Tinnitus and vertigo treatment review,ear nose throat box hill 100,sinus infection pus,ear ringing one side 821 - 2016 Feature

Every sufferer of Tinnitus, Vertigo, Dizziness or Meniere's Disease can apply to the clinic. Tinnitus, Vertigo, Dizziness and Meniere's Disease are not medical conditions that are limited to the field of Ear Nose and Throat.
In the International Congress of the TRI (Tinnitus Research Initiative) in Stresa (Italy), I was glad to hear from many internationally renowned colleagues that they accept the approach according to which a tinnitus patient must be related to as a whole person rather then focus only on the auditory system.
The medical approach based on clinical studies started in 1981 as a co-production between the Israeli Defence Forces (IDF) and "Hadassah" university Hospital along with consultants from other scientific institutions. A comprehensive evaluation of the main metabolic factors is essential in order to continue the medical assessment and establish a suitable treatment program. Since we are talking about western medicine, the basis for establishing the treatment program is the western medical literature.
There are patients who ask: How do you treat your tinnitus or vertigo patients–nutritional therapy? The main part of the treatment is a method of collecting data and analyzing the relevant information from the Anamnesis (medical history) and objective tests.
Each patient has a different and unique medical profile that requires a thorough investigation on my part. The individual treatment program, tailored for every patient, is directed towards creating a normal metabolic environment around the nerve cells in the auditory and vestibular systems. As a physician who fights for the cure of his patients I know that it is important to reach the depth of each medical problem: Disease, Cluster of symptoms, Discomfort or "Just" stress, in every patient who is asking for help. I sometimes encounter very motivated geriatric patients who are cooperative, and have realistic expectations. Because Chinese medicine treats the body as a whole organism, rather than treating one symptom at a time, acupressure points that cure tinnitus can be found in all corners of your body- your feet, abdomen, wrist, back, and head all have specific grid points that when triggered will cure whatever ailments are causing your tinnitus. To locate your Bai Hui, imagine a line running on top of your head, forward to back, between your ears, sort of like a Mohawk.  The point that is directly on top of your head in the middle is your Bai Hui.
GB 20 is another powerful point for curing illnesses of the head like tinnitus and headaches.
SI 19 is used in Chinese medicine to calm the spirit and treat ear problems, including tinnitus and deafness. Ting Gong is located in the hollow directly in front of each ear.  To access, open your mouth, and feel the depression where your jaws meet. GB 2 particularly helpful for treating all ailments related to the ear such as tinnitus and hearing loss. GB 8 is beneficial for treating damage caused by toxins.  This is especially helpful for curing tinnitus caused by long-time use of painkillers, antidepressants, birth control, and quinine. Do you believe that using natural supplements can reduce tinnitus triggers, when used in conjunction with acupressure for tinnitus?
How to cite this article Bittar RSM, Mezzalira R, Furtado PL, Venosa AR, Sampaio ALL, Oliveira CACP. Benign Paroxysmal Positional Vertigo (BPPV) is one of the most prevalent clinical disorders in common Neurotology practice and accounts for approximately 17% of complaints of vertigo1.
Given the noteworthy prevalence of BPPV, its health care and societal impacts are tremendous8. Positional vertigo is defined as a spinning sensation produced by changes in head position relative to gravity. Significant improvements in the diagnosis and treatment of patients with BPPV may lead to significant health care quality improvements as well as medical and societal cost savings.
The purpose of this paper is to review the available methods for diagnosis and treatment of BPPV intended for clinicians who are likely to diagnose and manage patients with BPPV, and applies to any setting in which BPPV would be identified, monitored, or managed. Of the two variants of BPPV, canalithiasis is the most common, and the posterior semicircular canal is the most affected because of its anatomical position (85-95% of cases of BPPV)8. Recently, Gacek21 proposed a neural theory for BPPV, in which there was degeneration of the saccular ganglion secondary to a latent viral reactivation.
Identifying the affected canal includes observation of the position that triggers the dizziness and the resulting type of nystagmus. When the patient gets in the position that triggers the dizziness, eye movement is observed resulting from the contraction of muscles related to the affected canal (slow component), followed by subsequent rapid correction in the opposite direction (fast component).
In the vertical canals, there are excitatory connections to the ipsilateral superior oblique and contralateral inferior rectus to the posterior canal; ipsilateral superior rectus and contralateral inferior oblique to the superior canal, so that the arising movements are always rotational, but the nystagmus is vertical upward in the posterior canal and vertically downward in the superior canal23. The characterization of the nystagmus, allows the identification of the canal involved as well as the mechanism involved, and it is essential to choose the repositioning procedure. The Dix-Hallpike maneuver is considered the gold standard tool for the diagnosis of BPPV of posterior canal8. The Dix-Hallpike maneuver is performed by the clinician moving the patient through a set of specified head-positioning maneuvers to elicit the expected characteristic nystagmus of posterior canal BPPV (Figure 1). The maneuver begins with the patient in the upright seated position with the examiner standing at the patient's side. After resolution of the subjective vertigo and the nystagmus, if present, the patient may be slowly returned to the upright position.
