The necessity of post-maneuver postural restriction in treating benign paroxysmal positional vertigo: a meta-analytic study

The objective of this article is to verify the role of postural restrictions after repositioning maneuvers in treating patients with benign paroxysmal positional vertigo (BPPV). The study included published articles yielded by a Pubmed search concerning post-maneuver postural restriction in treating BPPV. The search was limited to articles published in English language in the last three decades. The search was done on 1/11/2011. For the 18 relevant articles, we applied our inclusion and exclusion criteria and only 9 articles were included. The data collected from each article were statistically analyzed utilizing meta-analytic Review Manager (RevMan 5.1) software. (Version: 5.1.0.0). There were no significant differences between patients instructed with postural restriction after undergoing repositioning maneuver and patients left free to move after undergoing repositioning maneuver with regard to the presence or absence of post-maneuver symptoms. In conclusion, post-maneuver restrictions do not add to the success of the treatment of BPPV and there is no reason to submit patients to these impractical instructions.

Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV)

BACKGROUND

Benign paroxsymal positional vertigo (BPPV) is a syndrome characterised by short-lived episodes of vertigo associated with rapid changes in head position. It is a common cause of vertigo presenting to primary care and specialist otolaryngology (ENT) clinics. BPPV of the posterior canal is a specific type of BPPV for which the Epley (canalith repositioning) manoeuvre is a verified treatment. A range of modifications of the Epley manoeuvre are used in clinical practice, including post-Epley vestibular exercises and post-Epley postural restrictions.

OBJECTIVES

To assess whether the various modifications of the Epley manoeuvre for posterior canal BPPV enhance its efficacy in clinical practice.

SEARCH METHODS

We searched the Cochrane ENT Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 15 December 2011.

SELECTION CRITERIA

Randomised controlled trials of modifications of the Epley manoeuvre versus a standard Epley manoeuvre as a control in adults with posterior canal BPPV diagnosed with a positive Dix-Hallpike test. Specific modifications sought were: application of vibration/oscillation to the mastoid region, vestibular rehabilitation exercises, additional steps in the Epley manoeuvre and post-treatment instructions relating to movement restriction.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies from the search results and the third author reviewed and resolved any disagreement. Two authors independently extracted data from the studies using standardised data forms. All authors independently assessed the trials for risk of bias.

MAIN RESULTS

The review includes 11 trials involving 855 participants. A total of nine studies used post-Epley postural restrictions as their modification of the Epley manoeuvre. There was no evidence of a difference in the results for post-treatment vertigo intensity or subjective assessment of improvement in individual or pooled data. All nine trials included the conversion of a positive to a negative Dix-Hallpike test as an outcome measure. Pooled data identified a significant difference from the addition of postural restrictions in the frequency of Dix-Hallpike conversion when compared to the Epley manoeuvre alone. In the experimental group 88.7% (220 out of 248) patients versus 78.2% (219 out of 280) in the control group converted from a positive to negative Dix-Hallpike test (risk ratio (RR) 1.13, 95% confidence interval (CI) 1.05 to 1.22, P = 0.002). No serious adverse effects were reported, however three studies reported minor complications such as neck stiffness, horizontal BPPV, dizziness and disequilibrium in some patients.There was no evidence of benefit of mastoid oscillation applied during the Epley manoeuvre, or of additional steps in the Epley manoeuvre. No adverse effects were reported.

AUTHORS' CONCLUSIONS

There is evidence supporting a statistically significant effect of post-Epley postural restrictions in comparison to the Epley manoeuvre alone. However, it important to note that this statistically significant effect only highlights a small improvement in treatment efficacy. An Epley manoeuvre alone is effective in just under 80% of patients with typical BPPV. The additional intervention of postural restrictions has a number needed to treat (NNT) of 10. The addition of postural restrictions does not expose the majority of patients to risk of harm, does not pose a major inconvenience, and can be routinely discussed and advised. Specific patients who experience discomfort due to wearing a cervical collar and inconvenience in sleeping upright may be treated with the Epley manoeuvre alone and still expect to be cured in most instances.There is insufficient evidence to support the routine application of mastoid oscillation during the Epley manoeuvre, or additional steps in an 'augmented' Epley manoeuvre. Neither treatment is associated with adverse outcomes. Further studies should employ a rigorous randomisation technique, blinded outcome assessment, a post-treatment Dix-Hallpike test as an outcome measure and longer-term follow-up of patients.

Anxiolytics reduce residual dizziness after successful canalith repositioning maneuvers in benign paroxysmal positional vertigo

CONCLUSIONS

This study suggests that adjuvant anti-anxiety medication may be helpful for patients with benign paroxysmal positional vertigo (BPPV) even after a successful canalith repositioning procedure (CRP).

OBJECTIVE

Although the CRP is an effective treatment for BPPV, many patients suffer from persistent dizziness despite successful CRPs. The aim of this study was to evaluate the effect of adjuvant anxiolytic medication on residual dizziness after successful CRP.

METHODS

Between January 2011 and March 2011, 73 patients were diagnosed with BPPV and they underwent successful treatment with CRPs. The patients were randomly assigned to either the medication group or the control group. The patients in the medication group were prescribed low dose etizolam for 2 weeks whereas the patients in the control group were not prescribed any medication. All patients were scheduled to return 2 weeks after evaluation of subjective visual vertical. Subjective symptoms before and after CRP were measured using the Dizziness Handicap Inventory (DHI) and the Activities-specific Balance Confidence (ABC) scale.

RESULTS

Both groups demonstrated a significant improvement in DHI scores. However, the medication group showed significantly greater decrease in the functional (p = 0.018) and emotional (p = 0.030) subscale scores, as well as in the total DHI (p = 0.038) score.

