benign-positionel-vertigo (LH Indholdsside)

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    <Content>
      <HtmlField Name="PageContent"><![CDATA[<h2>Diagnose</h2>
<h3>Diagnostiske kriterier</h3>
<ul>
    <li>Typisk anamnese og reproduktion af svimmelhed ved stillingstest (Dix-Hallpikes test)</li>
    <li>Testen er positiv i den side hovedet er drejet mod, hvis der udl&oslash;ses vertigo og nystagmus mod det nederste &oslash;re</li>
</ul>
<h3>Sygehistorie</h3>
<ul>
    <li>Symptomerne begynder akut, ofte om morgenen eller om natten</li>
    <li>Patienter med BPPV har ofte karakteristiske symptomer med positionel svimmelhed af sekunder til minutters varighed. Initiale anfald ofte mere kraftige, og i sj&aelig;ldne tilf&aelig;lde m&aring; patienten indl&aelig;gges akut</li>
    <li>Svimmelhed
    <ul>
        <li>Kortvarigt anfald af rotatorisk svimmelhed&nbsp;(ca. 80 %) ledsaget af nystagmus, som udl&oslash;ses ved specifikke hovedbev&aelig;gelser</li>
        <li>Typisk sekunder efter at patienten har vendt sig i sengen eller sat sig op (latenstid)</li>
    </ul>
    </li>
    <li>Ophobning af anfald
    <ul>
        <li>Patienten oplever en periode med hyperakutte (paroksysmale), kortvarige (10-30 sekunder) anfald som kan ledsages af kvalme/opkastning</li>
        <li>25 % har flere anfald ugentlig, og 50 % besv&aelig;res af flere anfald dagligt</li>
    </ul>
    </li>
    <li>Positionelt udl&oslash;ste anfald
    <ul>
        <li>Anfaldene udl&oslash;ses ved bestemte hovedbev&aelig;gelser, hyppigst ved at patienten l&aelig;gger hovedet bagover eller vender sig i sengen</li>
        <li>Dette skyldes, at sygdommen i de fleste tilf&aelig;lde skyldes affektion af den bagerste (posteriore)&nbsp;buegang&nbsp;</li>
    </ul>
    </li>
    <li>Tr&aelig;tbarhed
    <ul>
        <li>Ved gentagelse sv&aelig;kkes symptomerne eller forsvinder helt (tr&aelig;tbarhed) og lader sig f&oslash;rst udl&oslash;se igen efter en refrakt&aelig;rperiode p&aring; op til en halv time</li>
    </ul>
    </li>
    <li>Det er ikke h&oslash;retab</li>
    <li>Nogle kan desuden have en mere generel vertigof&oslash;lelse og instabilitet, n&aring;r de g&aring;r oprejst
    <ul>
        <li>Enkelte patienter angiver helt ukarakteristiske svimmelhedssymptomer, og diagnosen stilles f&oslash;rst ved klinisk unders&oslash;gelse</li>
    </ul>
    </li>
</ul>
<h3>Kliniske fund</h3>
<ul>
    <li>Anfald lader sig ofte udl&oslash;se ved stillingstest.&nbsp;Testen er positiv i den side hovedet er drejet mod, hvis der udl&oslash;ses vertigo og nystagmus mod det nederste &oslash;re</li>
    <li>Udeluk arytmi og hypertension</li>
    <li>Diagnosen stilles ved relevante positionstests, f.eks. Dix-Hallpikes test</li>
</ul>
<h4>Stillingstest (<a href="~/link.aspx?_id=B1DDBD96062D49B09A9A21E7926EDFD8&amp;_z=z">Dix-Hallpike</a>) med henblik p&aring; bestemmelse af den p&aring;virkede side</h4>
<ul>
    <li>Tester for posteriore buegang</li>
    <li>Patienten sidder p&aring; unders&oslash;gelseslejet med hovedet drejet 45&deg; til siden</li>
    <li>Patienten l&aelig;gges hurtigt ned, med hovedet h&aelig;ngende udenfor lejekanten
    <ul>
        <li>Nakken er ekstenderet ca. 15&deg;</li>
        <li>Hovedet er fortsat drejet 45&deg; til siden</li>
        <li>&Oslash;jnene er &aring;bne og observeres hele tiden (30-60 sekunder) af unders&oslash;ger</li>
    </ul>
    </li>
    <li>Patienten s&aelig;tter sig op</li>
    <li>Samme man&oslash;vre p&aring; ny, denne gang med hovedet vendt 45&deg; til den anden side
    <ul>
        <li>Observation i 30-60 sekunder f&oslash;r patienten sidder op</li>
    </ul>
    <ul>
        <li>Nystagmusretningen er rotatorisk og vertikal</li>
        <li>Den rotatoriske komponent sl&aring;r med hurtig fase mod det syge &oslash;re (som &oslash;jets &oslash;vre pol bev&aelig;ger sig)</li>
        <li>Den vertikale komponent er opadsl&aring;ende</li>
        <li>Retningen reverseres, n&aring;r patienten s&aelig;tter sig op, men nystagmus og vertigo vil da v&aelig;re svagere</li>
        <li>Fundet regnes som patognomonisk uafh&aelig;ngig af sygehistorien</li>
    </ul>
    </li>
</ul>
<h4>Testen er positiv, hvis der kommer vertigo og nystagmus mod det nederste &oslash;re efter latenstid p&aring; 2-10 sekunder (nystagmus varer &gt; 15 sekunder)</h4>
<ul>
    <li>Der vil normalt v&aelig;re aftagende intensitet af anfaldene ved gentagne unders&oslash;gelser
    <ul>
        <li>Hvis anfaldsudl&oslash;sningen ikke er tr&aelig;tbar, kan der foreligge en central positionsvertigo</li>
    </ul>
    </li>
    <li>Tilstanden kan underinddeles s&aring;ledes
    <ul>
