Natural History of Benign Paroxysmal Positional Vertigo and Efficacy of Epley and Lempert Maneuvers

The reliability of a subtype-determining questionnaire in efficient benign paroxysmal positional vertigo diagnosis in geriatrics

Introduction

Benign paroxysmal positional vertigo (BPPV), the most common cause of dizziness, especially for older adults, exposes patients to the lethal risk of falling. However, the diagnosis of BPPV in this population can be more elusive as they present few characteristic symptoms. Therefore, we explored the application of a subtype-determining questionnaire in BPPV diagnosis among the geriatric population.

Methods

Patients were assigned to the aware and unaware groups. In the aware group, the technician would directly test the suspected canal indicated by the questionnaire, whereas, in the unaware group, the technician performed the regular positional test. The diagnostic parameters of the questionnaire were examined.

Results

The accuracy, sensitivity, and specificity of questions 1-3 for diagnosing BPPV were 75.8, 77.6, and 74.7%, respectively. Question 4 demonstrated an accuracy of 75.6% in ascertaining the BPPV subtype, question 5 showed an accuracy of 75.6% in determining the affected side, and question 6 yielded an accuracy of 87.5% in distinguishing canalithiasis or cupulolithiasis. Examination time was shorter in the aware group than that in the unaware group (P < 0.05). No difference was found between the two groups for treatment time (P = 0.153).

Conclusion

This subtype-determining questionnaire is practical in daily use and capable of providing instructive information for an efficient diagnosis in geriatric patients with BPPV.

Assessment of Osteoporosis and Vitamin D3 Deficiency in Patients with Idiopathic Benign Paroxysmal Positional Vertigo (BPPV)

Background and objectives: Osteoporosis and vitamin D3 deficiency may be risk factors of benign paroxysmal positional vertigo (BPPV). The aim of this study was to assess the prevalence of osteoporosis and 25(OH) vitamin D3 deficiency in a group of patients with idiopathic benign paroxysmal positional vertigo. Materials and Methods: Thirty-five patients (twenty-eight women and seven men) with posterior semicircular canal BPPV were enrolled in the study. The subjects underwent hearing assessment (tonal audiometry and impedance audiometry) and the Dix-Hallpike maneuver. Serum 25(OH) vitamin D3 levels were determined and lumbar spine bone densitometry was performed. The relationships between sex, age, height, Body Mass Index (BMI), vitamin D3 levels and bone densitometry results were assessed. Results: The diagnosis of osteoporosis was confirmed in 1 patient (3%), 3 subjects were osteopenic (8.6%), and normal bone densitometry was found in 31 (88.6%) patients. Conclusions: We found no statistically significant relationships between age, BMI or vitamin D3 levels and bone densitometry results in patients with idiopathic BPPV.

Epley maneuver for benign paroxysmal positional vertigo: Evidence synthesis for guidelines for reasonable and appropriate care in the emergency department

BACKGROUND

Canalith repositioning maneuvers (such as the Epley maneuver) are recommended by specialty guidelines for management of benign paroxysmal positional vertigo (BPPV) yet are frequently underutilized in the emergency department (ED).

METHODS

We conducted a systematic review of systematic reviews to summarize the evidence of Epley maneuver for the treatment of posterior canal (pc) BPPV in any setting. We included systematic reviews of randomized controlled trials (RCTs) that compared Epley to control in adult patients with pc-BPPV. Titles, abstracts, and full texts were screened in duplicate. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. Odds ratios (OR) and 95% confidence intervals (CI) are reported. Meta-analysis of individual studies was conducted with random and fixed effects.

RESULTS

From 2,228 titles, 7 systematic reviews were selected for quality assessment. One review was of higher methodological quality, included only RCTs, and was the most current and comprehensive. Five of the 11 RCTs of the review, including 312 patients with pc-BPPV diagnosed by Dix-Hallpike, were relevant to our question. Meta-analysis of 4 RCTs (251 patients) showed the use of Epley (as compared to control) was associated with higher complete resolution of vertigo at 1 week (OR 7.19, CI 1.52 to 33.98, moderate certainty). Meta-analysis of 3 RCTs (195 patients) showed the use of Epley was associated with higher conversion to negative Dix-Hallpike at 1 week (OR 6.67, CI 1.52 to 33.98, moderate certainty). The number-needed-to-treat was 3. Meta-analysis of the outcomes at 1 month, and when observational studies were included, showed similar results. No serious adverse effects were reported.

CONCLUSIONS

Symptoms of pc-BPPV improve with the Epley maneuver. Emergency clinicians should become familiar with performing the Epley for BPPV. Further studies on ED implementation and clinician education of Epley are needed.

Significance of subtype-determining questionnaire in efficient diagnosis and treatment of BPPV

BACKGROUND

Rapid recognition of benign paroxysmal positional vertigo (BPPV) matters in many ways, questionnaires evolve as a new alternative for diagnosis. A subtype-determining questionnaire is a more advanced but rarely studied type.