The particles present inside the semicircular canal undergo the effects of gravity and are shifted downward, and after a short latency, the liberating force created on the ampullar crista triggers the vertigo and nystagmus (Figure 2).
In the case of the superior semicircular canal, a torsional downbeating nystagmus is exhibited. If the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, the clinician should perform a supine roll test to assess for lateral semicircular canal BPPV8. Lateral canal BPPV (also called horizontal canal BPPV) is the second most common type of BPPV.
In many instances, the presenting symptoms of lateral canal BPPV are indistinguishable from posterior canal BPPV.
Due to an adaptation of the central nervous system8,26 or to the reversion of the direction of movement of the debris by the gravitational action26, it is not unusual that nystagmus spontaneously changes the direction without the head turning to the opposite side8,26.
Additional exams are essential to clarify the trigger and associated features of BPPV1,15, 23,35. Imaging is not useful in the routine diagnosis of BPPV because there are no radiological findings characteristic of or diagnostic for BPPV8.
Electronystmography has limited utility in the vertical canal BPPV diagnosis, since the torsional component of nystagmus cannot be registered by conventional techniques. Audiometry is not required for diagnosing BPPV, however it may offer additional information in cases where the clinical diagnosis of vertigo is unclear8. The treatment of BPPV is based on the performance of liberatory maneuvers or canalith repositioning procedures, with the aim of returning the displaced particles to their original location: utricular macula. A standard protocol, that is described in Table 3, is used in our service, considering the better results for each maneuver indicated for each BPPV variant. Some patients manifest severe symptoms with dizziness, nausea, sweating and vomiting while undergoing diagnostic or therapeutic maneuvers. The Epley maneuver39 is the most frequently performed repositioning maneuver of the vertical canal. According to the clinical practice guideline8, based on the review of the literature, it was not possible to determine the optimal number of cycles for the repositioning maneuvers. The maneuver described by Semont41 is indicated for the treatment of posterior canal cupulolithiasis.
Lempert42 described a maneuver (Barbecue Maneuver or Roll Maneuver) which is the most commonly employed maneuver for the treatment of lateral canal BPPV.
Forced prolonged position is another treatment maneuver, described by Vannuchi44, for the treatment of lateral canal BPPV. The Brandt-Daroff exercises were developed for home self-administration, as an additional therapy for patients who have been symptomatic, even after Epley or Semont maneuver40. Many patients complain of imbalance during and between vertigo attacks, as observed by Celebisoy45. The otolithic dysfunction induced by unequal loads of the macular beds has been considered as the underlying mechanism46. The repositioning maneuvers are associated to mild and self-limited adverse effects in about 12 percent of the treated patients8. During the course of repositioning maneuvers of vertical canals, the displaced particles could migrate into the lateral canal, in 6 to 7 % of the cases8.
During the repositioning maneuvers, some patients develop severe, persistent vertigo, nausea, vomiting and nystagmus, which has the same features observed in the diagnostic maneuvers. The treatment consists of performance of the reverse maneuver, to aim to eliminate the blockade.
By virtue of possible complications during the repositioning procedures, it is not a proper conduct to guide the patient self-treatment at home, without a physician. After repositioning procedures, it is important to keep the patient in sitting position, for 10 minutes, to avoid falls51. Epley39, in his original paper, described the application of a bone conduction vibrator associated to repositioning maneuver, in order to release some adhered particles in the ampullar crista. The effectiveness of repositioning and liberatory maneuvers varies from 70% to 100%14,15,23,48. It is important to be careful when performing diagnostic, repositioning and liberatory maneuvers in obese patients, with limited cervical range of motion or with unstable heart failure or carotid stenois8,25,58. Some authors believe in natural course of BPPV toward spontaneous relief48,59,60,61,62, which is possible in up to 89% of the patients in the first month, with subsequent recurrence in up to 33%, in three years37,38. Thirty to 50 % of the patients have vestibular system dysfunction associated with initially treated BPPV, which can be demonstrated by caloric testing abnormalities. The American Academy of Pediatrics reports that ear infections are one of the most common ailments for young children and the second leading cause for surgery in children under two years old.
For children with chronic ear infections, upper cervical care may be an ideal solution to treat the cause of the problem rather than just reacting to symptoms.A  Misalignments in the top two bones in the neck, often caused by birth trauma, may affect the proper functioning of eustachian tubes in the ear. A study of upper cervical corrections in children found that 80 percent of those cared for with a series of non-invasive corrections became free of ear infections by enabling the inner ear to properly open and drain.