        <li>Subjektiv benign paroksysmal positionel vertigo, dvs. frav&aelig;r af nystagmus ved positiv Dix-Hallpikes test<a href=" " data-type="journal-reference" data-value="Jung JY, Kim SH, Comparison between objective and subjective benign paroxysmal positional vertigo: clinical features and outcomes. Acta Otolaryngol 2016;136: 1267-1272" data-value-piped="Jung JY, Kim SH|Comparison between objective and subjective benign paroxysmal positional vertigo: clinical features and outcomes.|Acta Otolaryngol|2016|136|1267-1272|27388229" data-url="reference-link" data-pubmedid="27388229" title="Jung JY, Kim SH, Comparison between objective and subjective benign paroxysmal positional vertigo: clinical features and outcomes. Acta Otolaryngol 2016;136: 1267-1272"><sup>1</sup></a></li>
        <li>Posterior (bagerste) buegangscanalolithiasis (langt den hyppigste)</li>
        <li>Lateral (horisontal) buegangscanalolithiasis og cupulolithiasis</li>
        <li>Anterior (&oslash;vre) buegangs-canalolithiasis</li>
    </ul>
    </li>
</ul>
<h4>Effekt af reponeringsman&oslash;vrer</h4>
<ul>
    <li>Der udf&oslash;res en eller flere reponeringsman&oslash;vrer (se behandling)</li>
    <li>Kontrol af at positionsnystagmus og -vertigo er elimineret, stadf&aelig;ster diagnosen</li>
    <li>Efterf&oslash;lgende reponeringsman&oslash;vrer giver i nogle tilf&aelig;lde ikke symptomlindring, og positionstests er fortsat positive. Hos disse patienter er behandling i reponeringsstol relevant</li>
    <li>Ved patienter med komorbiditet ogs&aring; relevant med unders&oslash;gelse og behandling i reponeringsstol, f.eks. h&oslash;j alder, stivhed i ryg og nakke, neuromuskul&aelig;re sygdomme, whiplash og reumatoid artritis</li>
</ul>
<h4>Indikationer for behandling i behandlings-/reponeringsstol</h4>
<ul>
    <li>Positive positionstests, f.eks. Dix-Hallpikes tests trods gentagne reponeringsfors&oslash;g og hjemme&oslash;velser</li>
    <li>Nedsat bev&aelig;gelighed i ryg og nakke, s&aring;ledes at unders&oslash;gelse og behandling ikke kan gennemf&oslash;res</li>
</ul>
<h3>Supplerende unders&oslash;gelser i almen praksis</h3>
<ul>
    <li>Hvis kardiologisk og neurologisk status er normal, beh&oslash;ves ingen videre udredning</li>
    <li>I nogle tilf&aelig;lde kan audiometri eller EKG v&aelig;re aktuelt</li>
</ul>
<h3>Andre unders&oslash;gelser hos specialist</h3>
<ul>
    <li>Fuld otoneurologisk unders&oslash;gelse ved tvivlsom diagnose</li>
</ul>
<h3>Differentialdiagnoser</h3>
<h4>Perifer vertigo</h4>
<p>Generelle tegn p&aring; perifer vertigo</p>
<ul>
    <li>Korte anfald</li>
    <li>Rotatorisk svimmelhed</li>
    <li>Stillingsafh&aelig;ngig, udl&oslash;st af hovedbev&aelig;gelser</li>
    <li>Kvalme og opkastning er hyppig</li>
    <li>Evt. h&oslash;retab</li>
    <li><a href="~/link.aspx?_id=CAE00FC7AF164D8C9BFA3AE315AA0067&amp;_z=z">Neuritis vestibularis</a>
    <ul>
        <li>Akut vertigo med kvalme og opkastning</li>
        <li>Ingen h&oslash;resymptomer</li>
        <li>Viral eller post-viral inflammation (Herpes Simplex type1) af 8. kranienerve, oftest isoleret affektion af den &oslash;vre gren af balancenerven (nervus vestibularis superior)</li>
    </ul>
    </li>
    <li><a href="~/link.aspx?_id=9BF630AC53494DFB821BA28A98DE4838&amp;_z=z">Meni&egrave;res sygdom</a>&nbsp;
    <ul>
        <li>Hurtig inds&aelig;ttende anfald med rotatorisk vertigo, tinnitus og d&oslash;vhed</li>
        <li>D&oslash;vheden fornemmes som klap for &oslash;ret</li>
        <li>Varigheden for akutte anfald er 2-5 timer; ikke over et d&oslash;gn</li>
    </ul>
    </li>
    <li>Labyrintitis
    <ul>
        <li>Akut start, varer ofte dage til uger og omfatter vertigo, h&oslash;retab og tinnitus</li>
    </ul>
    </li>
    <li><a href="~/link.aspx?_id=7687D3B1239A45FAB273039BAED2E85C&amp;_z=z">Vestibularisschwannom</a>&nbsp;
    <ul>
        <li>Starter med nedsat h&oslash;relse (ensidig), efterh&aring;nden moderat vertigo, evt. tinnitus</li>
        <li>Vedvarer, der tilkommer hjernenervepareser, ataksi p&aring; samme side og hovedpine</li>
    </ul>
    </li>
    <li>Traumer
    <ul>
        <li>Frakturer i tindingebenet - vertigo som varer i flere dage til uger, og som kan inkludere d&oslash;vhed p&aring; det involverede &oslash;re</li>
        <li>Commotio labyrinthi - langvarige symptomer</li>
    </ul>
    </li>
    <li>Labyrint&aelig;r apopleksi (sv.t. endearterien der forsyner vestibul&aelig;rorganet)
    <ul>
        <li>Akut vertigo med kvalme og opkastning</li>
        <li>Ingen h&oslash;resymptomer</li>
        <li>Vedvarende udslukt vestibularisfunktion, symptomer svinder efter flere uger</li>
    </ul>
    </li>
    <li>Toksisk skade
    <ul>
        <li>Aminoglykosider, loop-diuretika og cisplatin</li>
        <li>Reversibel og mere ukarakteristisk svimmelhed kan ses ved behandling med kinin og salicylsyre, psykofarmaka, alkohol og opiater (s&aelig;rligt petidin)</li>
    </ul>
    </li>
</ul>
