Week 1 Part 1: Due Wednesday by 1159PM MT MN
You will research the two areas of content assigned to you and compare and contrast them in discussion post. NOTE: A comparison and contrast assignment is not about listing the info regarding each disease separately but rather looking at each disease side by side and discussing the similarities and differences given the categories below. Consider how each patient would actually present to the office. Consider how their history would affect their diagnosis, etc. Evaluation of mastery is focused on the student’s ability to demonstrate specific understanding of how the diagnoses differ and relate to one another.
Address the following topics below in your own words:
Topics of discussion:
Benign Paroxysmal Positional Vertigo and Meniere’s Disease
Of the approximate 5.6 million medical visits with chief complaint of dizziness that occur each year in the United States, up to almost half of those are diagnosed with benign paroxysmal positional vertigo (BPPV) (Bhattacharyya, Gubbels, & Schwartz, 2017). The implication behind the “benign” wording is due to the fact that the BPPV/ vertigo is not caused by any actual known central nervous system disorder and has the ability to self-resolve spontaneously. “Paroxysmal” is it’s reference to the sudden attacks of vertigo that the patient experiences. The patient’s sense of personal or environmental movement despite lack of actual movement constitutes the definition of vertigo (Bhattacharyya et al., 2017).
This positional vertigo is directly related to gravity whereas alternative forms are related to central or vascular origin.
Despite its benign status and primarily positive outcomes, it still has the ability to affect a patient’s daily quality of life significantly, particularly when the condition goes undiagnosed and untreated for an extended period of time. Of particular concern is the patient’s increased risk for falls, significant impact on completion of activities of daily living, associated depression, and loss of work days- to include leaving their current job. The longer that an older patient goes undiagnosed, the more likely they are to be considered a burden to their family and risk being placed into a nursing home. Additionally, there are two forms of BPPV, which affects the posterior or lateral semicircular canals. The posterior form of BPPV is the most common, affecting more than 85% of BPPV patients (Bhattacharyya et al., 2017).
BPPV typically presents between the fifth and seventh decades of age, and affects almost twice as many women as it does men, with a ratio of 1.5-2.2:1 respectively.
Presentation
BPPV- dizziness, vertigo
A patient will typically present with complaints of a spinning feelings when turning their head in a certain way when sitting or standing, or both. This sensation of spinning associated with head movement is known as positional vertigo. Benign paroxysmal positional vertigo is one form of positional vertigo that is a result on inner ear dysfunction, producing multiple instances of positional vertigo (Bhattacharyya et al., 2017).
The episodes are often provoked by everyday activities and commonly occur when rolling over in bed or when the patient is tilting the head to look upward (eg, to place an object on a shelf higher than the head) or bending forward (eg, to tie his or her shoes); Patients with BPPV most commonly report discrete, episodic periods of vertigo lasting ≤1 minute and often report modifications or limitations of their general movements to avoid provoking the vertiginous episodes.48Other investigators report that true “room spinning” vertigo is not always present as a reported symptom in posterior canal BPPV, with patients alternatively complaining of light-headedness, dizziness, nausea, or the feeling of being “off balance.” Approximately 50% of patients also report subjective imbalance between the classic episodes of BPPV.22 In contrast, a history of vertigo without associated light-headedness may increase the a priori likelihood of a diagnosis of posterior canal BPPV
Ménière’s disease is a chronic illness that is characterized by symptoms of episodic vertigo, aural fullness, tinnitus, and fluctuating sensorineural hearing loss.
Pathophysiology
Although debated, posterior canal BPPV is most commonly thought to be due to canalithiasis, wherein fragmented otolith particles (otoconia) entering the posterior canal become displaced, cause inertial changes to the cupula in the posterior canal, and thereby result in abnormal nystagmus and vertigo when the head encounters motion in the plane of the affected semicircular canal
The etiology of lateral canal BPPV is also felt to be due to the presence of abnormal debris within the lateral canal, but the pathophysiology is not as well understood as that of posterior canal BPPV.
The pathophysiology of Meniere’s disease is not entirely known and is a topic of controversy. Two theories of cause exist, either a sequelae of migraine or the more popular, endolymphatic hydrops
Assessment
During performance of the Dix-Hallpike maneuver in assessment of posterior canal BPPV, there is a small period of time that will occur between the time the patient is laid back and the time of the induction of positional vertigo symptoms and nystagmus, approximately 5-20 seconds, up to one minute at maximum. Once symptoms are induced, they should resolve in approximately 60 seconds. Nystagmus that will be observed is upbeating-torsional and presents with a crescendo-decrescendo. This means that the eye will beat towards the dependent ear and up towards the top of the head, with a gradual increase in intensity of movement before decreasing again. This observation may repeat as the patient is returned to seated position. As the procedure is repeated, the nystagmus become “fatigued”, but repeated movements are unnecessary and not recommended. Should the nystagmus beat downward versus up, this could be an indicator of anterior canal BPPV.
Diagnosis
There is no diagnostic test available for Meniere’s disease- it is a diagnosis based on clinical presenting symptoms.
BPPV: Dix-Hallpike maneuver
DIAGNOSIS OF POSTERIOR SEMICIRCULAR CANAL BPPV: Clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to 1 side and neck extended 20° with the affected ear down. The maneuver should be repeated with the opposite ear down if the initial maneuver is negative
Prior to performance of the maneuver, the patient needs to be made aware that they will experience vertigo and possibly nausea lasting up to a minute. Beginning in an upright position, the provider will have the patient turn their head 45° towards the affected side, then assists the patient to quickly lay supine with their neck placed in a supported 20° extension position. At this time, the provider will assess for presence and type of nystagmus. The patient will be slowly returned to a seated upright position and will be observed for resolution of symptoms.
Treatment
Ideally, resolution of all symptoms of BPPV is the primary goal of treatment.
-Heather Capps
Throughout the Week: Participate in Interactive Dialogue with faculty and students responding to their Part 1 Discussion post moving the discussion forward.