OBJECTIVE

To explore the practicability of a subtype-determining questionnaire in facilitating diagnosis and treatment of BPPV.

METHODS

A BPPV subtype-determining questionnaire was applied to vertiginous patients. All patients underwent the positional test, performed by one technician, who was either informed or uninformed about questionnaire results randomly. In the informed group, the technician checked the canal indicated by the questionnaire straightforwardly; in the uninformed group, she performed the conventional positional test. Diagnostic parameters of the questionnaire and disparities between the 2 groups were investigated.

RESULTS

The accuracy, sensitivity, specificity of question 1-3 for diagnosing BPPV is 74.4%, 90.9%, 66.6% respectively. Question 4 shows an accuracy of 80.7% in determining BPPV subtype, question 5 yields an accuracy of 78.7% in ascertaining the affected side, question 6 exhibits an accuracy of 87.2% in deciding canalithiasis or cupulolithiasis. Both examination and treatment time were shorter in the informed group (p < .05).

CONCLUSION

This subtype-determining questionnaire has appealing diagnostic ability. It provides valuable information that's conducive to fast diagnosis and efficient treatment of BPPV.

An analysis of correlation between persistent positional nystagmus and treatment outcome in patients with lateral canal benign paroxysmal positional vertigo

Objective

Material and method

Results

Conclusion

Early management for traumatic benign paroxysmal positional vertigo in traumatically injured patients

OBJECTIVES

The purpose of this study was to identify the clinical features of posttraumatic benign paroxysmal positional vertigo (t-BPPV) in traumatically injured patients, investigating the effectiveness of the early diagnosis and management including canalith repositioning procedures (CRPs).

PATIENTS AND METHODS

The subjects of the present study were 74 patients who were hospitalized in the Trauma Center, Ajou University Hospital. We investigated the relationship between injury mechanisms and t-BPPV. Patients with t-BPPV were categorized into mild (typical BPPV) and severe (bilateral, recurrent, or persistent) types.

RESULTS

Of the 74 patients, 41 were diagnosed with t-BPPV. Nineteen were mild and 22 were severe types. 'A fall' (36%) and 'pedestrian car accident' (32%) were common as the injury mechanisms provoking severe t-BPPV. In the severe t-BPPV group, they were hospitalized longer (as median value, 20 days in the severe group vs. 10 days in the mild group, P = 0.004), stayed longer in intensive care unit (3 days vs. 0 days, P = 0.016), and needed more days until the BPPV management (13.5 days vs. 6 days, P = 0.021). Major trauma (the Injury Severity Score >15) patients had a longer time to implementation of the first CRPs (10 days in major trauma and 3 days in minor trauma patients, P = 0.019).

CONCLUSIONS

Severity of trauma and longer duration of ICU treatment were factors delaying BPPV management. This delay could negatively affect the progress of t-BPPV. Diagnostic and therapeutic maneuvers including CRPs should be performed as early as possible, even in severely injured patients.

Poor Treatment Outcomes Following Repositioning Maneuvers in Younger and Older Adults With Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review aimed to methodically review the available evidence on poor treatment outcomes after repositioning maneuver treatments in adults with BPPV and whether there are differences in the outcomes for older and younger adults.

DATA SOURCES

Embase, CINAHL, Scopus, PsycINFO (Ovid), Central Register of Controlled Trials (CENTRAL), and PubMed.

REVIEW METHODS

Studies were included if they were prospective experimental or observational studies with a minimal follow-up of 1 month; the subjects were at least 18 years old, had BPPV, and were treated with repositioning maneuvers. Studies were excluded if they were not available in English full text and if the outcomes used were confined to positional tests and subjective vertigo rating. Methodological quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklists. Meta-analysis was performed to compare outcomes for younger and older (≥60 years) subjects where multiple studies utilized similar outcomes.

RESULTS

Thirty-five studies were selected. The methodological quality was poor in more than 60% of the studies. Treatment efficacy, based on positional test results and symptom resolution and recurrence were the most common outcomes. Balance and quality of life measures improved after treatment but were not always normalized. Residual symptoms and psychoemotional consequences persisted in some subjects, despite BPPV resolution. Meta-analyses indicated poorer dynamic balance recovery and increased self-perceived level of handicap in the older group relative to the younger group.

CONCLUSIONS AND IMPLICATIONS

Although repositioning maneuvers were effective in BPPV management, some patients experienced residual dizziness, postural instability, recurrences, and psychoemotional consequences at least 1 month after repositioning. Moreover, older adults experienced less improvements in dynamic balance and self-perceived handicap rating compared with younger people. These issues may further impact on older adults with BPPV physically and mentally and should be addressed by future better-quality research and interventions.

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.