<h4>Central vertigo</h4>
<ul>
    <li>Oftest langvarig, ofte nautisk, ikke s&aelig;rligt stillingsafh&aelig;ngig, kvalme/opkast og h&oslash;resymptomer mindre almindeligt, andre symptomer fra hjernestamme</li>
    <li>Vaskul&aelig;r sygdom i hjernestamme</li>
    <li>Arterioven&oslash;se malformationer</li>
    <li>Tumor i hjernestamme og cerebellum</li>
    <li><a href="~/link.aspx?_id=BF43C438F520402F9003F17299AD1C05&amp;_z=z">Multipel sklerose</a>&nbsp;</li>
    <li><a href="~/link.aspx?_id=5BDEAC8142624E78B092EAF9E4A0419E&amp;_z=z">Vertebrobasil&aelig;r migr&aelig;ne</a>&nbsp;</li>
    <li>Positionel vertigo kan hos nogle skyldes vertebrobasil&aelig;r insufficiens eller dysfunktion af cervikale columna</li>
    <li>Fobisk postural vertigo
    <ul>
        <li>Normale balancetests, varer ofte kun sekunder, ledsaget af psykiske symptomer</li>
    </ul>
    </li>
</ul>
<h2>Behandling<a href="http://ugeskriftet.dk/videnskab/behandling-af-benign-paroksysmal-positionel-vertigo" data-type="other-reference" data-value="Niels West, Søren Hansen, Sune Land Bloch, Martin Nue Møller &amp; Mads Klokker. Behandling af benign paroksysmal positionel vertigo. Ugeskrift for Læger, 2017" data-url="http://ugeskriftet.dk/videnskab/behandling-af-benign-paroksysmal-positionel-vertigo" title="Niels West, Søren Hansen, Sune Land Bloch, Martin Nue Møller &amp; Mads Klokker. Behandling af benign paroksysmal positionel vertigo. Ugeskrift for Læger, 2017"><sup>2</sup></a></h2>
<h3>Behandlingsm&aring;l</h3>
<ul>
    <li>Berolige patienten</li>
    <li>Fors&oslash;g eventuelt med specielle man&oslash;vrer for at manipulere krystallerne ud af buegangen og ind i utriklen, hvor de ikke giver gener</li>
    <li>At g&oslash;re patienten symptomfri&nbsp;</li>
</ul>
<h3>Generelt om behandlingen</h3>
<ul>
    <li>Partikelreponeringsman&oslash;vrer:
    De mest anvendte er Epleys man&oslash;vre og Semonts man&oslash;vre
    <ul>
        <li>Har f&aring; kontraindikationer </li>
        <li>Behandlingen best&aring;r i, at man udnytter tyngdekraften til at manipulere otolitterne ud af buegangen og ind i utriklen, hvor de ikke vil give gener</li>
        <li>Patienten angiver ofte symptomfrihed umiddelbart efter behandlingen, og frav&aelig;r af nystagmus og vertigo kan bekr&aelig;ftes objektivt ved ny man&oslash;vre</li>
        <li>P&aring; kort sigt mere effektiv end vestibul&aelig;r rehabilitering<a href="EditorPage.aspx?da=core&amp;id=%7B1770C45B-2325-4618-A02B-68F8951F9DE7%7D&amp;ed=FIELD241673865&amp;vs&amp;la=da&amp;fld=%7B850D32D3-55A1-49E4-9CDF-F0C88D91563C%7D&amp;so=%2Fsitecore%2Fsystem%2FSettings%2FHtml%20Editor%20Profiles%2FRich%20Text%20LHPH&amp;di=0&amp;hdl=H241674020&amp;mo&amp;pe=0&amp;fbd=1" data-type="journal-reference" data-value="Wegner I, Niesten ME, van Werkhoven CH, Grolman W, Otolaryngol Head Neck Surg. 2014 May 20;151(2):201Rapid Systematic Review of the Epley Maneuver versus Vestibular Rehabilitation for Benign Paroxysmal Positional Vertigo. Otolaryngol Head Neck Surg 2014;151: 201-7" data-value-piped="Wegner I, Niesten ME, van Werkhoven CH, Grolman W|Otolaryngol Head Neck Surg. 2014 May 20;151(2):201Rapid Systematic Review of the Epley Maneuver versus Vestibular Rehabilitation for Benign Paroxysmal Positional Vertigo|Otolaryngol Head Neck Surg|2014|151|201-7" data-url="reference-link" title="Wegner I, Niesten ME, van Werkhoven CH, Grolman W, Otolaryngol Head Neck Surg. 2014 May 20;151(2):201Rapid Systematic Review of the Epley Maneuver versus Vestibular Rehabilitation for Benign Paroxysmal Positional Vertigo. Otolaryngol Head Neck Surg 2014;151: 201-7"><sup>3</sup></a></li>
    </ul>
    </li>
    <li>Stolbehandling<a href=" " data-type="journal-reference" data-value="West N, Hansen S, Møller MN, Bloch SL, Klokker M, Repositioning chairs in benign paroxysmal positional vertigo: implications and clinical outcome. Eur Arch Otorhinolaryngol 2016;273: 573-80" data-value-piped="West N, Hansen S, Møller MN, Bloch SL, Klokker M|Repositioning chairs in benign paroxysmal positional vertigo: implications and clinical outcome.|Eur Arch Otorhinolaryngol|2016|273|573-80|25749489" data-url="reference-link" data-pubmedid="25749489" title="West N, Hansen S, Møller MN, Bloch SL, Klokker M, Repositioning chairs in benign paroxysmal positional vertigo: implications and clinical outcome. Eur Arch Otorhinolaryngol 2016;273: 573-80"><sup>4</sup></a>
    <ul>
        <li>Letter diagnostik og reponerende behandling</li>
        <li>Behandling i reponeringsstol foreg&aring;r ved, at patienten fastsp&aelig;ndes i en mobil stol, der kan bev&aelig;ges i alle planer</li>
        <li>Reponeringsstolen muligg&oslash;r forskellige ekstra reponeringsmetoder, f.eks. anvendelse af impuls eller hurtige rotationer, mens patienten er fastsp&aelig;ndt</li>
