各型BPPV 的診斷手法及復(fù)位技巧打印稿課件

各型BPPV的診斷手法及復(fù)位技巧DrXiaofengMeiFushanhospitaloftraditionalchinesemedicine,Departmentofotorhinolaryngology—headandnecksurgeryOverview發(fā)病率約1/10000,占外周性眩暈的50%屬周圍性旋暈多為自限性，能自行緩解，故稱為良性三個(gè)月不愈或喪失勞動(dòng)力者為頑固性男:女=1:2～3BackgroundBarany(1921)[1]:首次描述benignparoxysmalpositionalvertigo(BPPV):Theattacksonlyappearedwhenshelayonherrightside.Whenshedidthis,thereappearedastrongrotatorynystagmustotheright.Theattacklastedaboutthirtysecondsandwasaccompaniedbyviolentvertigoandnausea.If,immediatelyafterthecessationofthesesymptoms,theheadwasagainturnedtotheright,noattackoccurred,andinordertoevokeanewattackinthisway,thepatienthadtolieforsometimeonherbackoronherleftside.DixM.R.&HallpikeC.S.(1952)[2]:介紹了BPPV特點(diǎn)和Dix—HallpikeTestSchuknechtH.F.(1969)[3]:病人顳骨病理見后半規(guī)管壺腹嵴致密顆粒cupulolithiasisHallSF，RubyRRF，McClureJA.(1979)[4]:根據(jù)重復(fù)刺激疲勞性提出半規(guī)管結(jié)石癥canalithiasisBrandtT，DaroffRB(1980)[5]:首推體位治療SemontA，F(xiàn)reyssG，VitteE(1988)[6]：耳石解脫法liberatorymaneuverEpleyJM(1992)[7]:耳石復(fù)位法canalrepositionprocedures(CRP)ParnesLS，McClureJA.(1990)[8]:描述后半規(guī)管阻塞術(shù)治療難治性BPPVParnesLS，McClureJA.(1992)[9]:難治性BPPV手術(shù)中發(fā)現(xiàn)后半規(guī)管中嗜堿性顆粒GacekRR(1995):singularneurectomy[*]

MoriartyB，RutkaJ，HawkeM.(1992)[10]:大量顳骨病理發(fā)現(xiàn)其他半規(guī)管也見嗜堿性顆粒ThecupulolithiasisandThecanalithiasisBPPV病理生理正常耳石代謝：耳石膜含許多碳酸鈣結(jié)晶，耳石含大量鈣離子，酷似骨組織，是一動(dòng)態(tài)結(jié)構(gòu)，維持迷路內(nèi)離子動(dòng)態(tài)平衡，正常情況下耳石也會(huì)少量脫落，為吞噬細(xì)胞所消滅，這種情況多發(fā)生在囊斑、膠狀壺腹嵴[11][12]和內(nèi)淋巴囊[13]。BPPV病理生理：耳石脫落過多或吸收障礙時(shí),異位進(jìn)入半規(guī)管，當(dāng)達(dá)到或超出臨界狀態(tài)時(shí)“criticalmass”[圖1]

[圖2]

？BPPV后半規(guī)管開窗所見耳石團(tuán)塊ThevestibularsystemBPPV分類原發(fā)性：占34～68％.繼發(fā)性：以頭部外傷為多見，約17%，其他可見發(fā)生于梅尼挨病、迷路炎、偏頭痛、中耳術(shù)后、頭顱外傷等.按解剖部位分類:PC—BPPV,HC—BPPV,SC—BPPV,NC—BPPV.Schuknecht分類:自限性、復(fù)發(fā)性和頑固性.Dix—HallpikeTest[2]

取坐位,觀察有無(wú)自發(fā)性眼震,頭轉(zhuǎn)向一側(cè)45°,迅速仰臥,與水平面呈30°角，觀察有無(wú)眩暈及眼震.HC-BPPVtestMcClureJA(1985)[14][圖5]

:Rolltest:Thepatientlyingsupineandtheheadmovedtobothsides.RahkoT(2001)[15][圖6]

:WRWtest:thepatientwalksforwardandrotatesbrisklyontherotationdirectionfootandreturnsback.RolltestRahkonWRWtestHC-BPPV診斷標(biāo)準(zhǔn)在床上向左右翻身時(shí)發(fā)作，當(dāng)頭轉(zhuǎn)向患側(cè)時(shí)眩暈或眼震變劇烈，做頭部的垂直運(yùn)動(dòng)如抬頭或彎腰矢狀面運(yùn)動(dòng)則不引起眩暈.潛伏期稍短，約2～3秒.持續(xù)時(shí)間略長(zhǎng),可達(dá)1分鐘.疲勞性不明顯.Rolltest陽(yáng)性,兩側(cè)均出現(xiàn)向地性水平性眼震,以患側(cè)更強(qiáng)烈(canalithiasis)或背地性水平性眼震,但以健側(cè)更強(qiáng)烈(cupulolithiasis).眼震方向與頭轉(zhuǎn)動(dòng)方向一致，稱為向地性水平性眼震,否則為背地性水平性眼震SC-BPPVtestRAHKOTmanoeuvre[16][圖7]

:Whentheposteriorandhorizontalcanalswerefreeofotoconia,thepatientswereinstructedtobowforward60°andstraightenbackwithclosedeyesquickly.Theobserverrecordedthepossiblemovementofthepatientsidewaysduringstraightening.Dix—Hallpiketest[2].SC-BPPV診斷標(biāo)準(zhǔn)典型病史及癥狀：特殊體位出現(xiàn)旋暈、惡心、嘔吐排除PC-BPPV和HC-BPPV.SC-BPPVtest陽(yáng)性oraDix—Hallpiketest.有下跳性、扭轉(zhuǎn)性眼震管石復(fù)位原理示意圖PC-BPPV手法復(fù)位示意圖Brandt-DaroffExercises

HC-BPPV手法復(fù)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.LempertmanoeuvreSC-BPPV手法復(fù)位Honrubiamanoeuvre(1999)[19]:ThetreatmentwasareverseEpleymanoeuvreorareverseSemontmanoeuvre.RahkoTmanoeuvre[16]:thepatientliesonthehealthyside,theheadistilteddownwards45°,thenhorizontally,upwards45°for30seach,andfinallythepatientsitsupandstaystherewellsupportedforatleast3min.RahkoTmanoeuvreBPPV療效判定癥狀消失Dix—Hallpiketest、HC-BPPVtest或SC-BPPVtest陰性416例BPPV臨床資料自1997至2007年間，共收集416例BPPV病人，其中男136例，女280例，平均年齡