各型BPPV的診斷手法及復(fù)位技巧打印稿

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(jiàn)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(jiàn)嗜堿性顆粒BPPV假說(shuō)SchuknechtH.F.(1969)[3]

：壺腹嵴帽結(jié)石癥學(xué)說(shuō),后半規(guī)管壺腹嵴cupulolithiasis.HallSF.(1979)[4]:半規(guī)管結(jié)石癥學(xué)說(shuō),后半規(guī)管canalithiasis.BPPVcanbecausedbyeithercanalithiasisorcupulolithiasisandcantheoreticallyaffecteachofthe3semicircularcanals,althoughsuperiorcanalinvolvementisexceedinglyrare.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(guò)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(kāi)窗所見(jiàn)耳石團(tuán)塊ThevestibularsystemTheotoconiaBPPV分類原發(fā)性：占34～68％.

繼發(fā)性：以頭部外傷為多見(jiàn)，約17%，其他可見(jiàn)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.PC-BPPVtestDixM.R.&HallpikeC.S.(1952)[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)眩暈及眼震至少40秒鐘。[圖3][圖4]

.

有上跳性、扭轉(zhuǎn)性眼震（快相向下位耳），左側(cè)順時(shí)針?lè)较?，右?cè)反時(shí)針?lè)较颉?/p>

“Reversalnystagmus”occurswhenthepatientreturnstotheuprightposition.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.PC-BPPV診斷標(biāo)準(zhǔn)患耳向下突發(fā)強(qiáng)烈旋轉(zhuǎn)性眩暈及眼震,改變頭位后眩暈可減輕或消失.有3～30秒潛伏期.眼震通常持續(xù)數(shù)秒,一般在30秒內(nèi).眩暈持續(xù)時(shí)間可稍長(zhǎng)，多在1分鐘內(nèi)停止.具疲勞性.Dix—Hallpiketest陽(yáng)性.有上跳性、扭轉(zhuǎn)性眼震（快相向下位耳），左側(cè)順時(shí)針?lè)较?，右?cè)反時(shí)針?lè)较??！癛eversalnystagmus”occurswhenthepatientreturnstotheuprightpositionHC-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].RAHKOTmanoeuvreSC-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Epley耳石復(fù)位法CRP[7]

[圖8][圖9][圖10]

：平仰臥，頭微伸展，振動(dòng)器固定在患側(cè)乳突→頭轉(zhuǎn)向患側(cè)呈45°→保持15秒～30秒或至眼震消失，頭轉(zhuǎn)向健側(cè)呈45°→保持15秒～30秒，身體位慢慢向健側(cè)轉(zhuǎn)呈90°→保持1～2分鐘，坐位微向下視→保持頭位垂直兩天。Brandt體位治療[5]

：向患側(cè)側(cè)臥30秒，坐起向?qū)?cè)臥，交替至癥狀消失。Semont手法復(fù)位[6]

:頭轉(zhuǎn)健側(cè)45°→快速向患側(cè)臥→至眼震消失，約4分鐘后快速坐起向健側(cè)臥→5分鐘后慢慢坐起→保持頭位垂直兩天。PC-BPPV手法復(fù)位示意圖Afterthemaneuverisperformed(for2nights)Brandt-DaroffExercises

HC-BPPV手法復(fù)位Lempertmanoeuvre(1996)[17]orBarbecuemanoeuvre:Thepatientislyingsupine.Herotatestheheadtothehealthysideby90°,thenturnstotheproneposition,theheadisturnednose-downandagaintheheadisturnedwiththeaffectedeardown,eachphase30s.Finally,thepatientsitsup.Gufoni’sliberatory

manoeuvre(1998)[18]:(A)Thepatientisseated.(B)Thepatientisquicklybroughttotheside-lyingpositionontheaffectedside.(C)Theheadofthepatientisquicklyturned45degreesupward.(D)Thepatientreturnstothesittingposition.PositionsBandCaremaintainedfor2minutes.LempertmanoeuvreGufoni療法SC-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56歲，PC-BPPV382人，HC-BPPV12人，SC-BPPV3人,NC-BPPV28人，單耳發(fā)病390人，雙耳發(fā)病26人，281人單次復(fù)位有效，103人2次或2次以上復(fù)位有效，22人屬頑固性BPPV，12人接