Assessment of a Statistical Algorithm for the Prediction of Benign Paroxysmal Positional Vertigo

Importance

Benign paroxysmal positional vertigo (BPPV) is an otologic pathologic condition defined as a sensation of spinning triggered by changes in head position relative to gravity and caused by an entrapment of fragmented endolymph debris most commonly in the posterior semicircular canal. Confirmation of diagnosis requires experience with procedures that are poorly known by those other than practitioners with advanced otologic training. The complexity in the diagnosis of BPPV inspired the design of a questionnaire-based algorithm that would be useful for determining a vestibular diagnosis and treatment options.

Objective

To assess a statistical algorithm for the diagnosis of BPPV in a busy tertiary care setting, with the long-term goal of implementing a clinical pathway to efficiently diagnose and treat patients with dizziness.

Design, Setting, and Participants

In this retrospective case series, 200 patients who visited the Department of Otolaryngology-Head and Neck Surgery at Johns Hopkins University School of Medicine for their initial vertigo symptoms from September 1, 2016, to December 31, 2016, were assessed.

Interventions

Use of a validated patient questionnaire as a tool to differentiate patients with dizziness in an electronic medical record review.

Main Outcomes and Measures

Linear predictor (LP) value based on the questionnaire for the diagnosis of BPPV.

Results

Of the 200 patient visits reviewed (132 [66%] female), 106 (53.0%; 68 [64%] female) had the information necessary to calculate the LP value and had a confirmed final diagnosis. On the basis of an LP value of 0.2 or greater, the sensitivity for a diagnosis of BPPV was 0.75 and the specificity was 1.0. The positive predictive value was 1.0, whereas the negative predictive value was 0.96. Patients with BPPV had a statistically significantly different LP value (odds ratio, 5.92; 95% CI, 2.73-12.83) than did patients without BPPV.

Conclusions and Relevance

The findings of this study suggest that the algorithm is efficient for the diagnosis of BPPV in a clinical care setting.

Probable benign paroxysmal positional vertigo, spontaneously resolved: Incidence in medical practice, patients' characteristics and the natural course

Background

Probable benign paroxysmal positional vertigo, spontaneously resolved (pBPPVsr), is a variant of benign paroxysmal positional vertigo (BPPV) in which there is no observable nystagmus and no vertigo with any positional maneuver.

Objectives

To calculate the incidence pBPPVsr, compare the characteristics of the patients with pBPPVsr and BPPV not spontaneously resolved and describe the spontaneous resolution in the natural course of BPPV.

Methods

Multicenter prospective descriptive study. During a one-year period, all patients with suspected BPPV that presented to the Neurotology Units of five participating centers were recruited. The incidence of pBPPVsr was calculated as a percentage of the total number of patients with BPPV. The prevalence of several variables was compared between pBPPVsr and BPPV not spontaneously resolved. The timing of spontaneous resolution was estimated using Kaplan-Meier curves.

Results

457 patients met the inclusion criteria. The incidence of pBPPVsr was 33.5%. It was significantly higher in males, in patients with normal bone mass and in patients who were not taking sulpiride. A rate of 18% of spontaneous resolution after the first month and 51% after the first year was found. This percentage did not change in a significant way after this moment. The curves for males, patients under 50 and patients with normal blood pressure decreased significantly faster.

Conclusions

In our serie, BPPV spontaneously resolved in half of the patients with BPPV during the first year. This seemed to occur more commonly in males and could have been hindered by sulpiride intake, osteoporosis, advanced age and high blood pressure.

Optimal reassessment time for treatment response in posterior canal benign paroxysmal positional vertigo

OBJECTIVES/HYPOTHESIS

The present study aimed to evaluate the optimal reassessment time for treatment response in posterior canal benign paroxysmal positional vertigo (PC-BPPV) following the initial Epley maneuver.

STUDY DESIGN

Prospective, single-blinded, randomized study.

METHODS

One hundred eight patients with PC-BPPV agreed to participate. These patients received a single modified Epley maneuver (recommended by the 2008 American Academy of Otolaryngology-Head and Neck Surgery guidelines) daily until positional nystagmus disappeared during the Dix-Hallpike maneuver 24 hours after the treatment. Repeated Dix-Hallpike testing to reassess the treatment response was performed at 1 hour (post-1 hour), every 24 hours (post-24 hours) until the positional nystagmus resolved, 1 week (post-1 week), and 1 month (post-1 month) following the therapeutic maneuver. The difference in the resolution rates at post-1 hour and post-24 hours reassessment was analyzed, and the recurrence rates at post-1 week and post-1 month were evaluated.

RESULTS

The resolution rate was 67.6% at post-1 hour, which increased to 79.6% at post-24 hours reassessment. There was a statistically significant difference in the results of the Dix-Hallpike test between post-1 hour and post-24 hours follow-up. After complete resolution, nine out of 108 patients (8.3%) demonstrated recurrence within 1 month.

CONCLUSIONS

Reassessment after 24 hours following the initial Epley maneuver is more advantageous than a 1-hour follow-up in patients with PC-BPPV. This information may be helpful for clinicians in deciding the appropriate follow-up period after treatment for PC-BPPV.