Disorders of the inner ear can cause symptoms such as pain, dizziness or vertigo, nausea, hearing loss and ringing in the ears (called tinnitus). Even minor misalignments can result in nerve irritation that can affect the body in many ways, including causing disorders of the ear.
El Centro de Tesis, Documentos, Publicaciones y Recursos Educativos más amplio de la Red.
Anatomically speaking, a fracture is a break or a crack in a bone or in ossified cartilage.
Otobasal fractures are subdivided into longitudinal and transverse fractures, according to the x-ray findings. From our neurootological data bank (Neurootological Data Evaluation-Claussen [NODEC]), we chose 61 patients suffering from a posttraumatic otobasal fracture. All patients underwent a systematic neurootometric and equilibriometric analysis that included neurosensory network analysis by means of polygraphic electronystagmography (ENG) together with electrocardiographic (ECG) recordings and vestibular spinal test recordings by craniocorpography (CCG), for charting head and trunk movements. In comparing the test results of the weaker supraliminal caloric warm test with the stronger supraliminal perrotatory stimulus, we can establish the so-called vestibular stimulus response intensity comparison (VESRIC). Testing of the retinoocular pathways include optokinetic tracking tests on one hand and optokinetic nystagmus evaluation on the other.
As regards the history of patients suffering from otobasal fracture complaints, parameter frequencies as seen in Table 2 have been found (via NODEC). To obtain a synoptic overview of the most frequent combination of caloric responses, all the butterfly patterns were transcribed by trinary code and thereafter statistically evaluated (Fig.
Table 4 contains the statistical evaluation of the binaural vestibuloocular per- and postrotatory test results (rotatory intensity-damping test [RIDT]) with simultaneous ENG and ECG recording. The longitudinal fracture is a linear break through the floor of the middle cranial fossa passing parallel and adjacent to the anterior margin of the petrous pyramid.
In a transverse fracture, the break line is perpendicular to the long axis of the petrous pyramid. For this study, we evaluated the neurootological histories of and important neurootological findings in 61 patients who suffered from otobasal skull fractures. With respect to the duration of the single vertigo attacks, 32 patients (52.46%) reported that the dizzy spells lasted for only seconds. The number of subjective hearing symptoms was much higher than the amount of visual symptoms.
In analyzing the objective and quantitative results of neurootometric testing, we found that statistical evaluation of the ENG results of caloric nystagmus analysis showed a high value for spontaneous nystagmus, especially for right-beating nystagmus.
At the same time that the ENG was recorded during the caloric vestibuloocular test, the ECG was recorded and evaluated for heart rates during the response culmination phase.
Despite the failure in vestibular cardiac rate downregulation under the vestibuloocular stimulus (see Table 3), this vestibular vegetative reaction is beneficial for the ECG heart rate, counted during the perrotatory rightand left-beating reaction and the postrotatory right-beating reaction but not during the postrotatory left nystagmus (see Table 3). Putting the caloric warm responses and the perrotatory nystagmus responses together into the VESRIC, we found (see Fig. As regards otobasal fractures as a severe trauma to the inner-ear system and the head, patient medical history is typical, showing vertigo, nausea, and hearing symptoms.
Patients' hearing capacity as tested by speech audiometry also showed pathology, which corresponds to the high incidence of hearing symptoms, including hearing loss, deafness, and tinnitus. This article is based on a lecture presented at the Thirtieth Congress of the Neurootological and Equilibriometric Society, Porto, Portugal, April 3-5, 2003. Since the time of our ancestors, the medical community had already thought that these symptoms were caused by hypersensitive state of the brain.
Yes, we understand that you may have visited the department of Internal medicine, and consulted an ENT specialist, psychiatrist, and gynecologist, yet they gave you no proper answers. At one time, we heard that a certain drug or treatment works for these kinds of symptoms and 'without' the side effects.
This is something that will not only benefit you but your entire family as well, as it will bring back and recover the fun and the happiness you used to have together. If there's a low level of serotonin within the brain, the blood vessels will open rapidly and excessively dilate allowing blood to flow back into the brain. In these cases where there's a low level of serotonin in the blood, a migraine medicine called 'triptan' is recommended.


As a precautionary measure, we recommend you to consult your physician on when you should consider using triptan.
Junji Takano is a Japanese health researcher involved in investigating the cause of many dreadful diseases. When a patient is coming to Israel after examination near home, I can be sure (in most cases) that the expert covered all the aspects of the Tinnitus, Vertigo, Dizziness or Meniere's Disease according to the Text Book. The medical history is different, the symptom profile is different and the findings in the medical evaluation are different. After completing the first stage of the medical evaluation, I unify the data and discuss the meaning of the finding with my patient.
