Postmaneuver restrictions in benign paroxysmal positional vertigo: An individual patient data meta-analysis

Seven years of experience with treatment of benign paroxysmal positional vertigo with a mechanical rotational chair

Background

Throughout the last decade, several mechanical rotational chairs have been developed for diagnostics and treatment of patients with a typical case history of benign paroxysmal positional vertigo. Sparse evidence, however, exists in terms of diagnostic accuracy and treatment efficiency with these mechanical rotational chairs. Also, recommendations for optimal use of these chairs are yet to be determined.

Objective

Primary objective was to evaluate overall treatment of benign paroxysmal positional vertigo with a mechanical rotational chair and secondary objectives included description of patient- and BPPV characteristics, determination of subjective and objective outcomes, as well as analyzation of recurrence- and recurrence-related risk factors following successful treatment.

Methods

Retrospective cohort study with 635 patients diagnosed with benign paroxysmal positional vertigo and treated by means of a mechanical rotational chair during a 7-year period from 2014 to 2021 at a tertiary University hospital. Patient- and disease-specific characteristics, treatment and recurrence data were collected through reviewing of patient records.

Results

The mean number of required treatments was 2.7 when accounting for a six percent treatment failure rate (defined as a need of more than 10 treatments), and 3.7 when not. Bilateral mono-canal affection required 3.8 treatments, unilateral multi-canal 3.5 treatments, and the combination of bilateral and multi-canal affection 5.2 treatments. All these scenarios were associated with significantly higher numbers of required treatments when compared to unilateral mono-canal affection, which required 1.9 treatments. The overall recurrence rate was 25.4 percent.

Conclusion

A mechanical rotational chair provides successful treatment of benign paroxysmal positional vertigo. Mechanical rotational chairs should primarily be reserved for the treatment of retractable and atypical benign paroxysmal positional vertigo patients. Many aspects of the optimal use of these chairs still require elaborative assessment.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Benign paroxysmal positional vertigo

Objectives

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular end‐organ disease. This article aims to summarize research findings and key discoveries of BPPV. The pathophysiology, diagnosis, nonsurgical, and surgical management are discussed.

Methods

A comprehensive review of the literature regarding BPPV up through June 2018 was performed.

Results

BPPV is typified by sudden, brief episodes of vertigo precipitated by specific head movements. While often self‐limited, BPPV can have a considerable impact on quality of life. The diagnosis can be established with a Dix‐Hallpike maneuver for the posterior and anterior canals, or supine roll test for the horizontal canal, and typically does not require additional ancillary testing. Understanding the pathophysiology of both canalithiasis and cupulolithiasis has allowed for the development of various repositioning techniques. Of these, the particle repositioning maneuver is an effective way to treat posterior canal BPPV, the most common variant. Options for operative intervention are available for intractable cases or patients with severe and frequent recurrences.

Conclusions

A diagnosis of BPPV can be made through clinical history along with diagnostic maneuvers. BPPV is generally amenable to in‐office repositioning techniques. For a small subset of patients with intractable BPPV, canal occlusion can be considered.

Level of Evidence

N/A

Treatment of benign paroxysmal positional vertigo. A clinical review

Benign paroxysmal positional vertigo (BPPV) is the most frequent episodic vestibular disorder. It is due to otolith rests that are free into the canals or attached to the cupulas. Well over 90% of patients can be successfully treated with manoeuvres that move the particles back to the utriculus. Among the great variety of procedures that have been described, the manoeuvres that are supported by evidenced-based studies or extensive series are commented in this review. Some topics regarding BPPV treatment, such as controlling the accuracy of the procedures or the utility of post-manoeuvre restrictions are also discussed.

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.

Chiropractic management of benign paroxysmal positional vertigo using the Epley maneuver: a case series

OBJECTIVE

The purpose of this case series is to describe the management of benign paroxysmal positional vertigo in a chiropractic clinical setting.

CLINICAL FEATURES

Eight patients (4 women, 4 men) with symptoms of persistent benign paroxysmal positional vertigo presented for chiropractic care. The outcome measures included self-reported resolution of vertigo, a Short Form 12 Health Survey, Measure Yourself Medical Outcome Profile, and the Dix-Hallpike maneuver. Outcome measures were assessed at initial assessment, 6 days, 30 days, and 3 months postintervention.

INTERVENTION AND OUTCOME

The patients underwent one or more canalith repositioning procedures (Epley maneuver). Scores in each of the categories decreased from the initial to 6-day assessment and then again at the 30-day assessment. The effects of the treatment on the Short Form 12 scores showed changes between the initial assessment and 30 days posttreatment.

CONCLUSION

The patients in this case series demonstrated reduction in symptoms with chiropractic management.

Evidence-based practice: management of vertigo

The article focuses on the evidence basis for the management of benign paroxysmal positional vertigo, the most common diagnosis of vertigo in both primary care and subspecialty settings. An overview is presented, along with evidence-based clinical assessment, diagnosis, and management. Summaries of differential diagnosis of vertigo and outcomes are presented.

Vertigo during the Epley maneuver and success rate in patients with BPPV

To investigate whether reported vertigo during the Epley maneuver predicts therapeutic success in patients with benign paroxysmal positioning vertigo of the posterior semicircular canal (pc-BPPV). Fifty consecutive adult patients with pc-BPPV, based on a positive Dix-Hallpike test (DHT), were treated with the Epley maneuver and retested after 2 days. Patients were asked to report the presence of vertigo upon assuming each of the four positions of the maneuver. Thirty seven patients (74 %) were treated successfully in one session. Twenty out of 23 patients who reported vertigo at turning the head to the opposite side (2nd position) had a negative DHT on follow-up. These patients had a higher chance of a successful outcome compared to patients who did not report vertigo in the 2nd position (Odds ratio 5.3, 95 % CI: 1.3-22.2, p = 0.022). Report of vertigo at the other positions was not associated with the outcome. Report of vertigo at the second position of a single modified Epley maneuver is associated with therapeutic success.