LEVEL OF EVIDENCE

1b Laryngoscope, 130:496-499, 2020.

In whom does horizontal canal BPPV recur?

PURPOSE

The objective of this study is to examine the rate of horizontal canal BPPV recurrence of the same type and search for predisposing factors.

Practice Guidelines for the Diagnosis and Management of Benign Paroxysmal Positional Vertigo Otoneurology Committee of Spanish Otorhinolaryngology and Head and Neck Surgery Consensus Document

Benign Paroxysmal Positional Vertigo is the most frequent episodic vestibular disorder. The purpose of this guide, requested by the committee on otoneurology of the Spanish Society of Otolaryngology and Head and Neck Surgery, is to supply a consensus document providing practical guidance for the management of BPPV. It is based on the Barany Society criteria for the diagnosis of BPPV. This guideline provides recommendations on each variant of BPPV, with a description of the different diagnostic tests and the therapeutic manoeuvres. For this purpose, we have selected the tests and manoeuvres supported by evidence-based studies or extensive series. Finally, we have also included a chapter on differential diagnosis and a section relating to general aspects in the management of BPPV.

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.

Classification, diagnostic criteria and management of benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vertigo and the posterior and/or lateral semicircular canals are usually affected. BPPV is characterized by brief attacks of rotatory vertigo associated with positional and/or positioning nystagmus, which are elicited by specific head positions or changes in head position relative to gravity. In patients with the posterior-canal-type of BPPV, torsional nystagmus is induced by the Dix-Hallpike maneuver. In patients with the lateral-canal-type of BPPV, horizontal geotropic or apogeotropic nystagmus is induced by the supine roll test. The pathophysiology of BPPV is canalolithiasis comprising free-floating otoconial debris within the endolymph of a semicircular canal, or cupulolithiasis comprising otoconial debris adherent to the cupula. The observation of positional and/or positioning nystagmus is essential for the diagnosis of BPPV. BPPV is treated with the canalith repositioning procedure (CRP). Through a series of head position changes, the CRP moves otoconial debris from the affected semicircular canal to the utricle. In this review, we provide the classification, diagnostic criteria, and examinations for the diagnosis, and specific and non-specific treatments of BPPV in accordance with the Japanese practical guidelines on BPPV published by the Japan Society for Equilibrium Research.

Health care utilization, prognosis and outcomes of vestibular disease in primary care settings: systematic review

Vertigo and dizziness are frequent complaints in primary care that lead to extensive health care utilization. The objective of this systematic review was to examine health care of patients with vertigo and dizziness in primary care settings. Specifically, we wanted to characterize health care utilization, therapeutic and referral behaviour and to examine the outcomes associated with this. A search of the MEDLINE and EMBASE databases was carried out in May 2015 using the search terms ‘vertigo’ or ‘dizziness’ or ‘vestibular and primary care’ to identify suitable studies. We included all studies that were published in the last 10 years in English with the primary diagnoses of vertigo, dizziness and/or vestibular disease. We excluded drug evaluation studies and reports of adverse drug reactions. Data were extracted and appraised by two independent reviewers; 16 studies with a total of 2828 patients were included. Mean age of patients ranged from 45 to 79 with five studies in older adults aged 65 or older. There were considerable variations in diagnostic criteria, referral and therapy while the included studies failed to show significant improvement of patient-reported outcomes. Studies are needed to investigate current practice of care across countries and health systems in a systematic way and to test primary care-based education and training interventions that improve outcomes.

Long-term outcome of vertigo and dizziness associated disorders following treatment in specialized tertiary care: the Dizziness and Vertigo Registry (DiVeR) Study

To investigate the long-term outcome of interdisciplinary treatment in a tertiary care neuro-otology institution after 2 years as part of the Dizziness and Vertigo Registry study. Risk factors associated with unfavourable outcome were assessed. 3113 consecutive patients with disorders of vertigo and dizziness were recruited prospectively between March 2010 and February 2012. Patients were clinically assessed and treated according to their diagnosis. Standardized instruments were used at baseline and at 2-year follow-up [Dizziness Handicap Inventory (DHI), Quality of Life Questionnaire, General Depression Scale, Stait-Trait Anxiety Index], as well as a custom health-related questionnaire. The primary outcome variable of this observational study was the change in DHI after 2 years. Patients suffered from phobic postural vertigo (23%), benign peripheral paroxysmal vertigo (14.4%), unilateral vestibulopathy (10.5%), central vestibular disorders (8%), Menière's disease (9.8%), vestibular migraine (6.9%), bilateral vestibulopathy (5.5%), and vestibular paroxysmia (3.1%). Mean disease duration was 4.6 ± 6.3 years. 1272 patients were available for follow-up, 1159 completed the DHI score. 72.1% of patients improved in DHI score from baseline to 2 years follow-up. Mean reduction in DHI score was 14 points (p = 0.02). Long-term outcome following diagnosis and treatment in a specialized tertiary care centre is good and persistent after 2 years. Risk factors for an unfavourable outcome were advanced age, severe disability, constant vertigo or dizziness, and concomitant back pain, while depression and anxiety did not contribute to this risk considerably.