[Non-specific exercise therapy for benign paroxysmal postural vertigo]

We treated 1145 patients diagnosed as having benign paroxysmal postural vertigo at the Toho University Medical Center Sakura Hospital from August 2007 to July 2009 by the exercise therapy developed by us. The most advantageous characteristic of our method is that patients can perform the exercises themselves at their own pace in their homes, even if the affected side cannot be identified and/or the patients have any orthopedic cervical and/or spinal problems. In 80.7% and 91.7% of the patients in our case series, the vertigo was no longer present at one and three months, respectively. In addition, the vertigo disappeared within two weeks in the patients who were examined within one week of the start of the symptom. The longer the period between the onset of vertigo and the hospital visit, the longer the period needed for control of the symptom.

Etiology of vertigo in Thai patients at Thammasat Hospital

The purpose of this research is to study the causes of vertigo in the patients at Otoneurology Clinic, Thammasat Hospital. The data of these patients, collected from the medical records between January 2010 and January 2011, were reviewed and analyzed. From one hundred and forty-nine cases, 49 cases (33%) were men and 100 cases (67%) were women, which yielded the male-to-female ratio of 1:2. The average age of patients was 55 year olds. The most common diagnostic category was peripheral vestibular disorders (80.5%). Other causes were central vestibular disorders (4.7%) and non-vestibular related (4%), whereas the remaining (10.1%) was undiagnosed. The causes of vertigo included benign paroxysmal positional vertigo: BPPV (53%), Meniere's disease (10.1%) and recurrent vestibulopathy (8.1%), while the underlying diseases found were diabetes mellitus (11.4%), hypertension (32.2%) and dyslipidemia (34.2%). In Otoneurology Clinic, Thammasat Hospital, the peripheral vestibular disorders was the main etiology of vertigo, while the three most common causes were BPPV Meniere's disease, and recurrent vestibulopathy respectively.

Intermittent pressure therapy of intractable Meniere's disease and delayed endolymphatic hydrops using the transtympanic membrane massage device: a preliminary report

CONCLUSION

Middle ear pressure treatment by the tympanic membrane massage (TMM) device as well as the Meniett device is effective and provides minimally invasive options for intractable vertigo in patients with Meniere's disease (MD) and delayed endolymphatic hydrops (DEH).

OBJECTIVE

The effects of the TMM device were evaluated according to the criteria of the Japan Society for Equilibrium Research (1995) in patients with MD and DEH and compared to those in patients treated with the Meniett device.

METHODS

Twelve ears of 10 patients (MD 8; DEH 2) were treated with the TMM device, while 16 ears of 15 patients (MD 11; DEH 4) were treated with the Meniett device. All the patients had failed to respond to medical treatment including diuretics before each pressure treatment, and were followed up for more than 12 months after treatment. Tympanotomy is necessary before treatment for the Meniett device, not but for the TMM device.

RESULTS

With both devices, the frequency of vertigo after treatment was significantly lower than before treatment (p < 0.05). The time course of vestibular symptoms with the TMM device was not significantly different from that with the Meniett device (p > 0.05). No complications were directly attributable to treatment with the TMM device.

[An oto-neurological approach to the acutely dizzy patient]

Benign paroxysmal positional vertigo, vestibular neuronitis and Menière's disease cause most cases of acute vertigo. However, doctors must consider central neurological reasons to vertigo. If it is determined that a patient has oto-neurological vertigo, the next task is to determine whether the patient has a peripheral or a central cause of vertigo, if the condition is potentially lethal and if there is a need for acute radiological imaging and/or medical intervention. This review highlights the oto-neurological approach to the dizzy patient with particular focus on the patient's history, clinical tests and treatment.

[Individual management of Meniere's disease and evaluation of functional outcome]

OBJECTIVE

To investigate individual management for Meniere's disease and analyze outcomes of nonsurgical and surgical management of Meniere's disease.

METHOD

Patients with Meniere's disease were staged according to hearing and quality of life. The individual management according to the staging was established, including outpatient treatment (lifestyle change, medical management and intratympanic steroids), endolymphatic sac decompression or drainage, vestibular neurectomy and labyrinthectomy. The characteristics of patients who underwent surgical management were analyzed. The functional outcomes of surgery in dizziness, hearing loss and quality of life were evaluated for 12-month postoperative follow-up.

RESULT

Twenty patients underwent intratympanic injection of dexamethasone. Dizziness improved in 70% (14/20), tinnitus improved in 41% (7/17), and aural fullness improved in 36% (4/11). There were 55 patients who underwent surgical managements for 57 times. Endolymphatic sac decompression or drainage was carried out in 27 patients for 28 times, vestibular neurectomy in 26 patients and labyrinthectomy in 3 patients. Vertigo control rate was 75% in patients with endolymphatic sac decompression or drainage, 100% in vestibular neurectomy and 100% in labyrinthectomy at 12-month postoperative follow-up.

CONCLUSION

The non-surgical management and endolymphatic sac decompression or drainage can improve vertigo and ameliorate quality of life. Vestibular neurectomy and labyrinthectomy are effective surgical managements to eliminate vertigo. The management of Meniere's disease depends on several factors: stages of vertigo and hearing, quality of life, surgical contraindications and subjective desire. Therefore, the management for Menieres disease must be individualized for each patient.

[A pre- and post-treatment study of quality of life in patients with benign paroxysmal positional vertigo]

OBJECTIVE

To explore the effect of canalith repositioning procedure (CRP) on the quality of life (QOL) in patients with benign paroxysmal positional vertigo(BPPV).

METHOD

The clinical data of 86 patients with BPPV (treatment group) and 120 normal ones (control group) were reviewed through the medical outcomes study short form (SF-36)and the dizziness handicap inventory (DHI), and the results of two groups were analyzed.

RESULT

With SF-36 scales for evaluation of QOL, the results showed that the scores of treatment group before CRP were significantly lower than that of the control group (P < 0.05). While using of DHI scales in evaluation of the treatment group patients before CRP, the results were significantly higher than that of the control group (P < 0.05). After CRP for 3 months, not only with SF-36 scales but also with DHI scales, there were no significant difference between the two groups (P > 0.05).

CONCLUSION

CRP may obviously improve the clinical symptom of BPPV patients. The SF-36 and DHI scales could reflect the change of BPPV patient's QOL.

