Canal switch after canalith repositioning procedure for benign paroxysmal positional vertigo

Exploring Oral Cavity Cancer in the United Arab Emirates (UAE)

Background This study delves into the demographics and clinical characteristics of oral cavity tumors in the context of the United Arab Emirates. It further investigates the efficacy of four different treatment modalities in impacting patient survival rates. It aims to understand if any treatments significantly improve survival compared to others. Methodology To assess the survival outcomes across the different treatment groups, the study employed the log-rank test, a non-parametric statistical test widely used in survival analysis. The sample consisted of patients from the electronic medical records assigned to one of the following four treatment groups: radiotherapy only (RT), radiotherapy with surgery and chemotherapy (RT+S+C), radiotherapy with surgery (RT+S), and, finally, radiotherapy with chemotherapy including immunotherapy (RT+C). Data collection involved tracking survival times from the initiation of treatment until the last follow-up period or the occurrence of an event (e.g., death). The statistical analysis was conducted using the chi-squared statistic to determine the distribution of survival times across the groups, providing a quantitative measure of the difference between the observed and expected survival. The Kaplan-Meier curve was plotted for the cohort divided into four groups. Results The log-rank test yielded a p-value of 0.321019, suggesting no statistically significant difference in survival among the treatment groups at the 5% significance level. The chi-squared statistic was 3.498018, within the 95% acceptance region, further corroborating the null hypothesis of no significant survival difference across the groups. Despite this, an observed medium effect size of 0.59 indicates a moderate difference in survival between the groups. Conclusions The findings illustrate that while there is no statistically significant difference in survival rates among the four treatment groups, the medium effect size observed suggests a moderate difference in survival. This emphasizes the need to consider the statistical significance and effect size in clinical research, as they provide different insights into treatment efficacy.

The effectiveness of the modified Epley maneuver for the treatment of posterior semicircular canal benign paroxysmal positional vertigo

Objective

To compare the repositioning effect of the modified Epley maneuver and the traditional Epley maneuver for posterior semicircular canal benign paroxysmal positional vertigo (PC-BPPV).

Methods

Sixty-five patients with unilateral PC-BPPV were randomly divided into two groups. The control group received the traditional Epley maneuver, while the experimental group received the modified Epley maneuver, which prolonged the time in the healthy side lying position and the final bowing position. The number of successful repositions after one, two, and three attempts and the total number of successful repositions were recorded and compared between the two groups. A BPPV virtual simulation model was used to analyze the mechanism of the modified Epley maneuver.

Results

The first repositioning success rate of the experimental group was significantly higher than that of the control group (85% vs. 63%, p = 0.040). The experimental group achieved 100% repositioning success rate after two attempts, while the control group needed three attempts to reach 86% repositioning success rate. Four cases in the control group experienced canal switching during the repositioning process, while none in the experimental group did. The BPPV virtual simulation model showed that the modified Epley maneuver could facilitate the passage of otoliths through the posterior arm of the posterior semicircular canal, especially through the location of obstruction.

Conclusion

The modified Epley maneuver is more effective than the traditional Epley maneuver in improving the single repositioning success rate and reducing the canal switching rate for PC-BPPV. This study provides a new option for the treatment of BPPV.

Canal switch: a possible complication of physical therapeutic manoeuvers for posterior canal benign paroxysmal positional vertigo

Objective

To study the frequency of canal switch in posterior canal benign paroxysmal positional vertigo (BPPV) treated by canalith repositioning manoeuver (CRP), quick liberatory rotation manoeuver (QLR) or Semont manoeuver (SM).

Methods

Retrospective study on 1158 patients, 637 women and 521 men suffering from geotropic posterior canal BPPV treated by CRP, QLR, or SM, retested after 15 minutes and about seven days.

Results

1146 patients recovered from the acute phase; treatments failed in 12 patients treated with CRP. We observed 12 canal switches from posterior to lateral canal and 2 from posterior to anterior canal during or after CRP in 13/879 cases (1.5%) and after QLR in 1/158 (0.6%) with no significant difference between CRP vs SM and QLR. We did not consider slight positional downbeat nystagmus after the therapeutic manoeuvers as a sign of canal switch into the anterior canal, but as a sign of persistent small debris in the non-ampullar arm of the posterior canal.

Conclusions

Canal switch is rare for any manoeuver and it does not belong to the criteria to choose one manoeuver over another. Notably, due to the canal switching criteria, SM and QLR cannot be preferred over those with a more prolonged extension of the neck.

