各型BPPV的诊断手法及复位技巧

BPPV 假说
Schuknecht H.F. (1969) [3] ：壶腹嵴帽结石症 学说, 后半规管壶腹嵴cupulolithiasis. Hall SF. (1979) [4] : 半规管结石症学说, 后半 规管canalithiasis. BPPV can be caused by either canalithiasis or cupulolithiasis and can theoretically affect each of the 3 semicircular canals, although superior canal involvement is exceedingly rare.
Roll test
Rahkon WRW test
HC-BPPV 诊断标准



在床上向左右翻身时发作，当头转向患侧时眩晕 或眼震变剧烈，做头部的垂直运动如抬头或弯腰 矢状面运动则不引起眩晕. 潜伏期稍短，约2～3秒. 持续时间略长,可达1分钟. 疲劳性不明显. Roll test阳性, 两侧均出现向地性水平性眼震,以患 侧更强烈(canalithiasis )或背地性水平性眼震,但以健 侧更强烈(cupulolithiasis). 眼震方向与头转动方向一致， 称为向地性水平性 眼震,否则为背地性水平性眼震



Epley 耳石复位法CRP [7] [图8] [图9] [图10] ：平仰卧，头 微伸展，振动器固定在患侧乳突 →头转向患侧呈 45° →保持15秒～30秒或至眼震消失，头转向健 侧呈45° →保持15秒～30秒，身体位慢慢向健 侧转呈90°→保持1～2分钟，坐位微向下视 →保 持头位垂直两天。 Brandt 体位治疗[5] ：向患侧侧卧30秒，坐起向对 侧卧，交替至症状消失。 Semont手法复位[6] : 头转健侧45°→快速向患侧卧 →至眼震消失，约4分钟后快速坐起向健侧卧 →5 分钟后慢慢坐起→ 保持头位垂直两天。

The cupulolithiasis and The canalithiasis
BPPV 病理生理


正常耳石代谢：耳石膜含许多碳酸钙结晶， 耳石含大量钙离子，酷似骨组织，是一动 态结构，维持迷路内离子动态平衡，正常 情况下耳石也会少量脱落，为吞噬细胞所 消灭，这种情况多发生在囊斑、胶状壶腹 嵴[11] [12]和内淋巴囊[13] 。 BPPV 病理生理：耳石脱落过多或吸收障碍 时, 异位进入半规管，当达到或超出临界状 态时“critical mass” [图1] [图2] ？


发病率约1/10000, 占外周性眩晕的50% 属周围性旋晕 多为自限性，能自行缓解，故称为良性 三个月不愈或丧失劳动力者为顽固性 男:女 = 1:2～3
Background


Barany (1921)[1]: 首次描述benign paroxysmal positional vertigo (BPPV): The attacks only appeared when she lay on her right side. When she did this, there appeared a strong rotatory nystagmus to the right. The attack lasted about thirty seconds and was accompanied by violent vertigo and nausea. If, immediately after the cessation of these symptoms, the head was again turned to the right, no attack occurred, and in order to evoke a new attack in this way, the patient had to lie for some time on her back or on her left side. Dix M.R. & Hallpike C.S.(1952) [2] : 介绍了BPPV特点和Dix—Hallpike Test Schuknecht H.F. (1969) [3] : 病人颞骨病理见后半规管壶腹嵴致密颗粒 cupulolithiasis Hall SF，Ruby RRF，McClure JA. (1979) [4] : 根据重复刺激疲劳性提出半规管结石症 canalithiasis Brandt T，Daroff RB (1980) [5] : 首推体位治疗 Semont A， Freyss G， Vitte E (1988) [6] ：耳石解脱法 liberatory maneuver Epley JM (1992) [7] : 耳石复位法canal reposition procedures (CRP) Parnes LS，McClure JA. (1990) [8] : 描述后半规管阻塞术治疗难治性BPPV Parnes LS，McClure JA. (1992) [9] : 难治性BPPV手术中发现后半规管中嗜碱性颗粒 Gacek RR (1995) : singular neurectomy [*] Moriarty B，Rutka J，Hawke M. (1992) [10] :大量颞骨病理发现其他半规管也见嗜碱性颗粒
SC-BPPV test