[Clinical application of bloodletting method on the face]

The clinical practice of bloodletting method on the face is introduced in this paper through 4 medical cases: post-operative periarthritis of the shoulder in lung cancer, dizziness and vertigo, protrusion of lumbar intervertebral disc and keratitis. It is believed that the change in facial luster, vein condition on the face, the site with the most obvious change in facial luster and local skin abnormality are commonly regarded as the reaction points or areas of facial disease. According to the reaction points or areas on the face and in association with the syndrome differentiation in Lingshu: Wuse (Miraculous Pivot : Five Colors), the acupoints are selected and stimulated with bloodletting method in the treatment of some difficult and complicated cases, and the good efficacy could be obtained. But, this therapeutic method needs a further research and deserves to be promoted in practice.

[Penetrating needling on head points for vertigo caused by vertebral-basilar arterial blood-supply insufficiency]

OBJECTIVE

To observe the differences in therapeutic effect between penetrating needling on head points and acupuncture of syndrome division in the treatment of vertigo caused by vertebral-basilar arterial blood-supply insufficiency.

METHODS

Sixty cases of vertigo caused by vertebral-basilar arterial blood-supply insufficiency were divided into 2 groups: a penetrating needling on head points group (group A) and an acupuncture of syndrome division group (group B), 30 cases in each one. In group A, penetrating needling technique was applied from Baihui (GV 20) towards Qianding (GV 21), Shuaigu (GB 8) towards Qubin (GB 7) and Yuzhen (BL 9) towards Tianzhu (BL 10). Electric stimulation was added. In group B, the acupoints were selected according to syndromes. For example, upper disturbance of wind yang: Ganshu (BL 18), Xingjian (LR 2),etc. were selected; upper disturbance of turbid phlegm: Yinlingquan (SP 9), Fenglong (ST 40), etc. were selected; qi and blood deficiency: Baihui (GV 20), Xuehai (SP 10), etc. were selected; liver and kidney yin deficiency: Ganshu (BL 18), Shenshu (BL 23), etc. were selected. Electric stimulation and needling manipulation were conducted on those acupoints. Ten treatments made one session. After continuous 2 sessions of treatment, the efficacy, symptom score and physical sign score were compared between two groups. Transcranial Doppler (TCD) examination was done to observe hemodynamic changes of anterior cerebral artery (ACA), middle cerebral artery (MCA) and posterior cerebral artery (PCA) before and after treatment.

RESULTS

The total effective rate in group A was 96.7% (29/30) that was obviously better than 83.3% (25/30) in group B (P<0.05). The scores of vertigo degree, vertigo frequency, duration and accompanied symptoms after treatment were lower obviously as compared with those before treatment in two groups (all P<0.05). The improvements in group A were much significant (all P<0.05). The highest mean velocity(Vm) of bilateral MCA, ACA and PCA were apparently reduced after treatment in two groups (P< 0.05, P<0.01). The improvements in group A were much more apparently (all P<0.05).

CONCLUSION

The penetrating needling on head points can effectively relieve vertigo caused by vertebral-basilar arterial blood-supply insufficiency, reduce the attack frequency and improve in its accompanied symptoms. Its clinical efficacy is significantly superior to that in acupuncture of syndrome division group.

[Observation of therapeutic effects on cervical vertigo treated with different methods]

OBJECTIVE

To compare the therapeutic effects of routine acupuncture, the electroacupuncture and the combined therapy of electroacupuncture and acupoint injection.

METHODS

Ninety-one cases were randomly divided into a routine acupuncture group (30 cases), an electroacupuncture group (31 cases), and a combined therapy of electroacupuncture and acupoint injection group (30 cases). Zusanli (ST 36), Fengchi (GB 20), Anmian (Extra), Taiyang (EX-HN 5), Hegu (LI 4), Yintang (EX-HN 3), Baihui (GV 20) and Sishengcong (EX-HN 1) were selected among 3 groups. Even manipulation was applied in routine acupuncture group; G 6805 electroacupuncture apparatus was added in electroacupuncture group; in combined therapy of electroacupuncture and acupoint injection group, electroacupuncture was applied, besides, Vitamin B12 0.5 mg and 0.2%/ Lidocaine 2 mL were injected at Fengchi (GB 20) and Anmian (Extra). Twenty treatments were given in 4 weeks. The changes of average blood flow of vertebral artery and basilar artery before and after treatment were observed and graded by the cervical vertigo syndrome and function score; the therapeutic effects were evaluated as well.

RESULTS

The average blood flow of vertebral artery and basilar artery, and the cervical vertigo syndrome and function score were improved in 3 groups (all P < 0.01), in which, it was more obvious in combined therapy of electroacupuncture and acupoint injection group than in others (P < 0.05, P < 0.01), and it in electroacupuncture group was superior to that in routine acupuncture group (P < 0.05). The effective rate was 63.3% (19/30) in routine acupuncture group, 80.6% (25/31) in electroacupuncture group and 90.3% (28/30) in combined therapy of electroacupuncture and acupoint injection group, indicating the significant differences among them (P < 0.05, P < 0.01).

CONCLUSION

The routine acupuncture, electroacupuncture, and combined therapy of electroacupuncture and acupoint injection are effective for cervical vertigo; the combined therapy is the best, and electroacupuncture comes second. It illustrates that the routine acupuncture, electroacupuncture, and combined therapy of electroacupuncture and acupoint injection have additive effects on treatment of cervical vertigo.

Clinical characteristics of positional vertigo after mild head trauma

CONCLUSION

This study showed that a population with benign paroxysmal positional vertigo related to mild head trauma (BPPVAT) was younger and more frequently presented with bilateral canalithiasis than another population with idiopathic etiology (IBPPV). In both groups, females presented a higher risk of BPPV.

OBJECTIVE

To compare the clinical features of a population with BPPVAT and another with IBBPV.

