Prevalence of unrecognized benign paroxysmal positional vertigo in older patients

Numerical Simulations of the Epley Maneuver With Clinical Implications

OBJECTIVES

Canalith repositioning procedures to treat benign paroxysmal positional vertigo are often applied following standardized criteria, without considering the possible anatomical singularities of the membranous labyrinth for each individual. As a result, certain patients may become refractory to the treatment due to significant deviations from the ideal membranous labyrinth, that was considered when the maneuvers were designed. This study aims to understand the dynamics of the endolymphatic fluid and otoconia, within the membranous labyrinth geometry, which may contribute to the ineffectiveness of the Epley maneuver. Simultaneously, the study seeks to explore methods to avoid or reduce treatment failure.

DESIGN

We conducted a study on the Epley maneuver using numerical simulations based on a three-dimensional medical image reconstruction of the human left membranous labyrinth. A high-quality micro-computed tomography of a human temporal bone specimen was utilized for the image reconstruction, and a mathematical model for the endolymphatic fluid was developed and coupled with a spherical particle model representing otoconia inside the fluid. This allowed us to measure the position and time of each particle throughout all the steps of the maneuver, using equations that describe the physics behind benign paroxysmal positional vertigo.

RESULTS

Numerical simulations of the standard Epley maneuver applied to this membranous labyrinth model yielded unsatisfactory results, as otoconia do not reach the frontside of the utricle, which in this study is used as the measure of success. The resting times between subsequent steps indicated that longer intervals are required for smaller otoconia. Using different angles of rotation can prevent otoconia from entering the superior semicircular canal or the posterior ampulla. Steps 3, 4, and 5 exhibited a heightened susceptibility to failure, as otoconia could be accidentally displaced into these regions.

CONCLUSIONS

We demonstrate that modifying the Epley maneuver based on the numerical results obtained in the membranous labyrinth of the human specimen under study can have a significant effect on the success or failure of the treatment. The use of numerical simulations appears to be a useful tool for future canalith repositioning procedures that aim to personalize the treatment by modifying the rotation planes currently defined as the standard criteria.

Adoption of clinical practice guidelines in cases of benign paroxysmal positional vertigo

PURPOSE

Despite being one of the most common types of the peripheral vertigo encountered in clinical practice, benign paroxysmal positional vertigo (BPPV) remains underdiagnosed and undertreated, even in affluent health care systems. The publication of fully updated clinical practice guidelines significantly facilitated the diagnosis and treatment of BPPV. This study evaluates the adoption of the guidelines in our clinical setting and reviews further recommendations for quality-of-care improvement.

METHODS

This retrospective cross-sectional survey included a total of 1155 adult patients diagnosed with BPPV at the biggest tertiary care center in the country during a 5-year period (2017-2021). The data for the first three years (2017-2020) and 919 patients were collected in full, and for the remaining 236 patients (2020-2021) only partially due to the disturbance in referrals caused by COVID-19 pandemic.

RESULTS

The familiarity with and adherence to the published clinical guidelines by physicians judged by patients' charts and our health care database were overall unsatisfactory. The adherence varied from 0 to 40.5% in our sample. The recommendations for making the diagnosis and for repositioning procedure as first-line therapy were followed in only 20-30% of cases.

CONCLUSION

There are large opportunities for improvement in quality of care of BPPV patients. Apart from constant and systematic education at the primary health care level, the health care system may need to adopt more advanced measures of ensuring better adherence to guidelines and subsequent reduction in medical costs.

