各型bppv的诊断手法及复位技巧.ppt
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1、各型BPPV 的诊断手法及复位技巧,Dr Xiaofeng Mei Fushan hospital of traditional chinese medicine, Department of otorhinolaryngologyhead and neck surgery,Overview,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 = 1:23,Background,Barany (1921)1: 首次描述benign paroxysmal positional vertigo (BPPV):
2、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 tu
3、rned 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DixHallpike 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,Mc
4、Clure 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
5、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,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
6、and can theoretically affect each of the 3 semicircular canals, although superior canal involvement is exceedingly rare.,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
7、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3468. 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: PCBPPV, HCBPPV, SCBPPV, NCBPPV. Schuknecht分类: 自限性、复发性和顽固性.,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
8、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.,DixHallpike 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330秒潜伏期. 眼震通常持续数秒, 一般在30秒内.
9、眩晕持续时间可稍长,多在1分钟内停止. 具疲劳性. DixHallpike 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 :
10、the patient walks forward and rotates briskly on the rotation direction foot and returns back.,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23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(cupulolith
11、iasis). 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,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
12、sideways during straightening. DixHallpike test 2.,RAHKO T manoeuvre,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 DixHallpike 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,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
13、持12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。,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 lyin
14、g 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. Gufonis liberatory manoeuvre(1998) 18 :(A) The patient is seated. (B) The pa
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