METHODS

We carried out statistical analysis of a population of 51 subjects with BPPVAT and another of 325 subjects with IBPPV, comparing age, gender, recurrence of symptoms, associated chronic dizziness (CD), and clinical presentation. Kolmogorov Smirnov test, Student's t test, Mann-Whitney test, 95% binomial confidence interval for proportions, chi-squared, and Fisher's test were used as statistical tools. A significance level of p < 0.05 was considered in all cases.

RESULTS

The population affected with BPPVAT was younger and bilateral canalithiasis was also more frequent. No differences were found in gender distribution, semicircular canals involved in the symptoms, recurrence after repositioning maneuvers, or associated CD.

ENT morbidity at high altitude

BACKGROUND

People suffer unique health problems in high altitude areas, due to such factors as elevation, aircraft ascent and descent, extreme cold, hypoxia, hypobaria, and low relative humidity. This study was conducted to evaluate ENT morbidity at high altitude.

METHODS

Serving soldiers introduced to a high altitude environment who presented with various ENT symptoms were examined to identify ENT disease. In addition, patients undergoing hyperbaric chamber therapy, tracheostomy and treatment of cold injuries were also examined for ENT problems.

RESULTS

The following were detected: 13 cases of otic barotrauma, 11 cases of sinus barotrauma, three cases of vertigo, six cases of pinna frostbite, three cases of barotrauma caused by hyperbaric chamber therapy, an unusually high incidence of epistaxis, and innumerable patients with high altitude pharyngitis.

CONCLUSION

Diseases of the ear, nose and throat contribute significantly to high altitude morbidity. In a military context, health education of troops is necessary to avoid such problems.

Effect of the canalith repositioning procedure on subjective visual horizontal in patients with posterior canal benign paroxysmal positional vertigo

CONCLUSION

Substantial numbers of patients with posterior canal benign paroxysmal positional vertigo (p-BPPV) have signs of utricular dysfunction at baseline. This improves after performing the canalith repositioning procedure.

OBJECTIVE

To evaluate the changes of subjective visual horizontal (SVH) in patients with p-BPPV before and after treatment with the canalith repositioning procedure.

METHODS

Twenty-six patients with p-BPPV were treated with the canalith repositioning procedure, Epley's maneuver, according to the affected side. Baseline SVH measurements were taken before performing the Dix-Hallpike maneuver and Epley's maneuver, for comparison with measurements taken just after Epley's maneuver, and 2 weeks after Epley's maneuver.

RESULTS

Among 26 patients with p-BPPV, 11 (42%) showed abnormal deviation of SVH at baseline. Just after performing Epley's maneuver, the number of patients who showed an abnormal deviation of SVH decreased significantly to 15% (4 of 26 patients; p < 0.05). Two weeks after performing Epley's maneuver, only two patients (8%) showed an abnormal deviation of SVH (p < 0.001).

Unsteadiness and drunkenness sensations as a new sub-type of BPPV

AIM

Benign Paroxysmal Positional Vertigo (BPPV) represents at least 35% of vertigo cases and perhaps much more. The aim of this study was to review a proposed new type of BPPV which may be detected by using a mechanical assistance in BPPV diagnostic and therapeutic maneuvers. MATERIELS AND METHODS: The prospective study extracted subjects from 465 patients who presented with some positional vertigo or unsteadiness. Only 152 dizzy patients, who presented with positional nystagmus but no true vertigo, were included. The TRV armchair permits rotation of patients wearing infrared video goggles in all semi-circular planes. Treatment effectiveness was defined as absence of symptoms or findings 3 days after the therapy sessions. If not initially successful, repeat therapeutic sessions were performed or patients underwent further vestibular examination and sometime MRI.

RESULTS

One hundred nine of the 152 patients demonstrated a low level canalithiasis showing nystagmus. Unusual data were collected: Ninety seven had a lateral canal and 12 had posterior canal conditions. The average of the patients was 62 and they had an average of 1.6 mechanical therapeutic maneuvres to reach the success end-point.

CONCLUSION

Some patients have persistent unsteadiness or drunkenness sensations after being treated by conventional maneuvers for BPPV. Often considered a post-BPPV otolithic syndrome an alternative possibility is BPPV with a very few otoliths in the lateral canal. The therapeutic technique using the mechanical chair permits to improved diagnosis of canalithiasis, especially that involving the horizontal canals. Some mild dizziness, which may be disabling and chronic can be better investigated and treated with mechanical assistance.

Benign paroxysmal positional vertigo: diagnosis and treatment

Benign paroxysmal positional vertigo is a common disorder in Neurotology. This vestibular syndrome is characterized by transient attacks of vertigo, caused by change in head position, and associated with paroxysmal characteristic nystagmus. The symptoms result from movement of the free floating otoconia particles in the endolymph or their attachment to the cupulae of the semicircular canal. The diagnosis is essentially clinical and should be confirmed by performing diagnostic maneuvers. Treatment is based on the identification of the affected semicircular canal and performance of liberatory maneuvers or repositioning of free floating particles of otoliths. The effectiveness varies from 70 to 100%.

Early management of hearing and balance disorders: a review of literature and a proposal to overcome possible uncertainties

The lack of a correct diagnostic and therapeutic planning of vestibular diseases is still often observed, and some difficulties are still to deal with in clinical practice, even when treating acute hearing problems, although the needed competence is more easily identified as otologic. A review of the international literature confirms the existence of such a problem, and permits to underline the scarcity of connections between otology and neurotology, on one hand, and principles of basic sciences and general and internal medicine, on the other hand: this can explain some therapeutic contradictions in treating inner ear disorders, their frequent labelling as idiopathic and the persisting uncertainties concerning a correct diagnostic and therapeutic management. In order to overcome the difficulties deriving to insufficient interdisciplinary cooperation, the institution of hospital audiovestibular services with a strictly linked net of cooperation with internal medicine units could represent a progress. This could help prevent clinically and economically inadequate management, contributing to minimize the possibility of expensive and/or health-threatening mistakes; moreover, it could represent an example to easily improve the practical aspects of both pre graduate and postgraduate curricula, and to form more open-minded clinicians, starting both from an ear. Nose and throat (ENT)/audiological and from an Internal Medicine extraction.