        <li><a href="https://www.youtube.com/watch?v=s8vkakA2V1E">S&aring;dan foreg&aring;r behandling i reponeringsstol, se video</a></li>
        <li>I langt de fleste tilf&aelig;lde vil behandling i reponeringsstol kunne behandle patientens BPPV</li>
        <li>
        Der er ikke betydelige komplikationer til behandling i behandlingsstol, ud over hvad man kan forvente i forbindelse med andre repositionsman&oslash;verer, dvs. kvalme og svimmelhed
        </li>
        <li>
        Kontraindikationer for behandling i behandlingsstol&nbsp;er f&aring;, men kan v&aelig;re nylig apoplexi og aneurisme
        </li>
        <li>
        BPPV har en h&oslash;j recidivrate, idet omkring 30 % f&aring;r tilbagefald inden for det f&oslash;rste &aring;r.&nbsp;Fornyet behandling i behandlingsstol&nbsp;kan derfor blive n&oslash;dvendig
        </li>
    </ul>
    </li>
    <li>Information
    <ul>
        <li>Det kan i nogle tilf&aelig;lde v&aelig;re tilstr&aelig;kkeligt at forklare patienten, at tilstanden er godartet og almindeligt forekommende, og at den snart vil forsvinde</li>
        <li>En s&aring;dan passiv holdning fratager imidlertid patienten muligheden for hurtigt (umiddelbart) at blive af med symptomerne</li>
    </ul>
    </li>
    <li>Medikamenter
    <ul>
        <li>Har normalt ingen plads i behandlingen, de forkorter ikke sygdomsforl&oslash;bet, og de kan give bivirkninger</li>
    </ul>
    </li>
</ul>
<h3>H&aring;ndtering i almen praksis</h3>
<ul>
    <li>I nogle tilf&aelig;lde kan EKG v&aelig;re aktuelt</li>
</ul>
<h3>R&aring;d til patienten</h3>
<h4>Hjemme&oslash;velser</h4>
<ul>
    <li><a href="~/link.aspx?_id=A590BCE0DA28406F916A1BFCCB857B11&amp;_z=z">Hjemme&oslash;velser</a>&nbsp;kan fors&oslash;ges og er vist at v&aelig;re effektive</li>
    <li>Det anbefales, at man&oslash;vren gentages 6 gange p&aring; hver side mindst 3 gange dagligt</li>
    <li>&Oslash;velsen fremkalder forbig&aring;ende svimmelhed, og resultatet afh&aelig;nger af,&nbsp;om patienten er i stand til at tolerere dette</li>
    <li>Behandlingen b&oslash;r reserveres til patienter med manglende eller ufuldst&aelig;ndig effekt af reponering, og til at patienten evt. fors&oslash;ger det ved recidiv</li>
</ul>
<p>Hjemme&oslash;velser &aelig;ndrer ikke p&aring; tiden til evt. recidiv af anfald af BPPV, endsige neds&aelig;ttelse af anfaldsfrekvensen</p>
<h4>H&oslash;jresidig BPPV</h4>
<ol>
    <li>Sid p&aring; sengekanten, gerne s&aring; dine f&oslash;dder er i kontakt med gulvet</li>
    <li>Drej hovedet 45 grader til venstre side</li>
    <li>L&aelig;g dig hurtigt ned p&aring; din h&oslash;jre side, mens du holder hovedet i samme stilling. Hold denne stilling i 30 sekunder</li>
    <li>S&aelig;t dig op og bliv siddende i 30 sekunder</li>
    <li>Drej derefter hovedet 45 grader til h&oslash;jre. L&aelig;g dig s&aring; hurtigt ned p&aring; sengen p&aring; din venstre side. Hold stillingen i 30 sekunder</li>
    <li>Sid op og bliv siddende i 30 sekunder</li>
    <li>Gentag dette, indtil du har gennemf&oslash;rt hele &oslash;velsen flere gange</li>
</ol>
<p>Hvis det drejer sig om <strong>venstresidig </strong>BPPV, starter man med at dreje hovedet 45 grader til h&oslash;jre, hvorefter man l&aelig;gger sig p&aring; venstre side og f&oslash;lger samme procedure.<br>
<br>
Semonts man&oslash;vre er ligeledes velegnet til hjemmebehandling. Se n&aelig;ste afsnit.</p>
<h3>Reponeringsman&oslash;vrer</h3>
<h4>Epleys man&oslash;vre<a href="EditorPage.aspx?da=core&amp;id=%7B1770C45B-2325-4618-A02B-68F8951F9DE7%7D&amp;ed=FIELD1674101534&amp;vs&amp;la=da&amp;fld=%7B850D32D3-55A1-49E4-9CDF-F0C88D91563C%7D&amp;so=%2Fsitecore%2Fsystem%2FSettings%2FHtml%20Editor%20Profiles%2FRich%20Text%20LHPH&amp;di=0&amp;hdl=H1674101590&amp;us=sitecore%5Clahn&amp;mo&amp;pe=0&amp;fbd=1" data-type="book-reference" data-value="Hilton M, Pinder DK. The Epley (canalith repositoning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews: ; 2014, Issue 12. Art.No. CD003162" data-value-piped="Hilton M, Pinder DK|The Epley (canalith repositoning) manoeuvre for benign paroxysmal positional vertigo|Cochrane Database of Systematic Reviews||2014, Issue 12. Art.No. CD003162" data-url="reference-link" title="Hilton M, Pinder DK. The Epley (canalith repositoning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews: ; 2014, Issue 12. Art.No. CD003162"><sup>5</sup></a></h4>
<p>Man&oslash;vre for at fors&oslash;ge at manipulere otolitkrystallerne ud fra (bagre) buegang (<a href="http://www.youtube.com/watch?v=9SLm76jQg3g">link til video</a>):</p>
<strong>Ved <strong>h&oslash;jresidig</strong>&nbsp;BPPV</strong>
<ol>
    <li>Du starter med at sidde oprejst p&aring; lejet med hovedet drejet 45&deg; mod h&oslash;jre. Du bliver herefter hurtigt f&oslash;rt ned p&aring;&nbsp;ryggen med hovedet b&oslash;jet ca. 15&deg; bagover. Hold&nbsp;stillingen i 30 sekunder<br>