RAHKO T manoeuvre [16] [图7] : When the posterior and horizontal canals were free of otoconia, the patients were instructed to bow forward 60° and straighten back with closed eyes quickly. The observer recorded the possible movement of the patient sideways during straightening. Dix—Hallpike test [2].
Dix—Hallpike Test
[2]
取坐位,观察有无自发性眼震,头转向一侧45°, 迅速仰卧, 与水 平面呈30°角，观察有无眩晕及眼震.
PC-BPPV 诊断标准

患耳向下突发强烈旋转性眩晕及眼震, 改变头位后 眩晕可减轻或消失. 有3～30秒潜伏期. 眼震通常持续数秒, 一般在30秒内. 眩晕持续时间 可稍长，多在1分钟内停止. 具疲劳性. Dix—Hallpike test阳性. 有上跳性、扭转性眼震（快相向下位耳），左侧 顺时针方向，右侧反时针方向。 “Reversal nystagmus” occurs when the patient returns to the upright position
Lempert manoeuvre
Gufoni 疗法
SC-BPPV 手法复位


Honrubia manoeuvre (1999) [19] : The treatment was a reverse Epley manoeuvre or a reverse Semont manoeuvre. Rahko T manoeuvre [16] : the patient lies on the healthy side, the head is tilted downwards 45°, then horizontally, upwards 45° for 30 s each, and finally the patient sits up and stays there well supported for at least 3 min.
HC-BPPV test


McClure JA(1985) [14] [图5] : Roll test: The patient lying supine and the head moved to both sides. Rahko T(2001) [15] [图6] : WRW test : the patient walks forward and rotates briskly on the rotation direction foot and returns back.
PC-BPPV test
Dix M.R. & Hallpike C.S.(1952) [2]: 取坐位,观 察有无自发性眼震,头转向一侧45°→ 迅速 仰卧, 与水平面呈30°角→观察有无眩晕及 眼震至少40秒钟。[图3] [图4] . 有上跳性、扭转性眼震（快相向下位耳）， 左侧顺时针方向，右侧反时针方向。 “Reversal nystagmus” occurs when the patient returns to the upright position.
BPPV后半规管开窗所见耳石团块
The vestibular system
The otoconia
BPPV 分类



原发性：占34～68％. 继发性：以头部外伤为多见，约17%，其他 可见发生于梅尼挨病、迷路炎、偏头痛、 中耳术后、头颅外伤等. 按解剖部位分类: PC—BPPV, HC—BPPV, SC—BPPV, NC—BPPV. Schuknecht分类: 自限性、复发性和顽固性.
PC-BPPV 手法复位示意图
After the maneuver is performed
(for 2 nights )
Brandt-Daroff Exercises
HC-BPPV 手法复位


Lempert manoeuvre (1996) [17] or Barbecue manoeuvre : The patient is lying supine. He rotates the head to the healthy side by 90°, then turns to the prone position, the head is turned nose-down and again the head is turned with the affected ear down, each phase 30 s. Finally, the patient sits up. Gufoni’s liberatory manoeuvre(1998) [18] :(A) The patient is seated. (B) The patient is quickly brought to the side-lying position on the affected side. (C) The head of the patient is quickly turned 45 degrees upward. (D) The patient returns to the sitting position. Positions B and C are maintained for 2 minutes.
各型BPPV 的诊断手法及复位技巧
Dr Xiaofeng Mei
Fushan hospital of traditional chinese medicine, Department of otorhinolaryngology—head and neck surgery
Overview

RAHKO T manoeuvre
Байду номын сангаас
SC-BPPV 诊断标准




典型病史及症状：特殊体位出现旋晕、恶 心、呕吐 排除PC-BPPV 和HC-BPPV. SC-BPPV test阳性 or a Dix—Hallpike test. 有下跳性、扭转性眼震
管石复位原理示意图
PC-BPPV 手法复位