Benign paroxysmal positional vertigo after decompression sickness: a first case report and review of the literature

Benign paroxysmal positional vertigo is a common cause of vertigo. We describe a previously unreported case of this clinical entity in a young, fit recreational water diver, having experienced decompression illness. Full recovery occurred after hyperbaric recompression therapy, and he remained symptom free on 6-week follow-up. We review the literature and discuss the pathogenesis of benign paroxysmal positional vertigo, proposing that semicircular canal nitrogen bubble formation could have been the primary etiological event leading to this condition.

Clinical study of vertigo in the outpatient clinic of Kyoto University Hospital

CONCLUSION

The epidemiology of vertigo remains unclear. This study might contribute to an understanding of the mechanisms underlying vestibular disease.

OBJECTIVE

To investigate the epidemiological features of patients with vertigo.

METHODS

A retrospective study on 612 patients with vertigo who visited Kyoto University Hospital.

RESULTS

Elderly individuals comprised > 30% of patients presenting with vertigo, with more female patients than male patients.

Clinical and epidemiological study on inpatients with vertigo at the ENT Department of Kyoto University Hospital

CONCLUSION

The number of studies on inpatients with vertigo is limited. This study provides useful information for clarifying the underlying causes of vertigo.

OBJECTIVE

To investigate the epidemiological features of patients with vertigo.

METHODS

This retrospective study investigated 78 patients who had been emergently hospitalized in the Otolaryngology Department of Kyoto University Hospital with vertigo.

RESULTS

The number of female patients was significantly higher than the number of male patients. Meniere's disease was the most common underlying pathology among hospitalized patients. Mean patient age was 56.1 years, with no significant difference between male and female patients.

Effect of Epley's maneuver on the quality of life of paroxismal positional benign vertigo patients

Quality of life (QoL) is significantly impaired by vertigo. The effect of specific treatments on QoL deserves investigation.

AIM

To assess the effect of repositioning maneuvers on the QoL of benign paroxysmal positioning vertigo (BPPV) patients.

MATERIALS AND METHODS

A retrospective study design consiting of reviews of charts of BPPV patients in a vestibular rehabilitation unit at a teaching institution in Belo Horizonte, MG, Brazil, from 2007 to 2008. Pre- and post-therapy (Epley's repositioning maneuver) scores on the physical, functional and emotional dimensions of the Dizziness Handicap Inventory (DHI) were analyzed.

RESULTS

Twenty-one patients were included, eighteen (86%) were females; the average age was 53.2 years. Ten patients presented bilateral BPPV; in eleven it was unilateral. The mean interval between assessments (pre- and post-treatment) was 21 days. The average number of required maneuvers was 2.3 (±1.1). Pre-treatment DHI results showed a significant impact of BPPV on quality of life. Initial scores for physical (17.5), functional (17.3), emotional (13.2) dimensions decreased with therapy: respectively 3.7, 3.9, and 3.2 (p<0.001).

CONCLUSION

In the present sample, Epley's maneuver had a positive and significant effect on emotional, physical and functional dimensions of quality of life, as measured by the DHI scores before and after therapy.

Management of benign paroxysmal positional vertigo with the canalith repositioning maneuver in the emergency department setting

Vertigo is a common clinical manifestation in the emergency department (ED). It is important for physicians to determine if the peripheral cause of vertigo is benign paroxysmal positional vertigo (BPPV), a disorder accounting for 20% of all vertigo cases. However, the Dix-Hallpike test--the standard for BPPV diagnosis--is not common in the ED setting. If no central origin of the vertigo is determined, patients in the ED are typically treated with benzodiazepine, antihistamine, or anticholinergic agents. Studies have shown that these pharmaceutical treatment options may not be the best for patients with BPPV. The authors describe a case of a 38-year-old woman who presented to the ED with complaints of severe, sudden-onset vertigo. The patient's BPPV was diagnosed by means of a Dix-Hallpike test and the patient was acutely treated in the ED with physical therapy using the canalith repositioning maneuver.

Autonomic related vertigo

OBJECTIVES

To demonstrate clinical evidence that vestibular symptomatology can occur in relation to autonomic dysfunction. Characterization of clinical findings and treatment response would then allow autonomic related vertigo to be differentiated from other vertiginous conditions that present in a like manner.

STUDY DESIGN

This was a retrospective review of 113 patients that described symptoms consistent with spontaneous, rotational vertigo and autonomic dysfunction.

METHODS

Vestibular, otologic, and autonomic symptoms are presented along with the results of audiologic, orthostatic, and autonomic testing. Medical management included fluid loading, dietary changes, exercise, and patient education. Treatment results were analyzed according to the effectiveness in control of vestibular and otologic symptoms. Results were compared with a control group that demonstrated a similar vestibular and otologic presentation without autonomic symptomatology.

RESULTS

All patients described spontaneous, rotational vertigo, with complete or substantial vertigo control obtained in 93 (85%) of 110 patients. Postural vertigo and distinct lightheadedness were also documented in 53% and 97% of cases, respectively. Vertigo failed to improve or worsened with prior treatment of low sodium diet or diuretic in 53 (91%) of 58 cases. Vertigo improvement was subsequently achieved in 48 (86%) of 56 cases with an autonomic treatment regimen. Long-term vertigo control was obtained in 56 (88%) of 64 patients followed for at least 18 months. Tinnitus was reported in 97 (86%) patients, aural fullness in 93 (82%) patients, and subjective hearing loss (HL) in 46 (41%) of 111 cases. Bilateral tinnitus and aural fullness occurred in 65% and 63%, respectively. Tinnitus improved with treatment in 56 (67%) of 84 patients, whereas aural fullness improved in 59 (74%) of 80 patients. Autonomic symptoms included palpitations in 103 (91%) patients, chronic fatigue in 102 (90%) patients, cold extremities in 91 (81%) patients, and previous fainting in 72 (64%) patients. A history of mitral valve prolapse was documented in 51 (45%) of cases and demonstrated with echocardiogram in 68 (93%) of the 73 patients tested. Audiologic testing was normal in 104 (95%) of 109 patients, and electrocochleography was abnormal in 42 (40%) of 105 patients. Orthostatic blood pressure and heart rate testing met the criteria for orthostatic hypotension in 16 (15%) of 104 patients. Autonomic testing was obtained in 34 cases, with orthostatic intolerance demonstrated in 33 (97%) patients and orthostatic hypotension demonstrated in 13 (38%) patients. Overall, orthostatic hypotension was documented through combined testing results in 23 (21%) of 107 patients. Vertigo was reproduced during autonomic testing in 17 (77%) of 22 patients, and otologic symptoms were reproduce in 9 (47%) of 19 patients. Comparison of the study population with a control group without autonomic symptoms revealed statistically significant differences in orthostatic testing and treatment results. There was no statistical difference noted in findings between patients of this study that demonstrated or failed to demonstrate orthostatic hypotension.