    <img src="39D5C50D444A414B8775E5FC4207FA19-480-442" style="width:480px; height:442px;" alt="Første step i Epleys manøvre. " height="442" width="480">&nbsp; &nbsp;&nbsp;</li>
    <li>L&aelig;gen drejer herefter dit hoved 90&deg; mod venstre. Hold stillingen&nbsp;i 30 sekunder<br>
    <img src="A89C912810274CF78E7158A701F2928A-480-406" style="width:480px; height:406px;" alt="Andet step i Epleys manøvre" height="406" width="480">&nbsp;</li>
    <li>Du vender dig hurtigt til venstre og ligger i sideleje&nbsp;med hovedet drejet, s&aring; n&aelig;sen peger skr&aring;t ned mod gulvet.&nbsp;Hold stillingen i 30 sekunder<br>
    <img src="B658D05B722C47FD8256118189261068-480-446" style="width:480px; height:446px;" alt="Tredje step i Epleys manøvre" height="446" width="480">&nbsp;</li>
    <li>Du s&aelig;tter dig igen i oprejst stilling, stadig&nbsp;med hovedet drejet mod venstre. Drej hovedet fremad men undg&aring; at&nbsp;hovedet b&oslash;jes bagover<br>
    <img src="83E02AF5F340429F92A560EB8EC2D9AC-471-480" style="width:471px; height:480px;" alt="Fjerde step i Epleys manøvre" height="480" width="471"></li>
    <li>Man&oslash;vren gentages en eller flere gange. Hele man&oslash;vren skal gennemf&oslash;res hver gang for at forhindre, at &oslash;restenene glider tilbage i buegangen</li>
</ol>
<h4>Ved venstresidig&nbsp;BPPV</h4>
<ol>
    <li>Patienten sidder p&aring; lejet med hovedet drejet mod venstre i 45 graders vinkel. St&oslash;t patientens hoved. L&aelig;g patienten hurtigt ned, s&aring;dan at hovedet bliver h&aelig;ngende skr&aring;t bagover udenfor lejet (fortsat vinklet 45 grader mod venstre). Hold stillingen i 30 sekunder</li>
    <li>Skift greb. Vrid hovedet hurtigt 90 grader mod h&oslash;jre. Hold stillingen i 30 sekunder</li>
    <li>Patienten ruller hurtigt over i h&oslash;jre sideleje. Vrid nu hovedet s&aring;dan, at n&aelig;sen peger mod gulvet (hovedet er drejet mod h&oslash;jre). Hold stillingen i 30 sekunder</li>
    <li>Hj&aelig;lp patienten hurtigt op i siddende stilling, fortsat med hovedet drejet mod h&oslash;jre. M&aring; ikke kigge opad</li>
    <li>Gentag proceduren, til patienten ikke l&aelig;ngere har nystagmus</li>
</ol>
<h3>Semonts man&oslash;vre</h3>
<p>Semonts man&oslash;vre<a href=" " data-type="journal-reference" data-value="Strupp M, Mandala M, Vinck AS, Van Breda L, Salerni L, Gerb J, Bayer O, Mavrodiev V, Goldschagg N, The Semont-Plus Maneuver or the Epley Maneuver in Posterior Canal Benign Paroxysmal Positional Vertigo: A Randomized Clinical Study. JAMA Neurol 2023;80: 798-804" data-value-piped="Strupp M, Mandala M, Vinck AS, Van Breda L, Salerni L, Gerb J, Bayer O, Mavrodiev V, Goldschagg N|The Semont-Plus Maneuver or the Epley Maneuver in Posterior Canal Benign Paroxysmal Positional Vertigo: A Randomized Clinical Study.|JAMA Neurol|2023|80|798-804|37358870" data-url="reference-link" data-pubmedid="37358870" title="Strupp M, Mandala M, Vinck AS, Van Breda L, Salerni L, Gerb J, Bayer O, Mavrodiev V, Goldschagg N, The Semont-Plus Maneuver or the Epley Maneuver in Posterior Canal Benign Paroxysmal Positional Vertigo: A Randomized Clinical Study. JAMA Neurol 2023;80: 798-804"><sup>6</sup></a> er en enkel procedure og et godt alternativ til Epleys man&oslash;vre.&nbsp;Man&oslash;vren involverer, at patienten hurtigt bliver f&oslash;rt fra at ligge p&aring; den ene side til at ligge p&aring; den anden.&nbsp;</p>
<ul>
    <li>Patienten placeres p&aring; kanten af lejet med benene h&aelig;ngende ud over siden</li>
    <li>Hovedet drejes hoved ca. 45 grader v&aelig;k fra den p&aring;virkede side</li>
    <li>Patienten f&oslash;res hurtigt sidel&aelig;ns til en liggende position p&aring; den p&aring;virkede side. Patienten kigger nu op mod loftet. Hvis der udl&oslash;ses svimmelhed bevares den position, indtil det g&aring;r over</li>
    <li>Der er p&aring;vist &oslash;get effekt, hvis man&oslash;vren foretages, s&aring; hovedet h&aelig;nger ud over kanten p&aring; lejet (60 grader under vandret). Det kr&aelig;ver, at samme sides arm st&oslash;tter p&aring; gulvet. Denne variation kaldes <a rel="noopener noreferrer" href="https://www.youtube.com/watch?app=desktop&amp;v=2i2aPW0iMxA&amp;ab_channel=JAMANetwork" target="_blank">Semont Plus</a></li>
    <li>Herefter f&oslash;res patienten tilbage til siddende stilling og derefter hurtigt ned til den modsatte side. Patienten kigger nu ned mod gulvet. Hvis der udl&oslash;ses svimmelhed bevares den position, indtil det g&aring;r over</li>
    <li>Herefter f&oslash;res patienten igen tilbage til siddende stilling, som b&oslash;r bevares i flere minutter</li>
</ul>