The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2002 and previously updated in 2004 and 2007.Benign paroxysmal positional vertigo (BPPV) is a syndrome characterised by short-lived episodes of vertigo in association with rapid changes in head position. It is a common cause of vertigo presenting to primary care and specialist otolaryngology clinics. Current treatment approaches include rehabilitative exercises and physical manoeuvres, including the Epley manoeuvre.

OBJECTIVES

To assess the effectiveness of the Epley manoeuvre for posterior canal BPPV.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 23 January 2014.

SELECTION CRITERIA

Randomised controlled trials of the Epley manoeuvre versus placebo, no treatment or other active treatment for adults diagnosed with posterior canal BPPV (including a positive Dix-Hallpike test). The primary outcome of interest was complete resolution of vertigo symptoms. Secondary outcomes were conversion of a 'positive' Dix-Hallpike test to a 'negative' Dix-Hallpike test and adverse effects of treatment.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 11 trials in the review with a total of 745 patients.Five studies compared the efficacy of the Epley manoeuvre against a sham manoeuvre, three against other particle repositioning manoeuvres (Semont, Brandt-Daroff and Gans) and three against a control (no treatment, medication only, postural restriction). Patients were treated in hospital otolaryngology departments in eight studies and family practices in two studies. All patients were adults aged 18 to 90 years old, with a sex ratio of 1:1.5 male to female.There was a low risk of overall bias in the studies included. All studies were randomised with six applying sealed envelope or external allocation techniques. Eight of the trials blinded the assessors to the participants' treatment group and data on all outcomes for all participants were reported in eight of the 11 studies. Complete resolution of vertigo Complete resolution of vertigo occurred significantly more often in the Epley treatment group when compared to a sham manoeuvre or control (odds ratio (OR) 4.42, 95% confidence interval (CI) 2.62 to 7.44; five studies, 273 participants); the proportion of patients resolving increased from 21% to 56%. None of the trials comparing Epley versus other particle repositioning manoeuvres reported vertigo resolution as an outcome. Conversion of Dix-Hallpike positional test result from positive to negative Conversion from a positive to a negative Dix-Hallpike test significantly favoured the Epley treatment group when compared to a sham manoeuvre or control (OR 9.62, 95% CI 6.0 to 15.42; eight studies, 507 participants). There was no difference when comparing the Epley with the Semont manoeuvre (two studies, 117 participants) or the Epley with the Gans manoeuvre (one study, 58 participants). In one study a single Epley treatment was more effective than a week of three times daily Brandt-Daroff exercises (OR 12.38, 95% CI 4.32 to 35.47; 81 participants). Adverse effects Adverse effects were infrequently reported. There were no serious adverse effects of treatment. Rates of nausea during the repositioning manoeuvre varied from 16.7% to 32%. Some patients were unable to tolerate the manoeuvres because of cervical spine problems.

AUTHORS' CONCLUSIONS

There is evidence that the Epley manoeuvre is a safe, effective treatment for posterior canal BPPV, based on the results of 11, mostly small, randomised controlled trials with relatively short follow-up. There is a high recurrence rate of BPPV after treatment (36%). Outcomes for Epley manoeuvre treatment are comparable to treatment with Semont and Gans manoeuvres, but superior to Brandt-Daroff exercises.

A multicenter randomized double-blind study: comparison of the Epley, Semont, and sham maneuvers for the treatment of posterior canal benign paroxysmal positional vertigo

We evaluated the short-term efficacy of Epley, Semont, and sham maneuvers for resolving posterior canal benign paroxysmal positional vertigo (BPPV) in a prospective multicenter randomized double-blind controlled study. Subjects were randomly divided into three groups: Epley (36 patients), Semont (32 patients), and sham (Epley maneuver for the unaffected side, 31 patients). Out of 14 institutes which participated in this study, 5 institutes had previous experience of the Epley but not the Semont maneuver and the other 9 had previous experience of both maneuvers. Each maneuver was repeated twice if there was still positional vertigo or nystagmus on day 0, and the presence of nystagmus and vertigo on positional testing were evaluated immediately, 1 day, and 1 week after treatment. After the first maneuver, the Epley group showed a significantly higher resolution rate of positional nystagmus than the Semont or sham groups (63.9, 37.5, and 38.7%, respectively). After the second maneuver, the resolution rate (83.3%) of the Epley group was significantly higher than that (51.6%) of the sham group. At 1 day and 1 week after treatment, the resolution rate of the Epley group was significantly higher than those of the other groups. Similar results were seen for the resolution of positional vertigo. The Epley maneuver showed persistent resolution rates of positional vertigo and nystagmus without a fatigue phenomenon. The Epley maneuver was significantly more effective per maneuver than Semont or sham maneuvers for the short-term treatment of posterior canal BPPV. The Semont maneuver showed a higher success rate than the sham maneuver, but it was not significantly different.