Simulation Study of Canal Switching in BPPV

The objective of this research was to investigate the mechanism of canal switching in benign paroxysmal positional vertigo through a virtual simulation model. Using Unity 3D software and a built-in NVIDIA Physx physics engine, the virtual simulation software is developed using a browser-server architecture, and different models are imported. Based on the benign paroxysmal positional vertigo virtual simulation model, we constructed five different virtual reality scenes of diagnosis and treatment, set otoliths in different positions of the semicircular canals, and analyzed the effects of diagnostic and therapeutic procedures on otolith location. Through the analysis of otolith movement in five virtual scenes, we found that canal switching may be caused by otoliths in the utricle entering the semicircular canal in the supine position. Then, we used different methods to reposition the otolith, improved the repositioning maneuver, and explored in depth the mechanism of the canal switching. The results showed that the main reason for the canal switch is that in the supine position, the otolith in the utricle enters the semicircular canal. The repositioning maneuvers, including the Epley maneuver and Barbecue maneuver, will not directly lead to the canal switch in the ipsilateral inner ear. The supine roll maneuver leads to the otolith in the utricle entering the posterior or lateral semicircular canal, which is the most likely mechanism for canal switching.

Diagnostic and Therapeutic Maneuvers for Anterior Canal BPPV Canalithiasis: Three-Dimensional Simulations

Background and Objectives: Anterior canal BPPV is a rare BPPV variant. Various diagnostic and therapeutic maneuvers have been described for its management. The aim of this study was to use three-dimensional simulation models to visualize otoconial debris movement within the anterior canal during diagnostic tests and different liberatory maneuvers. This can help to optimize existing treatment maneuvers and help in the development of better management protocols. Methods: Based on reconstructed MRI images and fluid dynamics, a 3D dynamic simulation model (as a function of time) was developed and applied. Simulations of the supine head-hanging test for diagnosis of ac-BPPV were studied. Three repositioning maneuvers were simulated: 1) the Yacovino maneuver and its modifications, 2) the reverse Epley maneuver and 3) the short canal repositioning (CRP) maneuver. Results: The simulation showed that the supine head-hanging test is a good test for diagnosis of ac-BPPV affecting both labyrinths and demonstrated why there is no inversion of nystagmus on sitting up. The Yacovino maneuver was seen to be an effective treatment option for ac-BPPV without having to determine the side involved. However, simulations showed that the classical Yacovino maneuver carried a risk of canal switch to the posterior canal. To overcome this risk, a modified Yacovino maneuver is suggested. The reverse Epley maneuver was not an effective treatment. Short CRP is useful in ac-BPPV treatment; however, it requires determination of side of involvement. Conclusion: The 3D simulator of the movement of the otoconial debris presented here can be used to test the mechanism of action and the theoretical efficacy of existing diagnostic tests and maneuvers as well as to develop new treatment maneuvers to optimize BPPV treatment.

Efficacy of combined canalith-repositioning procedure and supine to prolonged lateral position in treating posterior canal benign paroxysmal positional vertigo

OBJECTIVES

Posterior benign paroxysmal positional vertigo (p-BPPV) is the most common type of BPPV, and canalith-repositioning procedure (CRP) is frequently applied for treatment. Supine to prolonged lateral position (SPLP), a simple home-based maneuver, can be performed for treatment of p-BPPV. The purpose of this study was to investigate whether combination of CRP and SPLP could be more effective in symptom alleviation compared with CRP alone and reduce times of repeated CRP for patients with p-BBPV.

METHODS

A retrospective chart review enrolled 96 patients diagnosed with primary p-BPPV. Of these patients, 64 patients were included in the CRP group and 32 patients, in the CRP+SPLP group. The outcome was determined according to days required to reach negative result in Dix-Hallpike test, duration of vertigo and dizziness following the first repositioning procedure, and times of CRP performed to reach resolution of p-BPPV.

RESULTS

Of patients in the CRP and CRP+SPLP groups, 38% and 16% received CRP at least twice to reach resolution, respectively (P = 0.034). Patients in the CRP group and CRP+SPLP group spent an average of 9.8 ± 6.1 days and 7.9 ± 3.4 days, respectively reaching a negative result in Dix-Hallpike test (P = 0.050). In terms of duration for relieving vertigo and dizziness, the CRP+SPLP group achieved symptom relief with shorter duration (P = 0.036 and P = 0.025, respectively).