The Effect of Modified Epley Maneuver Implementation on the Anxiety and Comfort Levels of Patients with Posterior Canal Bening Paroxysmal Positional Vertigo: A Prospective Study

To evaluate the effects of the modified Epley maneuver during Posterior Canal Benign Paroxysmal Positional Vertigo (BPPV) on patients' anxiety and comfort levels. The study, organized as a prospective, worked with 72 patients who were diagnosed with Posterior Canal BPPV through Dix-Hallpike maneuver. The data for the study was collected through Descriptive Characteristics Form, General Comfort Questionnaire Short Form, and Beck Anxiety Inventory. It was found that that 63.9% of the patients experienced average-level anxiety before the implementation of the Epley maneuver and received a total of 3.07 ± .37 (1-6) from the General Comfort Questionnaire. Before applying the modified Epley maneuver and I and IV When the score changes after the week were examined, it was determined that there was a statistically significant difference in all scale scores, as comfort levels increased, anxiety levels decreased. Anxiety was identified as the most important predictor of patients' comfort level before and after the implementation of the modified Epley maneuver. In light of these findings, it can be said that modified Epley maneuver can safely be used to increase the comfort of patients with Posterior Canal BPPV. Considering that patients with BPPV can consult to emergency rooms, family clinics along with polyclinics, it is recommended to organize regular trainings on BPPV and the implementation of the Epley maneuver. It is believed that evaluation of BPPV patients for their anxiety and offer support when needed is important for the prognosis and patients' comfort.

Evaluating the Epley Canalolith Repositioning Procedure With and Without a Visual Assistive Device

HYPOTHESIS

The primary goal of this study was to examine how accuracy is affected when we employ a guidance device to assist with the execution of the Epley canalolith repositioning procedure.

BACKGROUND

Benign paroxysmal positional vertigo is a common cause of vestibular vertigo. Treatment is noninvasive and generally effective when performed correctly. Deficiencies in clinical application result in unnecessary failures in response for those affected.

METHODS

Ten participants were each taken through six iterations of the Epley canalolith repositioning procedure. Iterations were divided evenly between those conducted with and without the use of a guidance device. One clinician performed all 60 procedures. Head movements were recorded using motion capture cameras and strategically placed motion tracking markers.

RESULTS

Results showed that the guidance device significantly improved the latter phase maneuver accuracy. Rotation error was significantly reduced for hold3 with-device (M = 20.23°, SD = 12.08°) versus without-device (M = 40.13°, SD = 14.62°, p  =  0.001). Maximal rotation error during rotation4 of the maneuver demonstrated a similar reduction of error with-device (M = 24.44°, SD = 10.43°) versus without-device (M = 41.36°, SD = 12.89°, p  =  0.002).

CONCLUSION

A simple visual guidance device can increase the execution accuracy of canalith repositioning procedures. Further research is required to show how such improvements influence treatment efficacy.

Benign paroxysmal positional vertigo and vestibular impairment among older adults with dizziness

OBJECTIVE

This article aimed to investigate older adults visiting a geriatric institution for a bone density measurement who reported dizziness on a daily or weekly basis (but who are not seeking care for dizziness), according to BPPV, vestibular function, walking abilities, and frequency of falls.

METHODS

Patients coming for a bone density measurement answered questions regarding occurrence of dizziness. Patients having dizziness on a daily or weekly basis were considered eligible for the study and invited for investigation at the Ear, Nose, and Throat clinic at Södra Älvsborg Hospital, Sweden. The patients answered questions about history of dizziness, medications, and comorbidities. They were also investigated for BPPV, vestibular deficits using the video head impulse test (vHIT), walking speed, Timed Up and Go test (TUG), and for perception of verticality and horizontality and Romberg test.

RESULTS

A total of 55 patients with dizziness were included. Fifteen (27%) were diagnosed with BPPV. Forty (73%) patients reported falling during the previous year, including 11 with BPPV. Dizziness when turning in bed was more common among patients with BPPV and increased the risk of BPPV 8-fold.

CONCLUSION

BPPV is common among older adults with dizziness, including among those not seeking medical care. It is important to identify older adults with BPPV and treat the condition since BPPV may contribute to falls. Asking about dizziness when turning in bed can help to distinguish patients with increased risk for BPPV and older adults with dizziness should be investigated for BPPV even when typical history is lacking. Level of evidence: 4.

BPPV: Comparison of the SémontPLUS With the Sémont Maneuver: A Prospective Randomized Trial

Objective: To compare the efficacy of the Sémont maneuver (SM) with the new “SémontPLUS maneuver” (SM+) in patients with posterior canal BPPV canalolithiasis (pcBPPVcan).