CONCLUSIONS

There is a subgroup of patients with spontaneous vertigo who also demonstrate symptoms and findings consistent with poor autonomic regulation. These patients report vertigo improvement with a treatment strategy that aims to improve autonomic dysfunction through expansion of effective circulating volume. Clinical findings and treatment results of this study suggest an underlying autonomic influence in the production of vertigo and otologic symptoms.

Systematic approach needed to establish cause of vertigo

Vertigo can be defined as an illusion or hallucination of movement. The control of balance is complicated. Vertigo can be caused by many different pathologies, some of which are potentially life threatening. An important differentiation is whether the symptoms of vertigo originate from a central or peripheral origin. Clues to a central origin are other brainstem symptoms or signs of acute onset such as headache, deafness and other neurological findings. These patients warrant urgent referral and investigation. Red flags in patients with vertigo include: headache; neurological symptoms; and neurological signs. It is useful to categorise vertigo into acute and chronic. The former usually has a single mechanism whereas chronic dizziness is often multifactorial. History is usually the most important part of the assessment. Key questions should be asked and it is vital to establish if the patient is suffering from vertigo or some other complaint such as anxiety or syncope. A neurological and otological examination should be performed, appropriate to the history. Assessment of gait and posture is crucial. If the patient has positional vertigo then a Hallpike test should be performed. Visual acuity should be checked as vision is a vital part of the balance system. The cranial nerves should be tested in particular eye movements for any ophthalmoplegia pointing to focal cranial nerve pathology and for nystagmus. The rest of the neurological examination should exclude evidence of central disease, in particular cerebellar disease, and neuropathy. If syncope is suspected it is wise to perform an extensive systemic examination in particular lying and standing BP, and cardiovascular and respiratory system assessments.

Long-term follow-up of patients with posterior canal benign paroxysmal positional vertigo

CONCLUSIONS

Recurrence of posterior canal benign paroxysmal positional vertigo (PC-BPPV) developed in one-third of patients when followed for an average of 5 years from diagnosis. History of head trauma and Ménière's disease contributed significantly to recurrence (p < 0.05). History of head trauma as an etiologic cause was more frequent in patients with recurrence of PC-BPPV.

OBJECTIVES

To estimate recurrence in the long-term follow-up of patients with PC-BPPV after successful canalith repositioning maneuvers, and to determine which factors contribute to recurrence.

METHODS

The charts of 118 patients with PC-BPPV were reviewed. Data of patients were recorded from the initial evaluation and treatment. Follow-up was performed at mean of 64 +/- 7.7 months after the initial phase. The Dix-Hallpike maneuver was performed for diagnosis, and all patients were treated by the canalith repositioning maneuver, which was repeated every 3 days until the patients were symptom-free or results of the Dix-Hallpike maneuver were negative.

RESULTS

At diagnosis, the most common etiology was idiopathic in 55 patients (46.6%). Recurrence occurred in 39 of 118 patients (33.1%). Recurrence occurred within the first 2 years in 21 of the 39 patients (53.8%). History of head trauma was a more frequent finding in patients who developed recurrence (12 of 39, 30.8%).

[The characteristics of benign paroxysmal positional vertigo and application of Epley's maneuver in very old patients]

OBJECTIVE

To analyze the characteristics of benign paroxysmal positional vertigo (BPPV) and the efficacy and safety of Epley's maneuver in very old patients.

METHODS

A retrospective review of 29 (16.5%) patients with BPPV out of 176 consecutively admitted patients aged 80 and over presented with a complaint of dizziness was performed.

RESULTS

In all 29 patients the BPPV origin was attributed to posterior canal involvement; 24 (82.8%) were idiopathic, 4 with a history of Ménière's disease, and 1 secondary to head trauma; 18 (62.1%) were right-side involved; and 25 (86.2%) were diagnosed previously as vertebral-basilar insufficiency. Cardio- and cerebrovascular diseases and the correlative risk factors were common both in patients with BPPV and those with non-BPPV dizziness. Twenty-one patients underwent Epley's maneuver, all were free of vertigo after treatment, 14 of them after a single session and the remaining 2 to 4 sessions. No significant complications were observed except in one who experienced vomiting during the procedure. Patients who received Epley's maneuver had a higher cure rate and short recovery time than those who did not.

CONCLUSIONS

BPPV is not uncommon in very old patients with dizziness. Clinicians should have the knowledge to diagnose and treat this condition. Epley's maneuver is safe and effective in very old patients with BPPV.

Clinical inquiries. What is the best approach to benign paroxysmal positional vertigo in the elderly?

A canalith repositioning maneuver (CRM), such as the Epley or Semont maneuver, should be the first-line treatment for benign paroxysmal positional vertigo (BPPV) in the elderly. Following the Epley maneuver with self-treatment at home using a modified Epley procedure improves outcomes. Postural restrictions are not necessary after CRM treatment. Medications do not work as well as a CRM, but studies comparing treatments are limited.