CONCLUSION

Compared with CRP alone, combination of CRP and SPLP improved the therapeutic effectiveness and shortened the duration of suffering from vertigo and dizziness in patients with p-BPPV.

Characteristics of assessment and treatment in Benign Paroxysmal Positional Vertigo (BPPV)

QUESTION:

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of dizziness presenting to specialist vestibular centres and accounts for approximately 20–30% of referrals to these clinics. In spite of the amount of clinical knowledge surrounding its diagnosis and management, the treatment of BPPV remains challenging for even the most experienced clinicians. This study outlines the incidence of BPPV in a specialised vestibular physiotherapy clinics and discusses the various nuances encountered during assessment and treatment of BPPV.

DESIGN:

Observational Study

PARTICIPANTS:

314 patients with various forms of Benign Paroxysmal Positional Vertigo (BPPV)

INTERVENTION:

Canalith repositioning manoeuvres (CRP) for posterior canal (PC) or horizontal canal (HC) BPPV depending on the canal and variant of BPPV.

OUTCOME MEASURES:

Negative Dix-Hallpike (DHP) or Supine roll test (SRT) examination.

RESULTS:

In 91% of cases, PC BPPV was effectively treated in 2 manoeuvres or less. Similarly, 88% of HC BPPV presentations were effectively managed with 2 treatments. Bilateral PC, multiple canal or canal conversions required a greater number of treatments. There was no noticeable difference in treatment outcomes for patients who had nystagmus and symptoms during the Epley manoeuvre (EM) versus those who did not have nystagmus and symptoms throughout the EM. Nineteen percent of patients experienced post treatment down-beating nystagmus (DBN) and vertigo or “otolithic crisis” after the first or even the second consecutive EM.

CONCLUSION:

Based on the data collected, we make several clinical recommendations for assessment and treatment of BPPV. Firstly, repeated testing and treatment of BPPV within the same session is promoted as a safe and effective approach to the management of BPPV with a low risk of canal conversion. Secondly, vertigo and nystagmus throughout the EM is not indicative of treatment success. Thirdly, clinicians must remain vigilant and mindful of the possibility of post treatment otolithic crisis following the treatment of BPPV. This is to ensure patient safety and to prevent possible injurious falls. Our results challenge several clinical assumptions about the assessment and treatment of BPPV including the utility of certain markers of treatment success; hence influencing the current clinical guidelines and clinical practice and paving the way for future studies of the assessment and management of patients with BPPV.

Does cervical range of motion affect the outcomes of canalith repositioning procedures for posterior canal benign positional paroxysmal vertigo?

PURPOSE

Canalith repositioning procedure (CRP) for posterior canal benign positional paroxysmal vertigo (BPPV), also known as Epley maneuver, is a common procedure for the treatment of BPPV. This maneuver entails flexion, extension and rotation of the patient's neck. This study aims to investigate the impact of cervical range of motion (C-ROM) on CRP efficacy.

MATERIALS AND METHODS

The study included 47 patients with posterior canal BPPV treated by CRP. The procedure was considered successful if vertigo and nystagmus disappeared at the post-treatment evaluation. If CRP resulted ineffective, it was repeated up to three times per session. C-ROM was measured at BPPV diagnosis before treatment. Patients were followed up for 30 days.

RESULTS

The first CRP was successful in 29 patients (61.7%), while it was ineffective in 18 patients (38.3%) requiring multiple repositioning maneuvers. Patients who needed two or more CRP showed lower C-ROM in extension (p = .003) and flexion (p = .042), and earlier recurrences (p = .006). Univariate regression analysis showed that lower cervical extension was significantly associated with the failure of the first CRP (OR: 0.899, 95% CI 0.831-0.973, p = .008).

CONCLUSIONS

Our data suggest that a reduced C-ROM can require multiple CRPs to successfully treat BPPV and increase the risk of early recurrences.

Comparative Study on the Roles of the Number of Accelerations and Rotation Angle in the Treatment Maneuvers for Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo

AIMS

This study aims to investigate the roles of the number of accelerations and rotation angle in the treatment of posterior semicircular canal benign paroxysmal positional vertigo (PC-BPPV).