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

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

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Meta-analysis of treatment outcomes for sinonasal undifferentiated carcinoma

OBJECTIVES

This study reviews the published outcomes regarding sinonasal undifferentiated carcinoma (SNUC) since the initial description in 1986. This article attempts to (1) understand and better describe the benefit and survival advantages associated with using radiation, chemotherapy, and surgical treatment and (2) support the recommendations of a treatment regimen with current available data in the literature.

DATA SOURCES

Published English-language literature.

REVIEW METHODS

A PubMed search for articles related to SNUC, along with the bibliographies of those articles to avoid missing articles. All articles were examined for an independent patient data meta-analysis. Thirty studies with 167 cases from 1986 to October 2009 were identified. Demographics, disease extent, treatment, follow-up, and survival were analyzed. Patient cohorts mirroring Kadish staging were created. Kaplan-Meier curves were constructed.

RESULTS

Follow-up range was 1 to 195 months (mean 23.4 months, median 15 months). At last follow-up, 26.3% of patients were alive with no evidence of disease, 21.0% were alive with disease, and 52.7% were dead of disease. The use of surgery was found to be the best single modality, but chemotherapy and radiation were important as adjuncts in extensive and aggressive disease. The presence of neck metastases was a poor prognostic sign.

CONCLUSION

This study, containing the largest pool of SNUC patients, confirms a poor overall prognosis. The data suggest that the optimal treatment should include surgery, with radiation and/or chemotherapy as adjunct treatments. Neck disease in advanced local disease is a poor prognostic sign and merits aggressive treatment with multimodality therapy.

The Role of Postural Restrictions after BPPV Treatment: Real Effect on Successful Treatment and BPPV's Recurrence Rates

Background. Canalith repositioning techniques are adequately established in the literature, as the treatment of choice for benign paroxysmal positional vertigo. However, the role of the posttreatment instructions is still not clearly defined. Patients and Methods. A retrospective chart review of 82 patients was conducted in order to determine the efficacy of postural restrictions, when combined with the classic canalith repositioning techniques, in terms of successful treatment and recurrence rates. Follow-up period reached at least 12 months after the initial treatment. Results. In this study, postural restrictions did not appear to significantly affect the outcomes of repositioning maneuvers, as well as the recurrence rate. Conclusions. Although this study, as well as most recent control studies, states that there is no significant effect of postmaneuver postural restrictions on both treatment and recurrence rates, larger multicentric research projects, adopting improved methodology, are still necessary in order to determine the contribution of such restrictions to both the therapeutic results and the prevention of recurrence. Adequate followup, focusing on the first six months after the initially successful repositioning maneuver, is also of paramount importance.

Postural Control in Older Patients with Benign Paroxysmal Positional Vertigo

Objective. To evaluate the effectiveness of a canalith-repositioning procedure in postural control of older patients with idiopathic benign paroxysmal positional vertigo (BPPV).

Study Design. Prospective clinical trial.

Setting. A tertiary referral center.

Methods. A 9-month follow-up survey with a prospective design was conducted among 33 older patients with BPPV. Patients underwent static posturography (Balance Rehabilitation Unit [BRU]) and were administered the Dizziness Handicap Inventory (DHI) before and after the maneuver. After the treatment, they were compared with 33 healthy older subjects. The posturography parameters were the limit of stability (LOS), the center of body-pressure area (COP), and the velocity of oscillation (VOS) under conditions of visual, somatosensory, and visual-vestibular conflict.

Results. One canalith-repositioning procedure relieved most patients’ complaints (54.5%), and 100% were relieved with 1 to 3 maneuvers. Total DHI score and all subscales improved after treatment ( P < .01). The LOS values pretreatment (mean [SD] 134.27 [55.32] cm2) and posttreatment (181.03 [47.79] cm2) were significantly different ( P < .01). Comparative analysis of COP values showed a relevant statistical difference in 8 of 10 postmaneuver conditions ( P < .01). The postmaneuver VOS showed a significant difference under 7 conflict conditions. There were no differences between the healthy older subjects and treated patients for all VOS values under all conditions and for COP values under 9 conditions.

Conclusion. The canalith-repositioning procedure promotes remission of symptoms, an increase in LOS, and improvement in postural control under conditions of somatosensory and visual conflict and visual-vestibular interaction.

Are postural restrictions necessary for management of posterior canal benign paroxysmal positional vertigo?

OBJECTIVES

An important component of management of benign paroxysmal positional vertigo (BPPV) has been the application of postural restrictions after use of a canalith repositioning maneuver (CRM) to prevent the return of otolithic debris into the posterior semicircular canal (PSC). This study was designed to explore the effectiveness of postural restrictions in patients with BPPV caused by otolithic debris in the PSC.

METHODS

Seventy-four adult patients with unilateral PSC BPPV were enrolled into this study. All patients were managed with a CRM--either the modified Epley maneuver or the Semont maneuver. The patients were divided randomly into 2 groups: group A, with postural restrictions, and group B, without postural restrictions. The statistical analysis was performed with X2 tests and t-tests.

RESULTS

No patients in either group showed positional nystagmus in the posttreatment evaluation under infrared videonystagmoscopy. No patients had symptoms of vertigo after the therapy. The results of follow-up vestibular tests were normal in both groups.

CONCLUSIONS

In our experience, postural restrictions do not enhance the beneficial effect of the CRMs. They do not seem to have any protective role and therefore should not be recommended as an adjunct to the treatment of PSC BPPV.