Postural stability during visual stimulation and the contribution from the vestibular apparatus

CONCLUSION

When combined with vestibular dysfunction, visual flow can exacerbate reductions in postural stability. This effect may be one of the mechanisms underlying visual vertigo, which can be evaluated using frequency analysis of body sway elicited by optokinetic stimulation (OKS).

OBJECTIVE

To clarify the interaction between the postural responses to visual flow and to input from the vestibular apparatus as a mediator of visual vertigo.

METHODS

Horizontal and vertical OKS with a stable fixation target were presented to 14 healthy subjects and 38 peripheral vestibular patients standing in a Romberg's posture, and the center of standing pressure was monitored using a force platform. The direction and amplitude of induced body sway were analyzed, along with the power spectra of the body mass fluctuations.

RESULTS

Each directional optokinetic stimulus induced body sway that would compensate for the virtual inclination of the subject's gravitational reference frame. However, the amplitude of this body sway was not increased by vestibular dysfunction. Healthy subjects showed increased stability in response to downward OKS and decreased stability in response to upward OKS, whereas no specific changes were seen in response to horizontal OKS. This stability was greatly diminished in patients with vestibular dysfunction subjected to the same directional OKS.

[Randomized controlled trial on manipulation for the treatment of cervical vertigo of high flow velocity type]

OBJECTIVE

To explore the effects of manipulation and traction combined with Nimodipine on the blood flow velocity of vertebrobasilar artery (VBA) in cervical vertigo of high flow velocity,and to evaluate clinical therapeutic effects between two methods.

METHODS

From March 2008 to Feburary 2009,70 patients who were diagnosed as high flow velocity of cervical vertigo were randomly divided into treatment group (35 cases) and control group (35 cases). Among 70 patients, 32 were male and 38 were female. The age ranged from 21 to 45 years with an average of 37.6 years. The disease course ranged from one day to two years with an average of 12.6 days. Patients of the treatment group were treated with manipulation for total three weeks, three times once week. The patients in the control group were treated with traction (weight ranged from 5 to 6 kg, 20 minutes each time, once every other day) and Nimodipine for total three weeks (three times each day, and with a dose of 40 mg each time). After three weeks, the changes of flow velacity of VBI and score before and after treatment were observed using transcranil Doppler (TCD) and Evaluation Scale for Cervical Vertigo. After six weeks, the therapeutic effects were assessed.

RESULTS

The mean velocity in left vertebral artery (LVA), right vertebral artery (RVA) and basilar artery (BA) were obviously lower than those before treatment in two groups (P < 0.01). The LVA, RVA and BA of the treatment group was lower than those of control group after 3 weeks (P < 0.01). There was significant difference in vertigo score after treatment between the two groups. The improvement rate of double-sides sign in X-ray image and the therapeutic effects of treatment group was superior to that of control group (P < 0.01).

CONCLUSION

The effect of manipulation on flow velocity of VBA is superior to that of traction combined with Nimodipine, and there are better therapeutic effects in treating cervical vertigo of high flow velocity in comparison with traction combined with Nimodipine. But there are more higher demands for manipulation's application.

Antisecretory factor-inducing therapy improves the clinical outcome in patients with Ménière's disease

CONCLUSION

Intake of antisecretory factor (AF)-inducing SPC-flakes significantly reduced vertigo in patients suffering from Ménière's disease (MD). The positive effect may be due to a modulation of the transport of water and ions in the endolymphatic space.

OBJECTIVE

To evaluate the effects of a 3-month treatment period with SPC-flakes in patients suffering from MD.

PATIENTS AND METHODS

A prospective, double-blind, placebo-controlled study was performed. A total of 51 adult patients with MD were included in the study: 27 subjects treated with SPC-flakes and 24 subjects with control cereals. The patients received SPC-flakes or control cereals (1 g per kg body weight per 24 h in two servings) for 3 months. Otoneurological examinations were carried out before and after this period.

RESULTS

The severity of MD was classified according to the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) grading system. Fourteen of the 27 patients randomized to intake of the AF-inducing SPC-flakes reported decreased vertigo, compared with 2 of 24 in the control group (p < 0.001). No consistent change in the otoneurological examinations could be demonstrated in any of the groups of patients.

[Observation of curative effect on fixed-point spin reduction of spinal manipulation therapy for cervical vertigo]

OBJECTIVE

To explore the role of fixed-point spin reduction of spinal manipulation therapy in the treatment of cervical vertigo and its effect on cervical artery spasm index (RI) and atlantoaxial displacement index (ADI).

METHODS

From January 2002 to May 2008, 168 patients with cervical vertigo were randomly divided into treatment group (84 cases) and the control group (84 cases), 22 males and 62 females in treatment group; 24 males and 60 females in control group. The patients of treatment group and control group were respectively treated with fixed-point spin reduction of spinal manipulation therapy and dialectical prescription. The score of symptoms and signs, RI, ADI were observed and compared between two groups.

RESULTS

The score of symptoms and signs markedly decreased after treatment, in treatment group: vertigo had (2.75 +/- 1.01) scores, neck-shoulder pain (1.58 +/- 0.36), headache (0.39 +/- 0.09), nausea-vomiting (1.58 +/- 1.30), ear noises (0.48 +/- 0.32), positive neck rotation test (0.59 +/- 0.21); and in control group: vertigo had (5.68 +/- 2.02) scores,neck-shoulder pain (3.12 +/- 1.82), headache (1.86 +/- 0.65), nausea-vomiting (3.25 +/- 0.69), ear noises (1.64 +/- 0.61), positive neck rotation test (1.79 +/- 0.67). Cervical artery spasm index and atlantoaxial displacement index had been significantly improved, cervical artery spasm index was respectively 0.54 +/- 0.07 and 0.52 +/- 0.13, atlantoaxial displacement index was respectively 2.92 +/- 0.82 and 4.50 +/- 1.32 between treatment group and control group.

CONCLUSION

Fixed-point spin reduction of spinal manipulation therapy for cervical vertigo can accurately correct single or multiple vertebral body displacement, restore normal spinal position, reduce the oppression and stimulus of the vertebral artery, release ischemia of vestibular labyrinth, eliminate symptoms of vertigo.