The result of this extensive medical evaluation enables a careful adjustment of a treatment plan for the individual patient. Such environment enables the "Curative Mechanisms" to initiate regeneration in a case of mild damage to the neurons. I study the patient's medical history and do my best to check each problem from all medical aspects in order to find the effective medical treatment. The highest probability for drop out is in skeptic patients, people who are not motivated enough, those who are not ready to invest time and effort in the treatment, or those who are looking for a miracle: immediate cure. According to my experience, the course of the disease and the associated symptoms may be very different from one sufferer to another.It is very normal for you to have many other questions regarding your specific medical condition. This vestibular syndrome is characterized by transient attacks of vertigo, caused by change in head position, and associated with paroxysmal characteristic nystagmus. It represents the most important peripheral vestibular impairment along the lifespan1,2,3, although the age at onset is commonly between the fifth and seventh decades of life4.
It is estimated that it costs approximately US$2000 to arrive at the diagnosis of BPPV, and that 86 percent of patients suffer some interrupted daily activities and lost days at work because of BPPV8.
Benign paroxysmal positional vertigo is defined as a disorder in the inner ear, characterized by repeated episodes of positional vertigo8, with typical paroxysmal nystagmus. Despite its significant prevalence, and quality of-life and economic impacts, considerable practice variations exist in the management of BPPV across disciplines8. Such improvements may be achievable with the reduction of the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of unnecessary tests such as radiographic imaging, and by increasing the use of appropriate cost effective therapeutic repositioning maneuvers. Displaced particles from utricule otoliths float around in the endolymph (canalithiasis)11 or adheren to the cupulae (cupulolithiasis)12 and may change the density relation of the cupulae-endolymph system.
The ampulla of the posterior semicircular canal is located in the lower region of the vestibule, both in the supine and standing position.
Such reinfection could result in the loss of its antagonistic effect on the posterior semicircular canal.
The classic complaint is vertigo in episodes, triggered by changes in the body position or head movements, lasting seconds and ceasing spontaneously. Each of the semicircular canals is directly connected to a pair of extrinsic muscles in the eye, having an excitatory and inhibitory influence, which determines the movement of the eyeball in the same plane as the canal24 (Table 1).
This biphasic movement, called nystagmus, is a standard direction that is known as being the same as the fast component.
In Table 2, we can observe the main features of involvement of different semicircular canals. Before beginning the maneuver, the clinician should counsel the patient regarding the upcoming movements and warn that they may provoke a sudden onset of intense subjective vertigo, possibly with nausea, which will subside within 60 seconds. During the return to the upright position, a reversal of the nystagmus may be observed and should be allowed to resolve8.
Mechanism of displacement of the debris from the dome of the canal at rest and under the action of gravity (g), indicated by the arrow. The direction of the torsional component of the positioning nystagmus indicates which ear is the origin of nystagmus. Because this type of BPPV has received considerably less attention in the literature, clinicians may be relatively unaware of its existence and the appropriate diagnostic maneuvers for lateral canal BPPV8. The supine roll test is performed by initially positioning the patient supine with the head in neutral position, followed by quickly rotating the head 90 degrees to one side with the clinician observing the patient's eyes for nystagmus. In canalithiasis, the movement of the head toward the affected ear promotes the displacement of free particles in the direction of the ampulla, triggering a horizontal nystagmus whose fast component will be toward the tested ear, so geotropic (towards the ground). The mechanisms that initiate geotropic and apogeotropic eye movements can be seen in Figure 3. We can observe the mechanism of displacement of the ampullar crista that is responsible for the origin of geotropic nystagmus in canalithiasis(a), or for apogeotropic nystagmus in cupulolithiasis (b). De la Meilleure et al.26 reported the inversion of the horizontal nystagmus, in electronystagmography, in 75% of patients with BPPV of the lateral canal, always on the affected side. Further radiographic imaging may play a role in diagnosis if the clinical presentation is felt to be atypical, if the diagnostic maneuvers are unusual, or if additional symptoms aside from those attributable to BPPV are present, suggesting an accompanying modifying central nervous system or otological disorders8. On the other hand in horizontal semicircular canal BPPV diagnosis, the nystagmus is present in the positional testing23.
These are non-invasive procedures that have been found to be long term effective for BPPV2,14. In these cases, vestibular suppressant medications are recommended as adjuncts not only to relieve the vertigo after maneuver but also to control the clinical symptoms until the procedure can be repeated4. The patient is placed in the upright position with the head turned 45 degrees to left when the left ear is affected. If the posterior canal is affected, the patient is seated in the upright position; then the patient's head is turned 45 degrees toward the unaffected side, and then is rapidly moved to the side-lying position.
Demonstration of Lempert Maneuver sequence - treatment of lateral semicircular canal BPPV (right ear in black). This maneuver involves rolling the patient 360 degrees in a series of steps to effect particle repositioning8. The strategy consists of maintaining the forced lateral decubitus, with affected ear in the undermost position for 12 hours23,25.