<p>Ved en vellykket&nbsp;procedure vil svimmelheden v&aelig;re forsvundet, evt. f&oslash;rst inden for en dag eller to. Hvis ikke, kan man fors&oslash;ge at gentage Semonts man&oslash;vre eller pr&oslash;ve Epleys man&oslash;vre.<br>
Semonts man&oslash;vre er s&aring; relativt enkel at udf&oslash;re og instruere i, at den er velegnet til hjemmebehandling.</p>
<h4>Manglende effekt af den valgte man&oslash;vre<a href="EditorPage.aspx?da=core&amp;id=%7B1770C45B-2325-4618-A02B-68F8951F9DE7%7D&amp;ed=FIELD241673865&amp;vs&amp;la=da&amp;fld=%7B850D32D3-55A1-49E4-9CDF-F0C88D91563C%7D&amp;so=%2Fsitecore%2Fsystem%2FSettings%2FHtml%20Editor%20Profiles%2FRich%20Text%20LHPH&amp;di=0&amp;hdl=H241674020&amp;mo&amp;pe=0&amp;fbd=1" data-type="book-reference" data-value="Hilton M, Pinder DK. The Epley (canalith repositoning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews: ; 2014, Issue 12. Art.No. CD003162" data-value-piped="Hilton M, Pinder DK|The Epley (canalith repositoning) manoeuvre for benign paroxysmal positional vertigo|Cochrane Database of Systematic Reviews||2014, Issue 12. Art.No. CD003162" data-url="reference-link" title="Hilton M, Pinder DK. The Epley (canalith repositoning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews: ; 2014, Issue 12. Art.No. CD003162"><sup>5</sup></a></h4>
<ul>
    <li>Fors&oslash;g evt. Semonts man&oslash;vre</li>
    <li>Ved manglende effekt: overvej anden lokalisering end posteriore buegang</li>
    <li>Otolitten kan ogs&aring; forsvinde, hvis patienten er i normal aktivitet</li>
    <li>Vibration mod processus mastoideus kan indg&aring; som en del af Epleys man&oslash;vre</li>
    <li>Kirurgiske procedurer er stort set forladt (lukning af syge buegang)</li>
</ul>
<h3>Medicinsk behandling</h3>
<ul>
    <li>Helt undtagelsesvist&nbsp;<a href="http://pro.medicin.dk/Laegemiddelgrupper/grupper/15030">antihistaminer</a>&nbsp;i det akutte stadie, f.eks.
    <ul>
        <li>[DliActiveSubstance;5105;Cyclizin], tbl. 50 mg: 1 tbl. indtil 3 gange daglig</li>
        <li>[DliActiveSubstance;5107;Meclozin], tbl. 25 mg: 1 tbl. 2 gange daglig
        <ul>
            <li>Obs sedation som bivirkning, forsigtighed hos &aelig;ldre</li>
        </ul>
        </li>
    </ul>
    </li>
</ul>
<h3>Andre behandlinger</h3>
<ul>
    <li>Andre behandlinger som fysioterapi/vestibul&aelig;r rehabilitering, kirurgisk behandling,&nbsp;<a href="http://pro.medicin.dk/Medicin/Indholdsstoffer/496">gentamicin</a>&nbsp;behandling, sedativer kan have effekt, men kr&aelig;ver mere langvarig behandling og er mindre effektive end reponeringsman&oslash;vrer<a href="EditorPage.aspx?da=core&amp;id=%7B1770C45B-2325-4618-A02B-68F8951F9DE7%7D&amp;ed=FIELD241673865&amp;vs&amp;la=da&amp;fld=%7B850D32D3-55A1-49E4-9CDF-F0C88D91563C%7D&amp;so=%2Fsitecore%2Fsystem%2FSettings%2FHtml%20Editor%20Profiles%2FRich%20Text%20LHPH&amp;di=0&amp;hdl=H241674020&amp;mo&amp;pe=0&amp;fbd=1" data-type="book-reference" data-value="McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews: ; 2015, Issue 1. Art. No.: CD005397" data-value-piped="McDonnell MN, Hillier SL|Vestibular rehabilitation for unilateral peripheral vestibular dysfunction|Cochrane Database of Systematic Reviews||2015, Issue 1. Art. No.: CD005397" data-url="reference-link" title="McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews: ; 2015, Issue 1. Art. No.: CD005397"><sup>7</sup></a></li>
</ul>
<h3>Kirurgi</h3>
<ul>
    <li>Kirurgi er forbeholdt de patienter, som har en invaliderende BPPV, der ikke lader sig behandle konventionelt - hvilket sj&aelig;ldent forekommer</li>
</ul>
<h3>Forebyggende behandling</h3>
<ul>
    <li>Der findes ingen forebyggende behandling</li>
</ul>
<h2>Henvisning</h2>
<ul>
    <li>Ved usikkerhed om diagnosen eller terapisvigt</li>
    <li>Ved mistanke om behandlingsrefrakt&aelig;r BPPV eller komorbiditet som forhindrer behandling henvises til &Oslash;NH-specialist eller specialafdeling</li>
    <li>Det er kun &Oslash;NH-l&aelig;ger, der&nbsp;har stillet en eksakt diagnose med lokalisation til den specifikke buegang og gennemf&oslash;rt de relevante repositionsman&oslash;vrer, der kan henvise til reponeringsstol</li>
</ul>
<h2>Opf&oslash;lgning</h2>
<h3>Plan</h3>
<ul>
    <li>Kontrol ikke n&oslash;dvendig ved typisk forl&oslash;b</li>
</ul>
<h2>Sygdomsforl&oslash;b, komplikationer og prognose</h2>
<h3>Sygdomsforl&oslash;b</h3>
<ul>
    <li>Lidelsen forsvinder oftest spontant efter nogle ugers forl&oslash;b, men kan vare i mere end et halvt &aring;r
    <ul>
        <li>En opf&oslash;lgningsunders&oslash;gelse fandt, at 84 % af ubehandlede patienter havde en negativ Dix-Hallpike man&oslash;vre efter 3 m&aring;neder</li>
        <li>En undergruppe (op til 30 %) har langvarige symptomer</li>
    </ul>
    </li>
    <li>Symptomerne vil som oftest aftage i styrke</li>
    <li>Tilstanden kan recidivere, men ofte med lange symptomfrie intervaller</li>
</ul>