An alternative manoeuvre for posterior canal BPPV treatment

OBJECTIVES

The aim of this study is to evaluate the effectiveness of a new manoeuvre in the treatment of posterior canal benign paroxysmal positional vertigo (p-BPPV) based on the idea that highly accelerated endolymphatic flow may lead a mass of otoconia to collide with the walls of the posterior semicircular canal, resulting in its disintegration and/or in the expulsion of the free particles from the posterior semicircular canal.

MATERIAL-METHODS

Our study group included 146 patients with a diagnosis of p-BPPV. All patients underwent the new manoeuvre, which consisted of several high-acceleration successive head movements in the horizontal plane performed by the same physician. The results of the study group were compared with those of a sham control group of 30 patients with p-BPPV undergoing placebo treatment. The patients of both groups were reviewed in a follow-up appointment 1 month and 1 year after the initial treatment.

RESULTS

Complete resolution of symptoms immediately after the manoeuvre was observed in 92% of patients. At 1-month and 1-year follow-up assessment, all the patients in the study group reported complete relief from their symptoms compared with only 13% and 43% of control patients respectively. Recurrence of symptoms was reported in 12 patients (8%) from the study group, who responded successfully to one additional session.

CONCLUSIONS

This study establishes the efficacy of the new manoeuvre in the short- and long-term management of p-BPPV. It is a quick office procedure, usually resolving this disorder with a single session, although there some limitations in patients with underlying cervical spine pathology.

[Management of vertigo]

INTRODUCTION

Dizziness is a non specific and incapacitating symptom. Its classification is based on the patient complaints and categorized in pre-syncope, disequilibrium, lightheadness and vertigo. Vertigo is the most prevalent cause of dizziness. This article pretends to review the management of vertigo, its causes, differential diagnosis and treatment.

METHODS

The articles used in this review were obtained from a Medline search with the keywords vertigo and dizziness, from publications from the past 5 years in the English, Spanish and Portuguese languages.

DISCUSSION

Vertigo is the most prevalent cause of dizziness in primary care. It is caused by an asymmetric involvement in the basal activity of the central and peripheric vestibular pathways. It occurs in episodes and the intensity of this symptom diminishes as the causative factor dissipates or compensation occurs. The clinical evaluation is bases on the clinical history and physical examination. The first step in the differential diagnosis is to differentiate central vertigo from peripheral vertigo. Knowing the duration of symptoms, precipitating factors and associated symptoms and performing the Dix-Hallpike manoeuvre is important in achieving this. The treatment of vertigo must be specific and oriented to the cause, and the use of symptomatic therapy must be reserved to the acute episodes. The definite treatment are rehabilitation exercises.

Temporal bone misalignment and motion asymmetry as a cause of vertigo: the craniosacral model

OBJECTIVE

To describe dysfunction of the craniosacral system, particularly temporal bone motion asymmetry, as a cause of vertigo and to suggest a new perspective on research, diagnosis, and treatment.

DATA SOURCES

A database search was conducted using MEDLINE, CINHAL; Health Sources: Nursing/Academic Edition; and the Internet.

KEYWORDS

vertigo diagnosis and treatment, craniosacral therapy, temporal bones, cranial bone mobility, Upledger, and temporomandibular disorders.

STUDY SELECTION

Articles that most clearly described a relationship between cranial bone misalignment and vertigo were selected for review.

CONCLUSION

Clinical experience suggests that craniosacral therapy is a powerful evaluative and treatment modality for vertigo patients who have not found relief from medical treatments. A narrative review of the literature describes and supports a theoretical link between dysfunction of the craniosacral system and vertigo. Dysfunction of the craniosacral system may include osseous, dural membrane, and fascial restrictions leading to asymmetric temporal bone movement and hence vertigo. Clinical trials are necessary not only to verify that craniosacral therapy is an effective treatment but also to determine the full range of symptoms and medical diagnoses for which craniosacral therapy is beneficial.

Bedside therapeutic experiences with horizontal canal benign paroxysmal positional vertigo (cupulolithiasis)

CONCLUSIONS

After forced prolonged position type one (FPP-one) and the appropriate repositioning maneuvers, or FPP-two, 95.45% of patients with cupulolithiasis of the horizontal semicircular canal benign paroxysmal positional vertigo (HSC-BPPV).were symptom-free.

OBJECTIVES

To treat patients with cupulolithiasis of the HSC-BPPV.

SUBJECTS AND METHODS

This was a prospective study including 22 subjects with HSC-BPPV (cupulolithiasis) based on apogeotropic direction-changing positional nystagmus (apo-DCPN). Patients adopted FPP-one, which means lying down on the side of the weaker nystagmus during nightly rest for 2 weeks. If apo-DCPN persisted, subjects adopted type two FPP (FPP-two), which means lying on the strongest nystagmus side during nightly rest for 2 weeks.

RESULTS

No vertigo or nystagmus was observed in 15 subjects after FPP-one. One subject experienced geotropic DCPN (geo-DCPN), two subjects had posterior BPPV, and another had superior BPPV. Three subjects had persistent apo-DCPN and they were subjected to FPP-two. After that, no vertigo or nystagmus was detected in two subjects. Apo-DCPN persisted in the other remaining subject after FPP-two.

[Emergency care of vertigo patients: suggestions for efficient management]

Some diseases in which persons show vertigo or dizziness may be life-threatening, regardless of symptom severity, and require careful attention. These include diseases of the inner ear, central nervous system, and cardiovascular manifestation. In May 2006, a group in charge of primary emergency consultation began work enabling physicians to treat vertigo patients more efficiently and safely, as detailed in this report. Of the 173 persons with vertigo hospitalized from January 2004 to March 2008, six had cerebrovascular manifestations clarified only after hospitalization, underscoring the importance of careful examination, especially of those 75 years of age older, having continuous headache, having severe trunk ataxia despite apparently mild eye nystagmus, or reporting a history of high blood pressure, diabetes mellitus, hyperlipidemia, or ischemic heart disease.