Methods and Patients: In a prospective trinational (Germany, Italy, and Belgium) randomized trial, patients with pcBPPVcan were randomly assigned to SM or SM+; SM+ means overextension of the head by 60+° below earth horizontal line during the movement of the patient toward the affected side. The first maneuver was done by the physician, and the subsequent maneuvers by the patients 9 times/day on their own. Each morning the patient documented whether vertigo could be induced. The primary endpoints were: “How long (in days) does it take until no attacks can be induced?” and “What is the efficacy of a single SM/SM+?”

Results: In the 194 patients analyzed (96 SM, 98 SM+), it took 2 days (median, range 1–21 days, mean 3.6 days) for recovery with SM and 1 day (median, range 1-8 days, mean 1.8 days) with SM+ (p = 0.001, Mann-Whitney U-test). There was no difference in the second primary endpoint (chi²-test, p = 0.39).

Interpretation: This prospective trial shows that SM+ is more effective than SM when repeated therapeutic maneuvers are performed but not when a single maneuver is performed. It also supports the hypothesis of the biophysical model: overextension of the head during step 2 brings the clot of otoconia beyond the vertex of the canal, which increases the effectivity.

Classification of Evidence: This study provides Class I evidence that SM+ is superior to SM for multiple treatment maneuvers of pcBPPVcan.

Benign Paroxysmal Positional Vertigo in the Elderly: A Single-center Experience

OBJECTIVES

Dizziness and balance problems are common in the elderly, and benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness. The aim of this study is to investigate the subtype distribution of geriatric BPPV in a single tertiary referral center, and compare the treatment efficacy according to the subtype of BPPV.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary referral academic center.

PATIENTS

The consecutive 316 elderly patients diagnosed with BPPV between March 2013 and March 2019 were included.

MAIN OUTCOME MEASURES

Using a head-roll and Dix-Hallpike tests, subtype of BPPV was determined. Once the diagnosis of BPPV was made, patients were treated by its corresponding canalith repositioning maneuver (CRM).

RESULTS

Among 316 elderly patients with BPPV, 143 patients (45%) were diagnosed with posterior semicircular canal BPPV, 46 patients (15%) were diagnosed with lateral semicircular canal (LSCC) canalolithiasis, 126 patients (40%) were diagnosed with LSCC cupulolithiasis, and 1 patient (0%) was diagnosed with anterior semicircular canal BPPV. While 66 and 63% of the patients with posterior semicircular canal BPPV and LSCC canalolithiasis recovered after one session of CRM, only 32% of the patients with LSCC cupulolithiasis recovered after one session of CRM.

CONCLUSION

The proportion of LSCC cupulolithiasis was higher in the elderly, and treatment efficacy by CRM is lower in LSCC cupulolithiasis than other subtypes of BPPV. High prevalence of LSCC cupulolithiasis may be explained by a delay between onset of BPPV and patient's presentation to the tertiary referral hospital or pathophysiology of ageotropic positional nystagmus other than otoconial attachment on the LSCC cupula in the elderly.

Efficacy of Epley Maneuver on Quality of Life of Elderly Patients with Subjective BPPV

OBJECTIVES

This study aimed to evaluate the efficacy of the repositioning maneuver on quality of life in elderly patients with dizziness and/or vertigo.

MATERIALS AND METHODS

This controlled, prospective randomized clinical trial was conducted in elderly patients aged 65 years and above with a positive history of benign paroxysmal positional vertigo (BPPV), presence of vertigo, and no observable nystagmus during the Dix-Hallpike test, so-called Subjective BPPV (S-BPPV). Individuals were evaluated by visual analog scale (VAS) and dizziness handicap inventory (DHI). Groups were defined as treatment (treated with Epley maneuver bilaterally) or no treatment control (no treatment modality or canalith repositioning maneuver). Ten days after the first assessment, all patients were reassessed using VAS and DHI.

