  the last several years. Currently requires a
  waiver.
• Perform a Particle Repositioning ManeuverEpley
  Canalith Repositioning Procedure or Semont
  Liberatory Maneuver
• Ground aircrew for 4 weeks to allow otoliths to
  stick
• Contact NAMI ENT Local Board and submit AMS