Some authors indicate them one week before the therapeutic maneuver, aiming to improve the patient's tolerability14. This observation lead to the investigation of postural balance in patients with lateral and posterior semicircular canal BPPV. Other possibilities are the persistency of small amounts of residual debris in the canal, paresis of the ampullar receptors or the vestibular re-adaptation after peripheral disorder45. This phenomenon could result from a jamming of the otolithic debris (named jam) when migrating from a wider to narrower segment, such as from the ampulla to the canal or at the bifurcation of the commom crus50.
The use of a cervical collar, positional avoidance, or other restrictions are not necessary52,53,54. However, studies found no benefit in the BPPV treatment, since it does not modify the results of repositioning or liberatory maneuvers2,55,56,57. The successful treatment is based on the identification of the affected semicircular canal, the distinction between cupulolithiasis and canalithiasis, the right choice of the most indicated maneuver2. The spontaneous resolution is faster in the lateral semicircular canal BPPV than in posterior canal because the former spatial and anatomic orientation facilitates the return of the particles to their original place63,64. Therefore, even if symptoms are typical of BPPV, the diagnostic maneuver has been positive, the repositioning maneuver has been successful, it is important that complete neurotological evaluation is obtained to rule out other vestibular disorders. For the therapeutic maneuvers, correct diagnosis of the BPPV variant and affected semicircular canal is necessary.
Central etiologies must be investigated when atypical nystagmus is found and therapeutic maneuvers are unsucessfully.
Bhattacharayya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, Chalian AA, Desmond AL, Earll JM, Fife TD, Fuller DC, Judge JO, Mann NR, Rosenfeld RM, Schuring LT, Steiner RWP, Whitney SL, Haidari J.
The frequency and severity of symptoms can vary from person to person, but there often is a common link between conditions of the inner ear and problems with the upper cervical spine.A  Injury or trauma to the neck from car accidents, sports or work-related accidents, or even simply sleeping wrong, can create vertebral misalignments that increase the chances for inner ear diseases. By correcting upper cervical positioning, many patients experience lasting relief from their symptoms. The fracture line begins in the posterior fossa, at or near the foramen magnum, and crosses the petrous ridge through the internal auditory canal or the otic capsule.
However, when the skull is subject to fracture, we can expect not only local complications but general cephalic complications due to a concussion of the adjacent brain structures or of the entire brain. However, affected patients are also differentiated into those suffering posttraumatically solely from hearing disturbances or solely from equilibrium disturbances and the major group suffering from hearing disturbances together with vertigo and disequilibrium. This combination of vestibuloocular nystagmus tests provides us with a tool for estimating the dynamics of processing and switching within the brainstem and higher centers of vestibuloocular nystagmus regulation in terms of parallel action and of recruitment and decruitment phenomena. The results of the polygraphic ENG together with the threechannel ECG represented the experimental investigations using the caloric test (Table 3).
Dynamic vestibular stimulus response intensity comparison (VESRIC) ranked and sorted according to the occurrences of the 12 most frequent patterns (n = 61). The results are charted using the mean and standard deviation for 61 patients with otobasal fracture. In nearly 50% of cases, the facial nerve is lacerated, and the resultant palsy may be permanent and require surgical solution. Additionally, in 8 patients (13.11%), head trauma was so severe that rhinobasal fractures also were seen (according to the NODEC). All in all, this is a shortlasting vertigo, with instability and rocking sensations and a certain amount of malaise. This can easily be understood, as this patient sample was selected for a history of otobasal fractures.
However, the caloric nystagmus mean frequencies were within the normal range, although they showed a tendency toward a disinhibition as regards standard deviation (see Table 3).
We found negative vestibular cardiac downregulation of the heart rate, especially the downregulation lost with respect to the means in the two caloric cold responses.
Concerning the postrotatory vestibular cardiac reaction, usually we see (for both postrotatory responses) upregulation as compared to the pretest situation in the spontaneous phase. Lateral sway, which usually is greatly increased in cerebello-pontomedullary dysfunctions, remained in the normal range, even for the sum of the mean plus standard deviation. Otobasal fractures lead to subjective statoacoustic complaints, which are reflected also in the results of objective and quantitative measurements of the vestibuloocular, vestibulospinal, and hearing pathways.
Untersuchungen uber den vom Vestibularapparat des Ohres reflektorisch ausgelosten rhythmischen Nystagmus und seine Begleiterscheinung. Uber eine Gleichgewichtsfunktionsprufung mit Hilfe der Cranio-Corpo-Graphie (CCG) und Polarkoordinaten im Raume.
Forschungsbericht Cranio-Corpo- Graphie (CCG)-Ein einfacher objektiver und quantitativer Gleichgewichtstest fur die Praxis.
