Medical Excellence - Issue 2

Vibrations are propagated throughout the bone structures, even- tually reaching the posterior labyrinth. At this level, mechanical energy would travel through endolymphatic fluids or bone even- tually leading to macular trauma. The membranous structures of the inner ear, which are contained in bony chambers, are par- ticularly vulnerable to traumatic lesions owing to the traveling of a mechanical wave. Even mild trauma, when caused by rotating structures whose vibrations are prolonged, can damage semicir- cular canals. The vibrations dislodge otoliths, which then enter canal causing BPPV [10, 11]. Dieago and associates think that use of the bone expansion technique with osteotomes in dental surgery can increase the in- cidence of BPPV. To prevent this, they recommended use of a surgical fraise in combination with osteotomes [2]. We used a dental drill for the surgery on our patients, but BPPV was seen. Su and associates defended a theory that percussive force may detach otoliths from the utricle or saccule of the vestibular system in the inner ear. The posteriorly displaced otoliths may then induce BPPV. During surgical positioning of the patient face up with his head hyper-extended may facilitate displace- ment of the detached otoliths into the posterior semicircular canal [7, 11]. Kaplan and associates thought that the use of an osteotome during rhinoplasty was sufficient to dislodge otoconia and produce BPPV [8]. The presumed cause of BPPV in our third case was blunt head trauma caused by the osteotomy. Also, tilting the head, particularly in patients having a nasal septoplasty or in those who need to be intubated during general anesthesia, may cause BPPV [10, 11]. The diagnosis of BPPV is easily made by the Dix–Hallpike test, which produces vertigo and nystagmus after the patient is rapidly moved from a sitting to head-hanging position [11]. Patients with BPPV experience vertigo when moved rapidly into a supine position with the head turned, so that the affected ear is 30 to 450 below the horizontal plane. Vertigo occurs 1 to 40 s after the patient has been placed in such a position. The patient also develops a characteristic nystagmus, with the eyes directed toward the affected side. The vertigo and nystagmus disappear in 30 to 60 s [11]. Although BPPV is a self-limiting disorder and commonly resolves within a couple of months, the symptoms are unpleas- ant. Treatment consists fundamentally of maneuvers to restore the calcium carbonate crystals from the anomalous location in the semicircular canal to their correct place in the utricle. Advocated treatments are maneuvers of canalith repositioning. The Epley maneuver is the most common. Here, the patient is seated with the operator behind. The head is placed over the end of the table and turned to affected ear 450. While the head is tilted downward, it is rotated 450 to the unaffected ear. The head and body are rotated until they face downward 1350 from a supine position. While the head is turned to the unaffected side, the patient is brought to a sitting position. The head is turned forward, with the chin down 200. This maneuver is repeated as necessary at weekly intervals until the vertigo symptoms have cleared and Dix– Hallpike maneuver is negative [12]. Dentists and surgeons must bear in mind that after dental treatment and surgical procedure, an episode of BPPV may occur. Acknowledgments  Conflicts of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this paper. References 1. Kansu L, Avci S, Yilmaz I et al (2010) Long-term follow-up of patients with posterior canal benign paroxysmal positional vertigo. Acta Otolaryngol 130:1009–1112. 2. Peñarrocha-Diago M, Rambla-Ferrer J, Perez V et al (2008) Benign paroxysmal vertigo secondary to placement of maxillary implants using the alveolar expansion technique with osteotomes: a study of 4 cases. Int J Oral Maxillofac Implants 23:129–132. 3. Aydin E, Akman K, Yerli H et al (2008) Benign paroxysmal positional vertigo after radiologic scanning: a case series. J Med Case Rep 2:92. 4. Parnes LS, Agrawal SK, Atlas J (2003) Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 169:681–693. 5. Viccaro M, Mancini P, La Gamma R et al (2007) Positional vertigo and cochlear implantation. Otol Neurotol 28:764–767. 6. Atacan E, Sennaroglu L, Genc A et al (2001) Benign paroxysmal posi- tional vertigo after stapedectomy. Laryngoscope 111:1257–1259. 7. Su GN, Tai PW, Su PT et al (2008) Protracted benign paroxysmal positional vertigo following osteotome sinus floor elevation: a case report. Int J Oral Maxillofac Implants 23:955–959. 8. Kaplan DM, Attal U, Kraus M (2003) Bilateral benign paroxysmal positional vertigo following a tooth implantation. J Laryngol Otol 117:312–313. 9. Magliulo G, Gagliardi M, Cuiuli G et al (2005) Stapedotomy and post-operative benign paroxysmal positional vertigo. J Vestib Res 15:169–172. 10. Chiarella G, Leopardi G, De Fazio L et al (2008) Benign paroxysmal positional vertigo after dental surgery. Eur Arch Otorhinolaryngol 265:119–122. 11. Chiarella G, Leopardi G, De Fazio L et al (2007) Iatrogenic benign paroxysmal positional vertigo: review and personal experience in dental and maxillo-facial surgery. Acta Otorhinolaryngol Ital 27:126–128. 12. Epley JM (1992) The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 107:399–404. Source: Kansu, L., Aydin, E. & Gulsahi, K. J. Maxillofac. Oral Surg. (2015) 14(Suppl 1): 113. https://doi.org/10.1007/s12663-012-0356-8. © Association of Oral and Maxillofacial Surgeons of India 2012. 8  |  Issue-2 MEDICAL EXCELLENCE