METHODS

We enrolled 344 patients with unilateral PC-BPPV. Of these, 167 patients in the simple-step maneuver (SSM) group were accelerated twice and rotated 120° per step, whereas 177 patients in the multi-step maneuver (MSM) group were accelerated 4 times and rotated 60° per step. Dix-Hallpike (DH) tests were performed to categorize the treatment outcome as follows: 'symptom free' if the result was negative, 'symptom persistent' if the result remained positive after performing the maneuver 3 times or 'canal conversion' if horizontal nystagmus was evoked.

RESULTS

Of the patients in the SSM and MSM groups, 78.4 and 91.5% became symptom free, respectively, while canal conversion occurred in 13.8 and 5.1%, respectively (p = 0.003, χ(2) test). The success rate after performing the maneuver once was 57.1% in the MSM and 32.3% in the SSM symptom-free patients (p = 0.001, χ(2) test). One month after the treatment, 22.0 and 9.6% of the SSM and MSM patients had symptom relapse, respectively (p = 0.007, χ(2) test).

CONCLUSIONS

More accelerations and a smaller rotation angle improved the effectiveness and efficiency of the repositioning maneuvers and reduced canal conversion.

Benign Paroxysmal Positional Vertigo in the Acute Care Setting

Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo characterized by brief episodes provoked by head movements. The first attack of BPPV usually occurs in bed or upon getting up. Because it often begins abruptly, it can be alarming and lead to emergency department evaluation. The episodes of spinning often last 10 to 20 seconds, but may occasionally last as long as 1 minute. There are several forms of BPPV. In nearly all cases, highly effective treatment can be offered to patients. This article reviews the current state of our understanding of this condition and its management.

Efficacy of computer-controlled repositioning procedure for benign paroxysmal positional vertigo

OBJECTIVES/HYPOTHESIS

To evaluate the short-term efficacy of the computer-controlled canalith repositioning procedure (CRP) for treatment of posterior canal benign paroxysmal positional vertigo (BPPV) compared with the current standard CRP.

STUDY DESIGN

Prospective case series.

METHODS

One hundred thirty-two patients diagnosed as having idiopathic posterior canal BPPV, with an age range of 28 to 86 years (mean 56 years), 47 men and 85 women, were treated with computer-controlled CRP mimicking the Epley maneuver. Resolution of vertigo and nystagmus on the Dix-Hallpike test at 1-week follow-up after treatment was the main outcome measure to assess the efficacy of treatment.

RESULTS

At 1-week follow-up after treatment with computer-controlled CRP, 108 (81.8%) of 132 patients had complete resolution of vertigo and nystagmus, nine (6.8%) had resolution of vertigo but presence of nystagmus, and 15 (11.4%) had provoked vertigo and nystagmus on the Dix-Hallpike test. The 81.8% success rate was comparable to those who received current standard CRP treatment in randomized controlled trials at about 80%. No significant adverse effects or complications occurred in the patients treated with computer-controlled CRP, aside from two patients (1.5%) with conversion into lateral canal BPPV.

CONCLUSIONS

Computer-controlled CRP is effective for the treatment of posterior canal BPPV, with a success rate similar to those treated with the Epley maneuver, and is safe and easy to perform on patients.

Repositioning nystagmus: prognostic usefulness?

CONCLUSIONS

The presence of orthotropic nystagmus (ON), in multiple positions, appears to predict the success of canalith repositioning maneuvers (CRMs). In this sense CRMs under video-Frenzel are informative for the immediate follow-up, although not related to the degree of disability or emotional distress. Still, attention should be given to psychological assistance even in cases of clinically cured benign paroxysmal positional vertigo (BPPV).

OBJECTIVE

The aim of the study was to highlight the prognostic value of nystagmus in CRMs for BPPV and its relevance for emotional and patient-perceived disability.

METHODS

A group of 57 patients were selected from 3 balance disorders centers. CRMs were performed under video-Frenzel control. Assessment of patient disability and positional nystagmus was performed 2 months later. Emotional (Cuestionario de Impacto Emocional del Vértigo, CIEV) and quality of life (Dizziness Handicap Inventory, DHI) impact were evaluated.

RESULTS

The posterior semicircular canal (SCC) was affected in 84.2% of cases, the horizontal SCC in 10.5%, and the anterior SCC in 5.1%. Appropriate CRMs were performed. ON was present in 67% of cases. Overall resolution after the first treatment was achieved in 56% of cases. With ON present the success rate was 63% and when not observed the rate was 42%. DHI or CIEV scores were not significantly different when comparing the presence vs absence of ON. In nine patients (16%) an abnormal CIEV score was observed after treatment, even though a cured status was achieved in six of these nine patients.