各型BPPV的诊断手法及复位技巧

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.
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Fra Baidu bibliotek～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
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.

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] ？
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.
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.
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