RESULTS

A total of 50 patients were randomized into two groups: 25 to the treatment group, and 25 to the control group. No significant differences were observed for baseline VAS and total DHI scores between the groups (p=0.636, p=0.846, respectively). On the other hand, after the reassessment, VAS and total DHI scores were both significantly reduced in the treatment group (p<0.001, p<0.001, respectively), but no reduction in either score was found in the control group (p=0.216, p=0.731, respectively).

CONCLUSION

This study showed that elderly patients with S-BPPV benefit from the Epley maneuver, in particular global and disease-specific quality of life.

Simultaneous Presentation of Benign Paroxysmal Positional Vertigo and Meniere's Disease - Case Report

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is one of the most common clinical entities, which develops spontaneously in most of the cases, but it can be secondary as a result of different conditions such as head injuries, viral neurolabyrinthitis, Meniere's disease and vertebrobasilar ischemia. The aim of presenting this case is to point out to the need of taking a precise clinical history and performing Dix-Hallpike manoeuvre in all patients who complain about vertigo regardless of the previously diagnosed primary disease of the inner ear.

CASE PRESENTATION

A 63-year-old female patient presented with the classical triad of symptoms for Meniere's disease (fluctuating sensorineural hearing loss in the right ear, tinnitus and fullness in the same ear and rotary vertigo), two years later complained of brief episodes of vertigo linked to changes in head position relative to gravity. Dix-Hallpike manoeuvre showed a classical response in the head-hanging right position. Benign paroxysmal positional vertigo (BPPV) in the same ear was diagnosed in this patient. After treatment with Epley's canal repositioning manoeuvre for a few days, the symptoms of positional vertigo resolved.

CONCLUSION

The authors recommend complete audiological and otoneurological evaluation in all patients with vertigo for timely recognition/diagnosis of any inner ear associated pathology.

Asking about dizziness when turning in bed predicts examination findings for benign paroxysmal positional vertigo

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is the single most common cause of vestibular vertigo and is characterised by short episodes of rotational vertigo precipitated by changes in head positions like lying down or turning in bed.

OBJECTIVE

This study aims to assess useful questions when suspecting benign paroxysmal positional vertigo (BPPV) caused dizziness as well as identifying if a single question can be useful in identify or distinguish patients with BPPV from other dizziness aetiology.

METHOD

A total of 149 patients admitted due to dizziness were included. Patients answered a questionnaire and were investigated for BPPV with diagnostic manoeuvres.

RESULT

Two of the 15 questions were of diagnostic importance. Dizziness when laying down or turning in bed, increased likelihood of BPPV by an odds ratio (95% confidence interval) of 60 (7.47-481.70). Continuous dizziness duration as opposed to lasting seconds decreased likelihood of BPPV with an odds ratio of 0.06 (0.01-0.27).

CONCLUSION

Vertiginous attacks by turning or laying down in bed together with dizziness <1 minute, are important questions and strongly related to BPPV. Such questions are important when taking a medical history and may help to early identify BPPV, also for non-medical staff, as well as reduce the need of further investigations.

Efficacy of methylprednisolone for treatment of persistent vertigo

BACKGROUND

This study will systematically investigate the efficacy and safety of methylprednisolone for treatment of persistent vertigo (PV).

METHODS

All following electronic databases will be searched from inception to the June 30, 2019 without language restrictions: MEDILINE, EMBASE, Cochrane Library, Web of Science, and Chinese Biomedical Literature Database. All randomized controlled trials focusing on assessing the efficacy and safety of methylprednisolone for patients with PV will be fully considered for inclusion. Cochrane risk of bias tool will be used for assessing methodological quality, and RevMan 5.3 software (Cochrane Community, London, UK) will be utilized for statistical analysis.

RESULTS

This study will assess the efficacy and safety of methylprednisolone for PV via assessing primary outcome of vertigo, and secondary outcomes of somatization, depression, anxiety, health-related quality of life, and adverse events.

CONCLUSION

This study will provide a high-quality evidence to judge whether methylprednisolone is an effective and safety therapy for patients with PV.

DISSEMINATION AND ETHICS

No individual data will be utilized in this study, thus, it does not need ethical approval. The results of this study will be published at peer-reviewed journals.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019138890.