Studies in Human Vestibular Function: Observation on the Directional Preponderance of Caloric Nystagmus Resulting from Cerebral Lesions. Die Kompensationsmechanismen nach einseitigen akuen Labyrinthstorungen in Abhangigkeit vom Lebensalter.
Vertigo after head and inner ear injuries-with special reference to neurotological findings. Neue objektive registrierbare Vestibulariskorperdrehreaktionen, erhalten durch Treten auf der Stelle. Department of Otorhinolaryngology Head and Neck Surgery, Semmelweis University, Budapest, Hungary. This causes too much stress in the brain that will trigger pain and migraine headache episode. In 1968, he invented PYRO-ENERGEN, the first and only electrostatic therapy machine that effectively eradicates viral diseases, cancer, and diseases of unknown cause. The patient tells his medical history, there is re assessment of his documents and objective tests, physical examination of the relevant systems and referrals to tests. The symptoms result from movement of the free floating otoconia particles in the endolymph or their attachment to the cupulae of the semicircular canal.
These variations relate to both diagnostic strategies for BPPV and rates of utilization of various treatment options available for BPPV within and across the various medical specialties and disciplines involved in its management.
In this context, BPPV should be mentioned not only because of the high prevalence, but also because of the relative simplicity of the diagnosis and cost effectiveness of the treatment9. The semicircular canals change their gravitational orientation plane while the patients move their head.
The fragments in suspension inside the labirinth tend to be deposited in this region, by the action of gravity1,13,14,15.
Typically, the vertigo arises in the lateral position of one or both sides, in hyperextension of the head, when standing up or lying down. Because the patient is going to be placed in the supine position relatively quickly with the head position slightly below the body, the patient should be oriented so that, in the supine position, the head can "hang" with support off the posterior edge of the examination table by about 20 degrees. The examiner rotates the patient's head 45 degrees to the left and, with manual support, maintains the 45-degree head turn to the left during the next part of the maneuver8. The Dix-Hallpike maneuver should then be repeated for the right side, with the right ear arriving at the dependent position.
If the upper pole of the eye beats away from the ground toward the uppermost ear, then it originates from the anterior canal of the uppermost ear.
Patients with a history compatible with BPPV (ie, repeated episodes of vertigo produced by changes in head position relative to gravity) who do not meet diagnostic criteria for posterior canal BPPV should be investigated for lateral canal BPPV. After the nystagmus subsides (or if no nystagmus is elicited), the head is then returned to the straight face-up supine position. When the head is rotated to the healthy side, the particles displace and lead to a current moving in the opposite direction from the ampulla (also generating geotropic nystagmus), and the stimulation is less intense than that observed on the affected side. Lee and colleagues27 described the spontaneous reversal of nystagmus bilaterally, and the primary phase of nystagmus was shorter and with greater velocity of the slow-phase. Other possible causes are ovarian hormonal dysfunction, hyperlipidemia, hypoglycemia or hyperglycemia, hyperinsulinemia, migraine, cervical trauma, otological surgery, sedentary and prolonged bed rest2,15,32,33,34.
Successful treatment depends mainly on the choice of the most appropriate maneuver for the case.
The patient is rapidly laid back in a supine head-hanging position, which is maintained for a period of 1 to 2 minutes.
The patient is in supine position; the patient's head is turned 90 degrees slowly toward the unaffected side.


The Brandt-Daroff exercises (Figure 8) are positioning exercises that, theoretically, promote habituation4. The treatment of each affected semicircular canal will be performed, in protocols according to the observed ocular movements and the correct identification of each affected semicircular canal. Patients with posterior BPPV had impaired static balance ability when visual and proprioceptive inputs were inadequate as described by Celebisoy45, Di Girolamo46.
The conversion to lateral canal BPPV (so called canal switch) and Canalith Jam are unusual conditions, however when present must be promptly diagnosed and treated47.
In the Epley Maneuver, it happens when the head of the patient is turned to facedown position (Figure 5 - position c and d). If the patient develops important symptoms, vestibular suppressant medications may be considered to help in a later repositioning. Therefore, it is possible to propose to the patient to wait the spontaneous resolution, in cases where the maneuver can't be indicated. Benign paroxysmal positional vertigo: 10 year experience in treating 592 patients with canalith repositioning procedure. Neuro-otological features of benign paroxysmal vertigo and benign paroxysmal positioning vertigo in children: a follow-up study. Free-floating endolymph particles: a new operative finding during posterior semicircular canal occlusion. Effectiveness of treatment techniques in 923 cases of benign paroxysmal positional vertigo.
Benign paroxysmal positional vertigo due to a simultaneous involvement of both horizontal and posterior semicircular canals.
Monitoring of caloric response and outcome in patients with benign paroxysmal positional vertigo.
Diagnostic, pathophysiologic, and therapeutic aspects of benign paroxysmal positional vertigo.