<h3>Komplikationer</h3>
<ul>
    <li>Kan i sv&aelig;re tilf&aelig;lde vanskeligg&oslash;re et normalt aktivt liv. Ofte dog kun forbig&aring;ende</li>
</ul>
<h3>Prognose</h3>
<ul>
    <li>Prognosen er god, men recidiv er almindeligt<a href=" " data-type="journal-reference" data-value="Jung JY, Kim SH, Comparison between objective and subjective benign paroxysmal positional vertigo: clinical features and outcomes. Acta Otolaryngol 2016;136: 1267-1272" data-value-piped="Jung JY, Kim SH|Comparison between objective and subjective benign paroxysmal positional vertigo: clinical features and outcomes.|Acta Otolaryngol|2016|136|1267-1272|27388229" data-url="reference-link" data-pubmedid="27388229" title="Jung JY, Kim SH, Comparison between objective and subjective benign paroxysmal positional vertigo: clinical features and outcomes. Acta Otolaryngol 2016;136: 1267-1272"><sup>1</sup></a></li>
    <li>BPPV har en h&oslash;j recidivrate, idet omkring 30 % f&aring;r tilbagefald inden for det f&oslash;rste &aring;r</li>
</ul>
<h2>Baggrundsoplysninger<a href=" " data-type="book-reference" data-value="Ovesen T, Buchwald C (eds). Lærebog i øre-næse-halssygdomme og hoved-halskirurgi. København: Munksgaard; 2013" data-value-piped="Ovesen T, Buchwald C (eds)|Lærebog i øre-næse-halssygdomme og hoved-halskirurgi|København|Munksgaard|2013" data-url="reference-link" title="Ovesen T, Buchwald C (eds). Lærebog i øre-næse-halssygdomme og hoved-halskirurgi. København: Munksgaard; 2013"><sup>8</sup></a><sup>,</sup><a href="https://dsohh.dk/wp-content/uploads/2022/05/BPPV.pdf" data-type="other-reference" data-value="Klinisk retningslinie (DSOHH) for Benign paroksystisk positionel vertigo (BPPV)" data-url="https://dsohh.dk/wp-content/uploads/2022/05/BPPV.pdf" title="Klinisk retningslinie (DSOHH) for Benign paroksystisk positionel vertigo (BPPV)"><sup>9</sup></a></h2>
<h3>Definition</h3>
<ul>
    <li><strong>B</strong>enign <strong>p</strong>aroksysmal <strong>p</strong>ositions&nbsp;<strong>v</strong>ertigo forkortes BPPV og kaldes i daglig tale &oslash;restenssvimmelhed</li>
    <li>BBPV er tidligere kendt som vertigo cephalostatica </li>
    <li>BPPV er karakteriseret ved st&aelig;rk rotatorisk vertigo i anfald, som typisk varer under 1 minut. Svimmelhedsanfaldene udl&oslash;ses af hovedbev&aelig;gelser i bestemte retninger, alt efter hvor de l&oslash;se &oslash;resten er lokaliseret i vestibul&aelig;rorganet</li>
    <li>Tilstanden blev i 1952 defineret af Dix &amp; Hallpike</li>
    <li>BPPV kan i de fleste tilf&aelig;lde diagnosticeres med stillingstests, f.eks. Dix-Hallpikes test og behandles med repositionsman&oslash;vrer, hyppigst anvendt er Epleys man&oslash;vre</li>
    <li>Men hos en gruppe patienter, som har behandlingsrefrakt&aelig;r BPPV, er det n&oslash;dvendigt med behandling i en s&aring;kaldt reponeringsstol</li>
    <li>Reponeringsstolen er ogs&aring; relevant for patienter, hvor de diagnostiske tests og behandlingsman&oslash;vrer ikke kan gennemf&oslash;res pga. f.eks. h&oslash;j alder, stivhed i ryg og nakke, neuromuskul&aelig;re sygdomme, whiplash og reumatoid artritis&nbsp; &nbsp; &nbsp; &nbsp;</li>
</ul>
<h3>Forekomst</h3>
<ul>
    <li>Tilstanden er relativt almindelig </li>
    <li>Er den hyppigste vestibul&aelig;re &aring;rsag til svimmelhed hos voksne, ca. 60 % skyldes BPPV</li>
    <li>Amerikanske tal tyder p&aring;, at 20 % med symptomet "svimmelhed" (vertigo) har BPPV </li>
    <li>Pr&aelig;valens
    <ul>
        <li>Er vanskelig at m&aring;le, fordi det vil altid v&aelig;re knyttet stor usikkerhed til validiteten af diagnosen i befolkningsstudier </li>
    </ul>
    </li>
    <li>Incidens
    <ul>
        <li>11-64 per 100.000 per &aring;r</li>
    </ul>
    </li>
    <li>Alder og k&oslash;n
    <ul>
        <li>Ses i alle aldre, men pr&aelig;valensen stiger med alderen, og en del &aelig;ldre har formentlig udiagnosticeret BPPV. Ofte pga. komorbiditet, f.eks. &aring;reforkalkning, ortostatisk hypotension og almen alderdomssv&aelig;kkelse</li>
        <li>Gennemsnitsalderen for patienter der udvikler BPPV er 50-60 &aring;r</li>
    </ul>
    </li>
</ul>
<h3>&AElig;tiologi og patogenese </h3>
<ul>
    <li>BPPV er en degenerativ sygdom i det indre &oslash;re, og i de fleste tilf&aelig;lde er &aelig;tiologien ukendt </li>
    <li>Hovedtraume kan i nogle tilf&aelig;lde v&aelig;re en udl&oslash;sende faktor (otolitterne l&oslash;snes) </li>
    <li>BPPV synes at have en klar patogenese </li>
    <li>BPPV rammer oftest ensidigt, flere buegange kan v&aelig;re involveret</li>
</ul>
<h4>Patogenesen ved BPPV </h4>
<ul>
    <li>Der opereres med to patogenetiske mekanismer for udvikling af BPPV, henholdsvis canalolithiasis og cupulolithiasis</li>
    <li>Canalolithiasis
    <ul>