Investigation of self-reported dizziness in the elderly when lying down or turning over in bed, and possible benign paroxysmal positional vertigo

OBJECTIVES

This study aimed to investigate the rate of dizziness and occurrence of benign paroxysmal positional vertigo in the elderly by physical examination in those reporting dizziness symptoms when lying down or turning over in bed.

METHODS

A total of 498 people, aged 70-85 years, were asked to complete a questionnaire regarding dizziness symptoms. Subjects answering that they became dizzy in bed were asked to participate in a physical examination and diagnostic manoeuvres investigating benign paroxysmal positional vertigo.

RESULTS

A total of 324 participants (65 per cent) completed the questionnaire. More than one-quarter (29 per cent) reported dizziness and 32 (10 per cent) reported dizziness when turning in bed. Of these 32 persons, 22 (69 per cent) underwent a physical examination. Six participants tested positive for benign paroxysmal positional vertigo.

CONCLUSION

Ten per cent of the elderly participants reported positional symptoms, and 6 out of 22 fulfilled diagnostic criteria for benign paroxysmal positional vertigo. Furthermore, benign paroxysmal positional vertigo was established despite a delay between questionnaire completion and investigation, emphasising that this type of dizziness may not be a self-limiting disorder.

Risk of benign paroxysmal positional vertigo in patients with depressive disorders: a nationwide population-based cohort study

OBJECTIVE

The association between depression and benign paroxysmal positional vertigo (BPPV) remains debated. This study aimed to investigate the risk of BPPV in patients with depressive disorders.

DESIGN

Longitudinal nationwide cohort study.

SETTING

National health insurance research database in Taiwan.

PARTICIPANTS

We enrolled 10 297 patients diagnosed with depressive disorders between 2000 and 2009 and compared them to 41 188 selected control patients who had never been diagnosed with depressive disorders (at a 1:4 ratio matched by age, sex and index date) in relation to the risk of developing BPPV.

METHODS

The follow-up period was defined as the time from the initial diagnosis of depressive disorders to the date of BPPV, censoring or 31 December 2009. Cox proportional hazard regression analysis was used to investigate the risk of BPPV by sex, age and comorbidities, with HRs and 95% CIs.

RESULTS

During the 9-year follow-up period, 44 (0.59 per 1000 person-years) patients with depressive disorders and 99 (0.33 per 1000 person-years) control patients were diagnosed with BPPV. The incidence rate ratio of BPPV among both cohorts calculating from events of BPPV per 1000 person-years of observation time was 1.79 (95% CI 1.23 to 2.58, p=0.002). Following adjustments for age, sex and comorbidities, patients with depressive disorders were 1.55 times more likely to develop BPPV (95% CI 1.08 to 2.23, p=0.019) as compared with control patients. In addition, hyperthyroidism (HR=3.75, 95% CI 1.67-8.42, p=0.001) and systemic lupus erythematosus (SLE) (HR=3.47, 95% CI 1.07 to 11.22, p=0.038) were potential risk factors for developing BPPV in patients with depressive disorders.

CONCLUSIONS

Patients with depressive disorders may have an increased risk of developing BPPV, especially those who have hyperthyroidism and SLE.

Traumatic versus Idiopathic Benign Positional Vertigo: Analysis of Disease, Treatment, and Outcome Characteristics

Objective

To compare characteristics between traumatic and idiopathic benign paroxysmal positional vertigo (BPPV) focusing on outcomes.

Study Design

Retrospective chart review.

Setting

High-volume tertiary otology center.

Subjects and Methods

Records of patients with BPPV treated at a single institution from 2007 to 2017 were analyzed. Traumatic BPPV was defined as BPPV symptoms beginning within 30 days following head trauma. Patient, disease, treatment, and outcome characteristics were compared between traumatic and idiopathic BPPV groups.