Reversal of initial positioning nystagmus in benign paroxysmal positional vertigo involving the horizontal canal.
Eletronytagmographic (ENG) findings in paroxysmal positional vertigo (PPV) as a sign of vestibular dysfunction. Canalith repositioning for benign paroxysmal positional vertigo: a randomized controlled trial.
The canalith repositioning procedure for treatment of benign paroxysmal positional vertigo.
A positional maneuver for treatment of horizontal-canal benign paroxysmal positional vertigo.
Balance in posterior and horizontal canal type benign paroxysmal positional vertigo before and after repositioning maneuvers. Treatment efficacy of benign paroxysmal positional vertigo (BVVP) with canalith repositioning maneuver and Semont liberatory maneuver in 376 patients.
Treatment of benign paroxysmal ositional vertigo: necessity of postmaneuver patient restrictions. Vibration with the canalith repositioning maneuver: a prospective randomized study to determine efficacy. The canalith repositioning procedure with and without mastoid oscillation for the treatment of benign paroxysmal positional vertigo. Natural course of the remission of vertigo in patients with benign paroxysmal positional vertigo. Natural history of benign paroxysmal positional vertigo and efficacy of Epley and Lempert maneuvers. Treatment of anterior canal benign paroxysmal positional vertigo by a prolonged forced position procedure. Diagnostic criteria for central versus peripheral positioning nystagmus and vertigo: a review. A thorough evaluation by a highly trained upper cervical doctor can determine whether upper cervical care can help with inner ear conditions. Queda bajo la responsabilidad de cada lector el eventual uso que se le de a esta información. By means of this study, we evaluated 61 patients who suffered otobasal fracture due to a traumatic event. For testing the vestibulospinal pathways, we used a CCG recording of the head and shoulders. In addition, we have set up a NODEC that comprises a list and statistical analysis of the entire sample of 61 patients. CCG served for objectively and quantitatively measuring the responses of the vestibulospinal standing test and the stepping test (Table 5).
Second, as can be observed also in other accident patient groups, is the low mean age of 33.8 years. With respect to visual disturbances, we found much double vision (6 patients [9.84%]) but a low proportion of oscillopsias. Tabulating all the caloric butterfly patterns after transferring them from the graphic design into a numerical design by trinary coding, we observed (see Fig. In other words, nearly 52 patients (85%) showed vestibuloocular pathology as a typical sign of the 60.80% of all patients suffering from an otobasal fracture. The two important parameters of longitudinal and lateral sway of the standing CCG remained fairly normal. However, the statistical significance of these symptoms is higher in other disease groups that we have investigated particularly. In C-F Claussen, MV Kirtane (eds), Vertigo, Nausea, Tinnitus and Hypoacusia Due to Head and Neck Trauma. Serotonin is a compound that acts as a neurotransmitter as well as constriction and dilation of the blood vessels. Today the usage of hypnosis is limited and used together with the current medical approach: Metabolic Intervention. The diagnosis is essentially clinical and should be confirmed by performing diagnostic maneuvers. Delays in the diagnosis and treatment of BPPV have both cost and quality-of-life implications for both patients and their caregivers8. The debris dislocates and promotes anomalous activation of the ampullar crista and may interfere with the neuronal output index that normally would be expected for that head and canal position.
The lateral semicircular canal may be involved in 5 to 15% of patients8 and the anterior canal is rarely involved8; but there is still the possibility of simultaneous involvement of two canals18,19,20. The examiner should ensure that he can support the patient's head and guide the patient through the maneuver safely and securely, without the examiner losing support or balance himself8. Next, the examiner fairly quickly moves the patient (who is instructed to keep the eyes open) from the seated to the supine left-ear down position and then extends the patient's neck slightly (approximately 20 degrees below the horizontal plane) so that the patient's chin is pointed slightly upward, with the head hanging off the edge of the examining table and supported by the examiner. Again, the examiner should inquire about subjective vertigo and identify objective nystagmus, when present.
After any additional elicited nystagmus has subsided, the head is then quickly turned 90 degrees to the opposite side, and the eyes are once again observed for nystagmus. Thus, the resulting eye movement is always stronger when the affected ear is placed downward23. The arrows indicate the direction of displacement of the cupulae by gravity with the lateralization movement of the head. It has been proposed by Korres22 that the unilateral vestibular hypofunction is more common in cases secondary to head trauma or viral infection. Next, the head is turned 90 degrees, to the right (usually necessitating the patient's body to move from supine position to the lateral decubitus position). The jam generates a constant counter-attraction force in the cupulae, as result from negative pressure.