Natural history of horizontal canal benign paroxysmal positional vertigo is truly short

The objective of the study is to characterize the natural course of positional vertigo and nystagmus in patients with horizontal canal benign paroxysmal positional vertigo (h-BPPV) and to analyze the difference in the natural course between the two variants of h-BPPV. We conducted a prospective study in 106 patients with geotropic type h-BPPV [h-BPPV (Geo)] (n = 43) and apogeotropic type h-BPPV [h-BPPV (Apo)] (n = 63) who agreed and signed the written informed consent of no treatment. All patients were asked to answer a detailed interview about the onset time of positional vertigo and to visit the hospital every 1-3 days. At every visit, they were interviewed about cessation time of positional vertigo and positional nystagmus was assessed. The mean period ± SD between the onset and remission of vertigo in the h-BPPV (Geo) was 6.7 ± 6.3 days, whereas that in the h-BPPV (Apo) was 3.7 ± 4.1 days. In addition, the mean period ± SD from the initial diagnosis to the disappearance of positional nystagmus in the h-BPPV (Geo) was 4.7 ± 3.9 days, whereas that in the h-BPPV (Apo) was 4.4 ± 5.0 days. Although the duration until natural remission of positional nystagmus did not differ between the two variants of h-BPPV, the remission of vertigo occurred faster in h-BPPV (Apo) than h-BPPV (Geo) (p < 0.05). The natural course of h-BPPV is much shorter than that indicated in previous reports. The positional vertigo disappeared faster in the h-BPPV (Apo) compared to the h-BPPV (Geo) unlike the positional nystagmus.

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.

Rapid Systematic Review of Repeated Application of the Epley Maneuver for Treating Posterior BPPV

Objective

To evaluate the effect of repeated application of the Epley maneuver on patient-reported symptom relief and resolution of nystagmus in patients with posterior benign paroxysmal positional vertigo (p-BPPV).

Data Sources

PubMed, Embase, and the Cochrane Library.

Methods

A systematic search was conducted. Studies reporting original study data were included. Relevance and risk of bias (RoB) of the selected articles were assessed. Studies with low relevance, high RoB, or both were excluded. Success percentages and mean values were extracted.

Results

A total of 955 unique studies were retrieved. Fourteen of these satisfied the eligibility criteria. All of the included studies carried a high relevance and a moderate RoB. The majority of studies were 1-armed trials, in which the Epley was repeated only in case previous attempt(s) had failed. The maneuver was not repeated if it was successful. In 32% to 90% of patients, the first treatment session was successful. Reported cumulative success percentages ranged from 40% to 100% after the second session, 67% to 98% after the third session, 87% to 100% after the fourth session, and 100% in the studies in which patients received 5 sessions. One study evaluating the effect of multiple maneuvers in a single session showed a rise in success percentages from 84% for 1 maneuver to 90% after 2 maneuvers and 92% after 3 maneuvers.

Conclusion

Multiple studies with moderate RoB show a beneficial effect of multiple sessions of the Epley maneuver in p-BPPV patients who are not fully cleared of symptoms after the first session.

Diagnosing and treating dizziness

Dizziness is a common presenting concern in primary care practice. The most useful diagnostic approach in distinguishing different types of dizziness is a thorough history and physical examination; additional tests are rarely necessary. Effective treatments exist for many causes of dizziness, and these treatments are often accomplished in the clinic or at home without the need for medication.

Rapid Systematic Review of the Epley Maneuver for Treating Posterior Canal Benign Paroxysmal Positional Vertigo

OBJECTIVE

The aim of this study was to compare watchful waiting to the Epley maneuver as a management option for patients with posterior canal benign paroxysmal positional vertigo (p-BPPV) regarding symptom relief.

DATA SOURCES

PubMed, Embase, and The Cochrane Library.

METHODS

A systematic search was conducted. Studies reporting original study data were included. Relevance and risk of bias (RoB) of the selected articles were assessed. Studies with low relevance, high RoB, or both were excluded. Absolute risk differences and their 95% confidence intervals (CIs) were extracted for the included studies.

RESULTS

A total of 1448 unique studies were retrieved. Eight of these satisfied the eligibility criteria. At 1-week follow-up, all included studies reported a clinically relevant effect in favor of the Epley maneuver regarding symptom relief (absolute risk differences ranging from 20% [95% CI, 5%-37%] to 59% [95% CI, 32%-76%]) or conversion to a negative Dix-Hallpike (absolute risk differences ranging from 17% [95% CI, -5%-37%] to 64% [95% CI, 29%-79%]). At 1-month follow-up, the results of the included studies diverged further. Absolute risk differences ranged from 6% (95% CI, -24%-35%) more symptom relief in favor of watchful waiting to 79% (95% CI, 56%-88%) in favor of the Epley maneuver.