        <li>Der er i dag udbredt enighed om, at tilstanden skyldes l&oslash;se partikler (otolitter) i endolymfen i det indre &oslash;re - canalolithiasis </li>
        <li>Normalt skal der ikke v&aelig;re otolitter i buegangene, men ved canalolithiasis har otolitter sandsynligvis l&oslash;snet sig fra macula utriculi </li>
        <li>Otolitter er anorganiske partikler med h&oslash;jere massefylde end endolymfen, og disse tunge partikler vil pga. tyngdekraften befinde sig i den del af buegangen, som til enhver tid er nederst&nbsp;</li>
        <li>Den ramte buegang er n&aelig;sten altid den bagre</li>
        <li>Ved bestemte hovedbev&aelig;gelser vil otolitterne flytte sig gennem en stor del af buegangens l&aelig;ngde, betinget af tyngdekraften</li>
        <li>Hvis rumfanget af partiklerne er stort nok, vil den v&aelig;skestr&oslash;mning dette for&aring;rsager i endolymfen, v&aelig;re tilstr&aelig;kkelig til at afb&oslash;je cupula. Cupula er d&aelig;kket&nbsp; af h&aring;rceller, som - n&aring;r de afb&oslash;jes - stimulerer de neuroner, der innerverer dem og derved fremkaldes en kortvarig, kraftig vertigo og nystagmus </li>
    </ul>
    </li>
    <li>Cupulolithiasis
    <ul>
        <li>Denne teori bygger p&aring;, at otolitter eller henfaldne dele af disse bliver adh&aelig;rente til cupula </li>
        <li>Ved tyngdekraftens p&aring;virkning fejlstilles en tung(ere) otolitbelastet cupula, hvilket medf&oslash;rer en bev&aelig;gelsesillusion </li>
    </ul>
    </li>
</ul>
<h3>Disponerende faktorer </h3>
<ul>
    <li>Hovedtraume </li>
    <li>Andre kendte sygdomme i det indre &oslash;re, som neuritis vestibularis, labyrintitis og Meni&egrave;res sygdom, kan udl&oslash;se BPPV i det samsidige &oslash;re </li>
</ul>
<h3>ICPC-2 </h3>
<p>[ICPC] </p>
<h3>ICD-10/SKS-koder</h3>
<p>[ICD10]</p>
<h2>Patientinformation&nbsp;</h2>
<h3>Hvad du b&oslash;r informere patienten om</h3>
<ul>
    <li>Mulige forklaringer</li>
    <li>Om tilstandens gode prognose</li>
</ul>
<h3>Hvad findes af skriftlig patientinformation</h3>
<ul>
    <li><a href="~/link.aspx?_id=A590BCE0DA28406F916A1BFCCB857B11&amp;_z=z">Information om procedure for egenterapi</a></li>
    <li><a href="~/link.aspx?_id=3DC03F65F95C4EF48ADAFCD2495943F9&amp;_z=z">Information om benign positionel vertigo</a>&nbsp;</li>
</ul>
<h2>Link til vejledninger</h2>
<ul>
    <li>Forl&oslash;bsbeskrivelser og regionale pakkeforl&oslash;b [ICPC]</li>
</ul>
<h2>Illustrationer</h2>
<h3>Plancher eller tegninger </h3>
<ul>
    <li>
    <a href="~/link.aspx?_id=0C799813EF25401CB0E89022155CC115&amp;_z=z">&Oslash;re og buegange </a>
    </li>
    <li>
    <a href="~/link.aspx?_id=B82AC7A009144C7B8D73C7C943E2742A&amp;_z=z">Buegange og balancenerve </a>
    </li>
    <li>
    <a href="~/link.aspx?_id=5C5DF217C65042ED805DFB111A9A880E&amp;_z=z">Cochlea og vestibulum </a>
    </li>
</ul>
<h3>Video </h3>
<ul>
    <li>
    <a href="~/link.aspx?_id=B1DDBD96062D49B09A9A21E7926EDFD8&amp;_z=z">Demonstration af Dix-Hallpikes diagnostisk man&oslash;vre </a>
    </li>
    <li>
    <a href="~/link.aspx?_id=FBF00079A64448CA858C51E51033614E&amp;_z=z">Demonstration af egenbehandling</a></li>
</ul>]]></HtmlField>
      <HtmlField Name="Resume"><![CDATA[<h2>Resum&eacute;</h2>
<h3>Diagnose</h3>
<ul>
    <li>Typisk anamnese</li>
    <li>Fremkaldelse af svimmelhed og karakteristisk nystagmus ved stillingstest (Dix-Hallpikes test)</li>
    <li>Testen er positiv i den side hovedet er drejet mod, hvis der udl&oslash;ses vertigo og nystagmus mod det nederste &oslash;re</li>
</ul>
<h3>Behandling</h3>
<ul>
    <li>Reponeringsman&oslash;vrer; Epleys man&oslash;vre og Semonts man&oslash;vre</li>
    <li>Instruktion i hjemme&oslash;velser ved manglende effekt&nbsp;</li>
    <li>Information om at tilstanden i sig selv er ufarlig og har en god prognose</li>
</ul>
<h3>Henvisning</h3>
<ul>
    <li>Ved manglende erfaring i reponeringsman&oslash;vrer</li>
    <li>Ved usikkerhed om diagnosen eller terapisvigt</li>
    <li>Ved behandlingsrefrakt&aelig;r BPPV eller komorbiditet som forhindrer behandling henvises til &Oslash;NH-specialist</li>
    <li>Kun &Oslash;NH-l&aelig;ger kan henvise til behandling i reponeringsstol</li>
</ul>
<h2>Seneste v&aelig;sentlige &aelig;ndringer</h2>
<ul>
    <li>Der forskes i den molekyl&aelig;re basis for BPPV herunder oxidativt stress og immunreaktioner, som kan f&oslash;re til en mere nuanceret opfattelse af BPPV og m&aring;ske personaliserede behandlingsmuligheder&nbsp;</li>
</ul>]]></HtmlField>
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      <TextField Name="MetaKeywords">anfaldsvis vertigo, benign paroksystisk positionel vertigo, bppv, canalolithiasis (otolitter i utriculus), dix-halpike, epley manøvre, paroksysmatisk vertigo, positionsvertigo, stillingsvertigo</TextField>
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