Possible explanations include some comorbidities and patient limitations during the maneuvers (for example: limited cervical range of motion or vascular failure)14. In cases of transverse fractures of the temporal bone, due to automobile accidents or other causes of head injury, the labyrinth is involved more frequently than in longitudinal fractures. The images received appeared strongly as radar images of a head and trunk floating through time and space. Therein, we have noted descriptive statistics of age, height, weight, and the like for all persons entered into this study (Table 1). The test results can be categorized into three groups within each of which are three subdivisions. In transverse fractures of the temporal bone, due to automobile accidents or other causes of head injury, the labyrinth is involved more frequently than in longitudinal fractures. Cerebrospinal fluid may continue to fill the middle ear even after the blood is absorbed and is drained through the Eustachian canal.
The first three pathological patterns - s1010, s0202, and s1000 - of recruitment behaviors showed a certain lability in the regulation, although in two of them, there was a tendency for recovery.
Treatment is based on the identification of the affected semicircular canal and performance of liberatory maneuvers or repositioning of free floating particles of otoliths. Some other symptoms could be associated and often persist after the interruption of the episode, such as nausea, imbalance, or postural instability1,15. The examiner observes the patient's eyes for the latency, duration, and direction of the nystagmus. Two potential nystagmus findings may occur with this maneuver, reflecting two types of lateral canal8.
In cupulolithiasis, the fragments are adhered to the cupulae of the affected semicircular canal, which make them heavier than the endolymph. Some authors prefer to wait for the natural course towards a spontaneous relief, considering BPPV a self-limited condition.
The patient is rapidly moved to the opposite side-lying position without pausing in the sitting position and without changing the head position relative to the shoulder.
Then, the head is turned to the facedown position and the body is moved to the ventral decubitus. The jam pressure induces cupulae displacement and consequent depolarization (vertical canals) or hyperpolarization (lateral canals).
The fracture passes through the vestibule of the inner ear, causing extensive destruction of the membranous labyrinth and usually complete loss of cochlear and vestibular function.
In ranking the next twelve most frequently found caloric butterfly patterns, we saw a mixture of central, peripheral, and combined vestibuloocular dysfunctions. 3), we found all in all that only 27.87% (17) were normal, meaning that some 72% (44) of all the stepping CCGs results were pathological. Only 9 patients (14.75%) showed no pathological changes on the vestibuloocular tests by calorization and perrotatory stimuli. Besides the clinical history, the diagnosis of BPPV takes into account the type, direction and duration of nystagmus provoked by maneuvers that provide clues for identifying the affected canal and the pathophysiological mechanism involved (whether canalithiasis or cupulolithiasis).
Again, the provoked nystagmus in posterior canal BPPV is classically described as a mixed torsional and vertical movement with the upper pole of the eye beating toward the dependent ear. When the head is rotated to one side, the action of gravity on the ampullar crista moves the debris into the opposite direction and it is possible to observe the nystagmus that is in the opposite direction from the tested ear (apogeotropic type)24,25.
Gradually the patient resumes the upright sitting position8.If the superior semicircular canal is affected, the movement is performed in the direction opposite to the procedure for posterior semicircular canal4,15,23,40. Later the patient's head is turned 90 degrees, and the body is placed on lateral decubitus.
In milder injuries, labyrinthine "concussion" may occur, with transitory auditory-vestibular symptoms. This then causes severe vertigo lasting for several days, with accompanying nausea and vomiting.
The per- and postrotatory nystagmus of the RIDT (see Table 4) demonstrated an elevated level of the means, although these remained within the normal range. The results of the trinary coded stepping CCGs gave us a mixed picture of typical peripheral lesions, as in patterns s00l0, s00ll, and s0020.
The incidence of pathologically changed stepping CCGs was very high, into the range of 72%.
Then the patient is asked to rest the chin on the shoulder and sit up slowly, completing the maneuver8 (Figure 4). Figure 6 demonstrates the Semont Maneuver for treatment of right-sided posterior semicircular canal cupulolithiasis. The force that causes the fracture is so great that it not only fractures the base of the skull but may cause a lesion of the brainstem, resulting in a combined peripheral and central lesion. The force that causes the fracture can be so strong that it not only results in the fracture of the base of the skull but also may cause a lesion of the brainstem, resulting then in a combined peripheral and central lesion. The standard deviations, however, exhibit a broad spread, especially for perrotatory and postrotatory right-beating nystagmus.
With respect to the vertigo history, more pathology was found in the equilibriometric tests based on nystagmus, as expected.
The head must stay in that position for some moments, before it returns to the normal position1,4,23,40. Each step is maintained for 15 seconds - for slow migration of the particles, in response to gravity. According to Alexander and Scholl, 15% of the patients having suffered this kind of trauma demonstrate signs of cerebral injury, and 33% have a hearing loss. Unsteadiness and a tendency to sway to the side of the involved ear may persist for months. To complete the maneuver, the patient is brought into the upright sitting position with head bowed down at 30 degrees23,43,44. A mild spontaneous nystagmus with the quick component to the opposite side may persist for many months or years or even may persist indefinitely.



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