CONCLUSION AND RECOMMENDATIONS

All data of the selected studies show a benefit in favor of the Epley maneuver at 1-week follow-up in the management of p-BPPV. The Epley maneuver should be considered in all patients with p-BPPV.

Can the affected semicircular canal be predicted by the initial provoking position in benign paroxysmal positional vertigo?

OBJECTIVES/HYPOTHESIS

The study evaluated the relationship between the position that initially provoked vertigo and the affected semicircular canal (SCC) in patients with benign paroxysmal positional vertigo (BPPV), and aimed to predict the side affected by BPPV through history taking regarding the provoking position.

STUDY DESIGN

Prospective study at a tertiary hospital.

METHODS

A total of 521 patients with BPPV involving the posterior or horizontal SCCs performed questionnaires at initial visit asking to choose the initial provoking position among the 10 positions corresponding to one of the three planes (roll, pitch, or yaw). After excluding 45 patients showing signs of simultaneous multiple canal or anterior canal involvement, the frequency of the provoking positions and the correlation between the side of the provoking position and the ear affected by BPPV were analyzed.

RESULTS

There were 239 patients with posterior SCC BPPV (p-BPPV) and 237 patients with horizontal SCC BPPV (h-BPPV). The waking-up position was the most common provoking position in both types of BPPV. Statistically significant correlation was demonstrated between the side of the provoking position at the onset of vertigo and the affected side by BPPV (P < .01) in patients with p-BPPV as well as h-BPPV (geotropic type [Geo]), but not in patients with h-BPPV (apogeotropic type [Apo]).

CONCLUSIONS

History taking regarding the side of provoking position at the onset of vertigo may help predict the side affected by BPPV in p-BPPV and h-BPPV (Geo). When h-BPPV (Apo) is suspected, further detailed examinations using additional localization methods should be performed.

Effects of sleep position on time course in remission of positional vertigo in patients with benign paroxysmal positional vertigo

CONCLUSION

The findings suggest that it is easy for otoconial debris dislodged from the utricle to fall into the posterior semicircular canal (PSCC) or the horizontal semicircular canal (HSCC) of the undermost ear during sleep, but not to exit from the uppermost ear in patients with benign paroxysmal positional vertigo (BPPV).

OBJECTIVE

The aims of the present study were two-fold. (1) To examine the association between the preferred side of head-lying during sleep and the side of the affected ear in patients with both posterior canal BPPV (P-BPPV) and horizontal canal BPPV (H-BPPV). (2) To see whether that position affects the time course in remission of their positional vertigo.

METHODS

One hundred and sixteen patients with P-BPPV and 40 patients with H-BPPV who showed a habitual preference for right or left side sleeping position were included in this study.

RESULTS

The side of the affected ear was significantly associated with the head-lying side during sleep in patients with P-BPPV and was closely but not significantly associated with it in patients with H-BPPV. However, the head-lying side during sleep did not affect the remission rate of their positional vertigo.

Benign paroxysmal positional vertigo after use of noise-canceling headphones

Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo. We describe a case of a woman presenting acutely with a severe episode of disabling positional vertigo. Although she had no known etiologic risk factors, this attack followed 12 hours of continuously wearing digital noise-canceling headphones. This is the first such reported association between BPPV and the use of this gadget. We also provide a short review of BPPV and speculate on the possible pathogenic mechanisms involved.

Does vertigo disappear only by rolling over? Rehabilitation for benign paroxysmal positional vertigo

CONCLUSION

We propose that the rolling-over maneuver (ROM) is as effective as the canalith repositioning maneuver (CRP) for the treatment of benign paroxysmal positional vertigo (BPPV). ROM involves easy movements, with only a small load. This therapy is suitable for most BPPV patients, even for those without an indication for CRP.

OBJECTIVES

BPPV is a common vestibular disorder. CRP is known to be an effective therapy for the treatment of BPPV. Because of its various movements of the head and body, it is impossible to perform CRP in BPPV patients with orthopedic impairments or in the elderly. For these patients, we perform a maneuver called ROM, which involves easy movements. In this study, we compared the efficacy of ROM with that of CRP in patients with posterior semicircular canal-type BPPV.

PATIENTS AND METHODS

The study included 22 patients with BPPV who were randomized and divided into the following 2 groups: 1) those treated by the modified Epley maneuver as CRP; and 2) those treated by ROM.

RESULTS

We found no significant difference between the two groups in the number of days from onset to remission of both nystagmus and vertigo.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo

Objectives:

This guideline provides evidence-based recommendations on managing benign paroxysmal positional vertigo (BPPV), which is the most common vestibular disorder in adults, with a lifetime prevalence of 2.4 percent. The guideline targets patients aged 18 years or older with a potential diagnosis of BPPV, evaluated in any setting in which an adult with BPPV would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with BPPV.

Purpose:

The primary purposes of this guideline are to improve 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 tests such as radiographic imaging and vestibular testing, and to promote the use of effective repositioning maneuvers for treatment. In creating this guideline, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of audiology, chiropractic medicine, emergency medicine, family medicine, geriatric medicine, internal medicine, neurology, nursing, otolaryngology–head and neck surgery, physical therapy, and physical medicine and rehabilitation.