Results

A total of 1378 patients with BPPV were identified, 110 (8%) of which had traumatic BPPV. The overall resolution rate was 76%, and the recurrence rate was 38%. Patients with traumatic BPPV were younger (mean age: 61 vs 65 years, P = .007) and more likely to be male (40% vs 27%, P = .004) than patients with idiopathic BPPV. Traumatic BPPV was more likely to affect both ears (32% vs 19%, P = .009). No significant association was detected between trauma history and resolution rate, recurrence rate, number of treatment visits, or affected semicircular canals.

Conclusion

Patients with traumatic BPPV are more likely to be young and male than those with idiopathic disease. Although traumatic BPPV is often bilateral, outcomes for traumatic BPPV may be similar to those for idiopathic BPPV, contrary to prior reports.

Patient, disease, and outcome characteristics of benign paroxysmal positional vertigo with and without Meniere's disease

BACKGROUND

Meniere's disease (MD)-associated benign paroxysmal positional vertigo (BPPV) is complex and difficult to diagnose, and reports of its prevalence, pathologic features and outcomes are sparse and conflicting.

OBJECTIVE

Report disease characteristics and outcomes associated with the presence of MD in patients with BPPV.

MATERIALS/METHODS

A retrospective study of patients with BPPV between 2007 and 2017 at a single, high-volume institution.

RESULTS

Of 1581 patients with BPPV identified, 7.1% had MD and 71.9% of those patients had BPPV in the same ear(s) as MD. Patients with MD were more likely to have lateral semicircular canalithiasis (11.6% vs. 5.5%, p = .009) and multiple canalithiasis (7.1% vs. 2.5%, p = .005). MD was associated with an increased rate of resolution of BPPV (p = .008) but also increased time to resolution (p = .007). There was no association between MD and recurrence of BPPV.

CONCLUSIONS

MD is associated with lateral canalithiasis. Contrary to prior reports, BPPV in MD can affect either ear and was not associated with poorer outcomes than idiopathic BPPV.

SIGNIFICANCE

The largest series to date investigating disease and outcome characteristics for BPPV in MD is presented. These data inform diagnosis and expectations in the management of these complex patients.

Causes of Persistent Positional Vertigo Following Posterior Semicircular Canal Occlusion for Benign Paroxysmal Positional Vertigo

OBJECTIVE

To report causes of persistent recalcitrant positional vertigo (PRPV) after posterior semicircular canal occlusion (PSCO) for benign paroxysmal positional vertigo (BPPV).

STUDY DESIGN

Retrospective chart review.

SETTING

Single high-volume otology practice.

PATIENTS

Patients diagnosed with BPPV from 2007 to 2017.

INTERVENTION

PSCO and follow-up care including diagnostic and particle repositioning maneuvers for recurrent BPPV.

MAIN OUTCOME MEASURES

PRPV, defined as recalcitrant positional vertigo for any reason following PSCO.

RESULTS

Twenty seven PSCO operations were performed in 26 patients. Twenty five patients (96.2%) had resolution of the Dix-Hallpike test in the operated ear. Eleven patients (42.3%) developed BPPV postoperatively, three (11.5%) in the operated ear and eight (30.8%) in the contralateral ear. Five of eight patients (62.5%) who developed contralateral BPPV had unilateral BPPV preoperatively. Eight patients (30.8%) developed BPPV at least twice after surgery or did not resolve, qualifying as PRPV, and all but one of these events occurred in the nonsurgical ear. No instances of cerebrospinal fluid leak, postoperative infection, facial palsy, clinically significant hearing loss, or death occurred.

CONCLUSIONS

PSCO is a safe and effective option for recalcitrant BPPV. However, 30.8% of patients, including patients with initially unilateral BPPV, had recalcitrant positional vertigo postoperatively, usually due to contralateral BPPV. Patients considering PSCO should be counseled regarding this risk to ensure realistic expectations.

Treatment of Patients With Benign Paroxysmal Positional Vertigo and Severe Immobility Using the Particle Repositioning Chair: A Retrospective Cohort Study

OBJECTIVE

To report treatment of benign paroxysmal positional vertigo (BPPV) in patients unable to undergo traditional canalith repositioning maneuvers (CRMs) using a particle repositioning chair (PRC).

