Medical Excellence - Issue 2

While sitting up after surgery, the patients experienced intense vertigo with nausea, especially when he changed the position of his head. He sat in the dental chair and rested for 30 min, but the vertigo remained. The dentist referred the patient to the emergency department. The results of standard laboratory analyses, and his neurologic examination were within normal limits. His oculomotor examination was normal. No spontane- ous nystagmus was observed. The Dix–Hallpike test was per- formed and during the left-sided swing, the patient experienced vertigo and rotatory nystagmus was observed. The nystagmus had a 4- to 7-second latency and lasted ~25 s. The Epley maneu- ver with mastoid oscillation was performed on the left side, and he was sent home. After the procedure, the patient was advised to avoid moving his head abruptly, to sleep in a slightly elevated po- sition, and to avoid turning during sleep toward the affected ear for 48 h. A cervical collar or medication for BPPV was not used. After the first Epley maneuver, the patient was asked to revisit our clinic in 3 days. The results of a control Dix–Hallpike test were negative, and the patient was symptom-free. Case 2 A 44-year-old healthy woman came to the endodontics clinic with tooth pain. After clinical and radiographic examination, tooth decay was established in right upper first and second molar tooth. Like first case, a low-powered surgical drill was used to preserve healthy tooth tissue. The surgery lasted about 35 to 40 min. After the procedure, the patient was sent home. Her husband called us after 2 or 3 h and he said that his wife had intense vertigo and nausea. The patient was referred to otolaryn- gology department for diagnosis and treatment of vertigo. The history of central nervous system or otological disease was nega- tive in her past medical history. There was no systemic disease like hypertension, anemia, increased cholesterol level, coronary artery disease or diabetes mellitus. The otological symptoms as hearing loss, tinnitus or aural pressure were established. A Dix– Hallpike test was done. During the right swing, the patient had severe vertigo, and rotatory nystagmus started 4 to 6 s after and was observed for 25 to 30 s. An Epley maneuver was performed on the right side. After the procedure, the patient was advised to avoid moving her head abruptly, to sleep in a slightly elevated po- sition, and to avoid turning during sleep toward the affected ear for 48 h. A cervical collar or medication for BPPV was not used. The results of a control Dix–Hallpike test were negative. In both cases, a low-powered drill was used for endodontic treatment. This drill is used to keep the tooth tissue healthy, but when it touches the tooth, high vibration would be caused in the tooth and the maxilla. Case 3 A 30-year-old female nurse came to the otolaryngology clinic with a nose obstruction since 2 to 3 years. On examination, we found she had a deviated septum and bilateral inferior turbinate hyperplasia. The patient was in good physical health. She was taking no medications. With the patient under general anesthe- sia, she underwent a nasal septoplasty, and radiofrequency was applied bilaterally to the inferior turbinate. The day after the op- eration, she had vertigo and nausea. There was no hearing loss, tinnitus or vomiting. The physical and neurological examinations were normal. No spontaneous nystagmus was noted. The results of a Dix–Hallpike test demonstrated vertigo, and torsional nys- tagmus was noted when she hung her head to the right. The can- alith repositioning maneuver with mastoid oscillation was done on the right side. After the procedure, the patient was advised to avoid moving her head abruptly, to sleep in a slightly elevated position, and to avoid turning during sleep toward the affected ear for 48 h. A cervical collar or medication for BPPV was not used. On follow-up 3 days later, she felt better. The results of the Dix–Hallpike maneuver were normal. None of the patients re- experienced BPPV during 1-year follow-up. Discussion Although BPPV is usually idiopathic, cases have been discovered after traffic accidents, head trauma, otologic surgery, or other surgical interventions with prolonged bed rest. More recently, BPPV has been reported as a complication of surgical procedures involving the cochlea, such as a stapedectomy, a stapedotomy, and a cochlear implant. Atacan and associates found a 6.3%, and Magliulo and associates found an 8.5% incidence of BPPV after stapedectomy [6, 9]. During these surgical procedures, the oc- curence of BPPV could be explained in 2 different ways by the pathophysiological mechanisms in the literature—direct trauma or indirect trauma (vibration induced by the drill) [5]. The tip of the piston could be affected by direct trauma. The vibration of the drill on the cochlea would be sufficient to dislodge several oto- conia into the labyrinth, where they could cause canalolithiasis. The vibratory trauma affecting the cochlea during use of the drill plays a fundamental role in developing paroxysmal vertigo in patients with dental surgery. The vibrations involving the cochlea are sufficient to dislodge otoconia, as reported in the case of a dental implant, performed with the use of osteotomes [5]. In our two patients with endodontic treatment, we used the low-powered drill. Indirect trauma on the posterior labyrinth is linked with use of either a drill or a hammer and a chisel on the maxilla. Issue-2  |  7 MEDICAL EXCELLENCE