Results

The panel made strong recommendations that 1) clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with nystagmus is provoked by the Dix-Hallpike maneuver. The panel made recommendations against 1) radiographic imaging, vestibular testing, or both in patients diagnosed with BPPV, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to BPPV that warrant testing; and 2) routinely treating BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines. The panel made recommendations that 1) if the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, clinicians should perform a supine roll test to assess for lateral semicircular canal BPPV; 2) clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo; 3) clinicians should question patients with BPPV for factors that modify management including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling; 4) clinicians should treat patients with posterior canal BPPV with a particle repositioning maneuver (PRM); 5) clinicians should reassess patients within 1 month after an initial period of observation or treatment to confirm symptom resolution; 6) clinicians should evaluate patients with BPPV who are initial treatment failures for persistent BPPV or underlying peripheral vestibular or CNS disorders; and 7) clinicians should counsel patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The panel offered as options that 1) clinicians may offer vestibular rehabilitation, either self-administered or with a clinician, for the initial treatment of BPPV and 2) clinicians may offer observation as initial management for patients with BPPV and with assurance of follow-up. The panel made no recommendation concerning audiometric testing in patients diagnosed with BPPV.

Disclaimer:

This clinical practice guideline is not intended as a sole source of guidance in managing benign paroxysmal positional vertigo. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgement or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem. ® 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

Clinical features of benign paroxysmal positional vertigo in Western Turkey

BACKGROUND

It was the aim of this study to analyze the clinical manifestations, the incidence of each variant and the comorbid conditions of benign paroxysmal positional vertigo (BPPV) as well as the response to treatment.

METHODS

One hundred and fifty-seven patients with BPPV were reviewed prospectively. An extensive neurotologic examination was performed. All patients were treated with an appropriate canalith repositioning maneuver (CRM).

RESULTS

In 138 patients, the posterior canal (PC) was involved, in 14 patients, the horizontal canal (HC), in 2 patients, the anterior canal (AC), and in 3 patients, both the PC and HC. A history of head trauma was identified in 17 patients. In 1 patient sensorineural hearing loss on the affected side and in another bilateral peripheral vestibular loss was present. A history of migraine was reported in 21 cases. A resolution attributable to the first CRM was achieved in 132 patients.

CONCLUSIONS

PC involvement was the most frequent type constituting 87.9% of all BPPV cases. HC, AC and mixed canal types were relatively rare constituting 8.9, 1.3 and 1.9% of the cases, respectively. Response to the first CRM was recorded in 84.1%. Association with migraine was recorded in 13.4% of the patients.

The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is a syndrome characterised by short-lived episodes of vertigo in association with rapid changes in head position. It is a common cause of vertigo presenting to primary care and specialist otolaryngology clinics. Current treatment approaches include rehabilitative exercises and physical manoeuvres including the Epley manoeuvre.

OBJECTIVES

To assess the effectiveness of the Epley manoeuvre compared to other treatments available for posterior canal benign paroxysmal positional vertigo, or no treatment.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library Issue 1, 2004), MEDLINE (1966 to 2004), EMBASE (1974 to 2004) and reference lists of identified publications. Date of the most recent search was January 2004.

SELECTION CRITERIA

Randomised trials of adults diagnosed with posterior canal BPPV (including a positive Dix-Hallpike test). Comparisons sought: Epley manoeuvre versus placebo Epley manoeuvre versus untreated controls Epley manoeuvre versus other active treatment Outcome measures that were considered include: frequency and severity of attacks of vertigo; proportion of patients improved by each intervention; and conversion of a "positive" Dix-Hallpike test to a "negative" Dix-Hallpike test

DATA COLLECTION AND ANALYSIS

Both reviewers independently extracted data and assessed trials for quality.

MAIN RESULTS

Fifteen trials were identified but twelve studies were excluded because of a high risk of bias, leaving three trials in the review. Trials were mainly excluded because of inadequate concealment during randomisation, or failure to blind outcome assessors. The studies included in the review (Lynn 1995; Froehling 2000; Yimtae 2003) addressed the efficacy of the Epley manoeuvre against a sham manoeuvre or control group by comparing the proportion of subjects in each group who had complete resolution of their symptoms, and who converted from a positive to negative Dix-Hallpike test. Individual and pooled data showed a statistically significant effect in favour of the Epley manoeuvre over controls. There were no serious adverse effects of treatment.

REVIEWERS' CONCLUSIONS

There is some evidence that the Epley manoeuvre is a safe effective treatment for posterior canal BPPV, although this is based on the results of only three small randomised controlled trials with relatively short follow up. There is no good evidence that the Epley manoeuvre provides a long term resolution of symptoms. There is no good evidence comparing the Epley manoeuvre with other physical, medical or surgical therapy for posterior canal BPPV.