Vertigo or tinnitus 2014,seya walnut wooden earring jewelry box plans,left ear ringing for days episodios - Reviews

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Tinnitus can be defined as a sound that a patient can hear and relates it to the ear, head or both the ear and the head, while there is no such sound outside theear of tinnitus patient head (in a subjective tinnitus), or a structure inside the head is generating a noise (in objective tinnitus).
Subjective tinnitus may be heard as a sound that come from a source that is located outside the head.
When the sound can be heard or recorded by someone else (usually pulsatile sound) it is called objective tinnitus. The patient may tell about sounds of sea waves, high voltage cables, electric engine such as the engine of a refrigerator, discharge of air under pressure, sounds of birds or insects. The objective tinnitus can be heard by another person with or without instruments for amplification of the sound. The pulsations can have the same rate as the heart beats or have a different counts per minutes than the heart beats of the patient. Insomnia (disturbance to sleep), irritability, inability to concentrate on intellectual activities, fatigue, exhaustion, deterioration in ability to work, disturbance to family life, detachment from social life, anhedonia (inability to derive pleasure from life), anxiety, depression, hyperacusis (sensitivity to noise), palpitations, hypertension and hearing impairement. Psychotropic medications, H2-Blockers, Psychotherapy (hypnosis, cognitive behavioral therapy, bio-feedback, relaxation exercises), sound therapy (Tinnitus Maskers, TRT, hearing aids). Surgery for tumors, surgery for blood vessels abnormality, drainage of abscesses, Drainage of infection, antibiotic therapy for bacterial infections, removal of Otto-Toxic medication and Metabolic Intervention which is the main part in my medical approach. If a structure that is innervated by (or being monitored by) the sympathetic system becomes injured, then it is the job of the sympathetic system to react to that injury. Diagnosis can be difficult, especially if the treating physician is not familiar with the disorder. Medications, physical therapy and sympathetic blocks (nerve blocks directed toward the sympathetic system) are all used to restore physiology to normal and relieve symptoms. Traditional and pioneering assessments using leading-edge technology help uncover diagnoses faster. Cuando este circuito se encuentra alterado el paciente escucha el tinnitus en forma permanente y sobredimensionado haciéndole intolerable una vida normal. Fifteen neuro-otological patients have been investigated for post-traumatic vertigo, hearing loss and tinnitus.
The neurotological clinical manifestations of posttraumatic vestibular lesions demonstrate variation. Accidental head injury and its sequelae constitute major medical problems in Europe and America. The Glasgow Coma Scale has reported data from 1248 patients: 21% had severe head trauma, 24% moderate, and 55% minor head injuries.
Craniocorpography (CCG) is a simple and more rapid method for the evaluation of vestibular function than Computerized Electronystagmography (CNG).4,5,6 Both techniques were performed in a group of 15 patients with post-traumatic vertigo in an attempt to establish the value of each test for the identification of the site of lesion.
The clinical charts of all patients with a diagnosis of posttraumatic vertigo between 1990 - 1995 seen at the Audiologic and Otoneurology Clinic were reviewed. Sex, age, type and degree of head trauma, time interval that elapsed between the onset of head trauma and the complaints of hearing loss, tinnitus and vertigo, results of audiologic and otoneurologic studies were recorded. The history included questions to elicit complaints reflecting involvement of other cranial nerves. CCG is a test initially developed as a screening procedure in occupational medicine for patients with the chief complaint of vertigo. CNG was performed with both horizontal and vertical leads to record extra-ocular eye movements.
Fifteen neurotological patients with a diagnosis of posttraumatic vertigo were selected for this study. All completed the neurologic examination including the history form NODEC IV (Germany) and Neurophysiology Otoophthalmologic (Argentina) ENT examination, CCG, and ENG tests. The incidence of occurrence of head trauma and post traumatic vertigo was found to be greater in male patients by a ratio of 2 to 1. Evaluation of the Craniocorpography (CCG) and Computerized Electronystagmography (ENG) revealed an association between both. Fifteen patients with the diagnosis of post-traumatic vertigo completed a neurotologic examination which included audiometry and equilibriometry tests. CCG is considered a useful test in the diagnosis of central and peripheral lesions of the vestibular system secondary to head trauma.
The incidence of occurrence of head trauma and posttraumatic vertigo was found to be greater in male patients by a ratio of 2 to 1. CCG and the Butterfly Calorigram are considered significant tests to establish the diagnosis of central and peripheral lesions of the vestibular system secondary to head trauma. 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. Some of the main associated factors are: all types of noise exposure, car crush, work accidents, medications and pathology of the auditory system.


