各型BPPV的诊断手法及复位技巧

各型BPPV的诊断手法及复位技巧DrXiaofengMeiFushanhospitaloftraditionalchinesemedicine,Departmentofotorhinolaryngology—headandnecksurgeryOverview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=1:2～3BackgroundBarany(1921)[1]:首次描述benignparoxysmalpositionalvertigo(BPPV):Theattacksonlyappearedwhenshelayonherrightside.Whenshedidthis,thereappearedastrongrotatorynystagmustotheright.Theattacklastedaboutthirtysecondsandwasaccompaniedbyviolentvertigoandnausea.If,immediatelyafterthecessationofthesesymptoms,theheadwasagainturnedtotheright,noattackoccurred,andinordertoevokeanewattackinthisway,thepatienthadtolieforsometimeonherbackoronherleftside.DixM.R.&HallpikeC.S.(1952)[2]:介绍了BPPV特点和Dix—HallpikeTestSchuknechtH.F.(1969)[3]:病人颞骨病理见后半规管壶腹嵴致密颗粒cupulolithiasisHallSF，RubyRRF，McClureJA.(1979)[4]:根据重复刺激疲劳性提出半规管结石症canalithiasisBrandtT，DaroffRB(1980)[5]:首推体位治疗SemontA，FreyssG，VitteE(1988)[6]：耳石解脱法liberatorymaneuverEpleyJM(1992)[7]:耳石复位法canalrepositionprocedures(CRP)ParnesLS，McClureJA.(1990)[8]:描述后半规管阻塞术治疗难治性BPPVParnesLS，McClureJA.(1992)[9]:难治性BPPV手术中发现后半规管中嗜碱性颗粒GacekRR(1995):singularneurectomy[*]MoriartyB，RutkaJ，HawkeM.(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SchuknechtH.F.(1969)[3]：壶腹嵴帽结石症学说,后半规管壶腹嵴cupulolithiasis.HallSF.(1979)[4]:半规管结石症学说,后半规管canalithiasis.BPPVcanbecausedbyeithercanalithiasisorcupulolithiasisandcantheoreticallyaffecteachofthe3semicircularcanals,althoughsuperiorcanalinvolvementisexceedinglyrare.ThecupulolithiasisandThecanalithiasisBPPV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“criticalmass”[图1][图2]？BPPV后半规管开窗所见耳石团块ThevestibularsystemTheotoconiaBPPV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-BPPVtestDixM.R.&HallpikeC.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。“Reversalnystagmus”occurswhenthepatientreturnstotheuprightposition.Dix—HallpikeTest[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—Hallpiketest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。“Reversalnystagmus”occurswhenthepatientreturnstotheuprightpositionHC-BPPVtestMcClureJA(1985)[14][图5]:Rolltest:Thepatientlyingsupineandtheheadmovedtobothsides.RahkoT(2001)[15][图6]:WRWtest:thepatientwalksforwardandrotatesbrisklyontherotationdirectionfootandreturnsback.RolltestRahkonWRWtestHC-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.Rolltest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SC-BPPVtestRAHKOTmanoeuvre[16][图7]:Whentheposteriorandhorizontalcanalswerefreeofotoconia,thepatientswereinstructedtobowforward60°andstraightenbackwithclosedeyesquickly.Theobserverrecordedthepossiblemovementofthepatientsidewaysduringstraightening.Dix—Hallpiketest[2].RAHKOTmanoeuvreSC-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-BPPVtest阳性oraDix—Hallpiketest.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。PC-BPPV手法复位示意图Afterthemaneuverisperformed(for2nights)Brandt-DaroffExercisesHC-BPPV手法复位Lempertmanoeuvre(1996)[17]orBarbecuemanoeuvre:Thepatientislyingsupine.Herotatestheheadtothehealthysideby90°,thenturnstotheproneposition,theheadisturnednose-downandagaintheheadisturnedwiththeaffectedeardown,eachphase30s.Finally,thepatientsitsup.Gufoni’sliberatorymanoeuvre(1998)[18]:(A)Thepatientisseated.(B)Thepatientisquicklybroughttotheside-lyingpositionontheaffectedside.(C)Theheadofthepatientisquicklyturned45degreesupward.(D)Thepatientreturnstothesittingposition.PositionsBandCaremaintainedfor2minutes.LempertmanoeuvreGufoni疗法SC-BPPV手法复位Honrubiamanoeuvre(1999)[19]:ThetreatmentwasareverseEpleymanoeuvreorareverseSemontmanoeuvre.RahkoTmanoeuvre[16]:thepatientliesonthehealthyside,theheadistilteddownwards45°,thenhorizontally,upwards45°for30seach,andfinallythepatientsitsupandstaystherewellsupportedforatleast3min.RahkoTmanoeuvreBPPV疗效判定症状消失Dix—Hallpiketest、HC-BPPVtest或SC-BPPVtest阴性416例BPPV临床资料自1997至2007年间，共收集416例BPPV病人，其中男136例，女280例，平均年龄56岁，PC-BPPV382人，HC-BPPV12人，SC-BPPV3人,NC-BPPV28人，单耳发病390人，双耳发病26人，281人单次复位有效，103人2次或2次以上复位有效，22人属顽固性BPPV，12人接受手术治疗，10例失访。416例BPPV年龄分布图病例数020406080100120140∽2021∽3031∽4041∽5051∽6061∽7071∽病例数416例BPPV病人病因分布图0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%unknowtraumaeardiseaseother系列1416不同类型BPPV病例发病情况0.00%20.00%40.00%60.00%80.00%100.00%PC-BPPVHC-BPPVSC-BPPVNC-BPPV406不同病因BPPV病例手法复位效果0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%100.00%unknowtraumaeardiseaseothertotalonce%twice%morethantwice%aborted%药物在BPPV治疗中的作用复位前药物治疗可减轻病人在检查/复位时产生的激惹症状1