METHODS

A retrospective chart review was conducted at a single high-volume otology practice of patients diagnosed with BPPV from 2007 to 2017 with immobility prohibiting use of traditional CRMs. Patients were diagnosed and treated using a PRC, and outcome measures including resolution, recurrence, and number of treatment visits were recorded.

RESULTS

A total of 34 patients meeting criteria were identified, 24 of whom had cervical spine disease and 10 of whom had other prohibitive immobility. Symptoms were present for between 5 days and 11 years at presentation, with mean and median of 552 and 90 days, respectively. Symptoms resolved in 68% of patients and recurred in 13% of those patients. Most patients required 1 treatment visit.

CONCLUSIONS

Successful treatment of patients with BPPV and concomitant immobility prohibiting traditional CRMs is reported using the PRC. Benign paroxysmal positional vertigo in the setting of immobility is an indication for treatment with a PRC if available.

Idiopathic benign paroxysmal positional vertigo in the elderly: a long-term follow-up study

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral-type vertigo in the elderly. While some studies have investigated BPPV among the elderly, no study has focused on the isolated idiopathic BPPV (iBPPV) in the elderly.

AIMS

To investigate the clinical features and recurrence rate in elderly patients diagnosed with iBPPV.

METHODS

The authors prospectively reviewed the medical records of 627 patients diagnosed with BPPV, and a total of 370 patients fulfilled the inclusion criteria. The subjects were divided into two groups by age (experimental group ≥65 years and control group 17-64 years), and the gender, numbers of canalith reposition maneuver (CRM) for successful treatment, time elapsed from onset of symptoms to clinic visit, the affected semicircular canal, and the 1- and 5-year recurrence proportion were analyzed.

RESULTS

The gender, numbers of CRM for successful treatment, affected semicircular canal, and the 1- and 5-year recurrence proportion showed no statistically significant difference between two groups (p > 0.05). The only exception was the experimental group which took a longer duration from manifestation of symptoms to hospital visit than control group (student's t test, p = 0.021).

DISCUSSION

Several previous studies report that the elderly with iBPPV shows more protracted clinical course and much higher recurrence rate than younger adult. Unlike those reports, our study showed no significant differences about the clinical features and recurrence rate between age groups.

CONCLUSION

The elderly with iBPPV could be treated as effective as general population.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)

Objective

This update of a 2008 guideline from the American Academy of Otolaryngology—Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV.

Purpose

The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV.

Action Statements

The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow-up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.

Validation of 5-item and 2-item questionnaires in Chinese version of Dizziness Handicap Inventory for screening objective benign paroxysmal positional vertigo

As possible candidate screening instruments for benign paroxysmal positional vertigo (BPPV), studies to validate the Dizziness Handicap Inventory (DHI) sub-scale (5-item and 2-item) and total scores are rare in China. From May 2014 to December 2014, 108(55 with and 53 without BPPV) patients complaining of episodic vertigo in the past week from a vertigo outpatient clinic were enrolled for DHI evaluation, as well as demographic and other clinical data. Objective BPPV was subsequently determined by positional evoking maneuvers under the record of optical Frenzel glasses. Cronbach's coefficient α was used to evaluate the reliability of psychometric scales. The validity of DHI total, 5-item and 2-item questionnaires to screen for BPPV was assessed by receiver operating characteristic (ROC) curves. It revealed that the DHI 5-item questionnaire had good internal consistency (Cronbach's coefficient α = 0.72). Area under the curve of total DHI, 5-item and 2-item scores for discriminating BPPV from those without was 0.678 (95 % CI 0.578-0.778), 0.873(95 % CI 0.807-0.940) and 0.895(95 % CI 0.836-0.953), respectively. It revealed 74.5 % sensitivity and 88.7 % specificity in separating BPPV and those without, with a cutoff value of 12 in the 5-item questionnaire. The corresponding rate of sensitivity and specificity was 78.2 and 88.7 %, respectively, with a cutoff value of 6 in 2-item questionnaire. The present study indicated that both 5-item and 2-item questionnaires in the Chinese version of DHI may be more valid than DHI total score for screening objective BPPV and merit further application in clinical practice in China.