In the USA the estimation is that 40 million Americans report of tinnitus, and 10 to 12 millions suffer from severe Tinnitus.
The answer lies within the sympathetic nervous system (a portion of the autonomic nervous system) that monitors and regulates various activities that occur independently from the rest of the nervous system.
In the case of Barre-Leiou, the Posterior Cervical Sympathetic Chain forgets to stop monitoring the injury site; like a car engine that diesels, it forgets to shut down. People with persistent head and neck pain, such as after a motor vehicle accident, or with persistent migraine associated with blurred vision, numbness or tinnitus, should consider Barre-Lieou when looking for help. En condiciones de normalidad de los circuitos superiores de control cortical o cerebral, el tinnitus es modulado por el eje cortico-estriado-talámico-cortical. Clinical examination and laboratory tests included audiometry and equilibriometry in all patients.
Correlations for vertigo with the type of head trauma, nystagmus frequency, Slow Phase Velocity (SPV), and associated complaints of hearing loss and tinnitus were analyzed. A detailed questionnaire (NO DEC IV (Germany); and Neurophysiology Otoophthalmologic (Argentina) ENTexamination was completed for each patient.
The past history was explored to identify underlying disease with emphasis on past or recent post-traumatic vertigo. The test is simple to perform, less time consuming, objective, and a quantitative equilibriometric test. The polygraphic Electronystagmogram was analyzed for coordinated or dissociated eye movements. Localization of peripheral vestibular disease can be easily differentiated from central states of dysequilibrium.
The correlation of SPY and frequency of 40ºC left ear with LD right suggests an indirect response of the site of lesion and a central lesion. On the other hand the SPY right 40ºC showed a direct response suggesting a peripheral lesion. Claussen CF, De Sa J: Clinical Study of Human Equilibrium by Electronystagmography and Allied Tests. Hickey SA, Ford GR, Buckley JG, Fitzerald O-Connor: Unterberger stepping test: a useful indicator of peri pheral vestibular dysfunction? Claussen CF, Schneider D, Marcondes LG, Patil NP: A computer analysis of typical CCG Patterns in 1021 Neuro-otological Patients. 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.
Examples include pupil accommodation to light, equilibrium within the inner ear, and respiration. Treatment should be directed toward restoring normal sympathetic nerve function, enhancing blood flow, and reducing total load (the total number of things that do not allow the system to heal). It is more frequent in men than women with a ratio of 2 to 1; and was found of increased incidence of occurrence in patients age 20 and above. Vertigo was categorized to be of five sub-groups: tilting, lift, rotation, falling, and blackouts. The methods of statistical analysis included Chi Square and Pearson's for dependence or independent variable; and Spearman correlation for association. In our series a significant associated complaint in patients with post-traumatic vertigo was identified.
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. Amir Backman (tinnitus and hyperacusis after Barotrauma) can help to understand the symptoms.
More traditional studies include MRI (to rule out structural problems in the head and neck) and electrodiagnostic studies (to check for nerve damage).
Correlations for vertigo with the type of head trauma, nystagmus frequency Slow Phase Velocity (SPV) and associated complaints of hearing loss and tinnitus were analyzed.
Neurootological symptoms like vertigo and tinnitus were subjectively difficult to describe and to classify; and frequently varied over time and following treatment. It provides a photographic, quantifiable record using a video-camera and a computer that receives, analyzes, and prints physiologic graphic significant data of the response of the patient to stimulation by stepping and standing. 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.
Some authors consider vertigo to be a consequence of the concussion and not due to alteration only of the ear.
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).
Head trauma is well recognized as a cause of vertigo and is a common disturbance of the nervous system. 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. The attacks had begun the previous day, out of the blue, while he was playing with the couple's dog, Sascha. 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 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. To complete the maneuver, the patient is brought into the upright sitting position with head bowed down at 30 degrees23,43,44. Farquhar that he was most likely suffering from benign paroxysmal positional vertigo.The problem accounts for perhaps 25 to 40 percent of patients seeking medical attention for dizziness.
The disorder has been nicknamed "top-shelf vertigo," and hair salon customers sometimes experience it when leaning back for a shampoo, as do patients sitting in dental chairs. The three semicircular canals of the inner ear loop out - more or less at right angles, like three edges of a box meeting at the corner - from a chamber called the vestibule.
The slight fluid movements in these canals in response to head movements and gravity activate the hair-trigger cells that relay positional information to the brain.Inside the vestibule, scores of tiny "stones" called otoliths are attached to \na membrane, and when the head turns in any direction, the slight force imparted to the otoliths is translated into nerve messages about motion and orientation.



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