Horizontal Canal Benign Positional Vertigo

Prevalence of and Theoretical Explanation for Type 2 Benign Paroxysmal Positional Vertigo

BACKGROUND AND PURPOSE

A variant of benign paroxysmal positional vertigo (BPPV) involves the subjective report of vertigo without the coinciding nystagmus. This presentation includes truncal retropulsion when sitting up from the ipsilesional provocative test (ie, Dix-Hallpike), which we term type 2 BPPV. The primary objective of this study is to prospectively determine the prevalence and describe the clinical course of type 2 BPPV. We offer a theoretical explanation for the absence of nystagmus.

METHODS

Prospective, observational study carried out in 2 tertiary hospitals. One hundred eighty patients (134 women, 46 men) met the inclusion criteria and were included between January 10, 2018, and October 30, 2019. Efficacy of physical therapy maneuvers was determined at 1-week follow-up. Three-dimensional reconstructions of the planes of the semicircular canal cupula from histological preparations are offered as evidence for the theoretical explanation.

RESULTS

One-third of the patients met the criteria for type 2 BPPV; the remainder had typical posterior or horizontal semicircular canal involvement. Symptoms from type 2 BPPV were longer in duration yet responded favorably to physical therapy maneuvers. Upon repeat testing, 19 patients treated for posterior canalithiasis developed a slight, persistent positional downbeat nystagmus in the Dix-Hallpike position that we propose as evidence the otoconia entered the short arm of the posterior semicircular canal.

DISCUSSION AND CONCLUSIONS

Our data and 3-dimensional rendering suggest the report of vertigo, yet absent nystagmus in type 2 BPPV is from otoconia aligning with the gravitoinertial vector during provocative testing that precludes cupular stimulation. Type 2 BPPV appears to be a common and treatable form of vertigo.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A372).

The role of low levels of vitamin D as a co-factor in the relapse of benign paroxysmal positional vertigo (BPPV)

BACKGROUND

Benign paroxysmal positional vertigo is characterized as brief episodes of vertigo that are exacerbated by the unexpected act of moving to a current provoking location. It is thought to be an otoconia-related balance disorder. Our objectives were to assess the serum concentrations of vitamin D and calcium (total and ionized) in cases with BPPV, determine if low vitamin D levels were regarded as a cause for BPPV relapse, and determine whether vitamin D supplementation would minimize the risk of BPPV relapse.

RESULTS

Sixty cases with BPPV were included in the study; 53 cases had posterior canal BPPV, while seven had lateral canal BPPV. Canalithiasis was the most common type of BPPV pathology. Forty cases had abnormally low levels of vitamin D. There was a statistically significant positive correlation between the mean vitamin D assay for all cases with BPPV and serum calcium. There was statistically significant difference in comparing the relapse of BPPV for group that receive vitamin D after one year follow up.

CONCLUSION

Abnormal vitamin D levels were linked with the incident and relapse of BPPV. Correction of low vitamin D levels was linked with the reduction of the relapse of BPPV.

Comparison of outcomes of the Epley and Semont maneuvers in posterior canal BPPV: A randomized controlled trial

OBJECTIVES

This study aims to compare the efficacy of the Epley and Semont maneuvers in relieving posterior canal benign paroxysmal positional vertigo (BPPV) arising in the in patients at the Outpatient Department of the Department of Otolaryngology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.

METHOD

In this prospective, randomized, comparative study, patients were assigned to receive one of the two treatment methods. First, BPPV was diagnosed with the Dix-Hallpike test. Then, each patient was treated by either the Epley or Semont maneuver. Immediately afterward, the efficacy of treatments was evaluated with the Dix-Hallpike test, and dizziness intensity was assessed with the visual analog scale (VAS).

RESULTS

This study enrolled 80 patients with posterior canal BPPV, 40 of which underwent the Epley maneuver and the other 40 underwent the Semont maneuver. In the first week, The Epley maneuver cured 37 (92.5%) of the 40 patients, and the Semont maneuver cured 36 (90%) of the 40 patients. Statistical analysis revealed no significant difference in the efficacy of these treatments (P = .251). Regarding dizziness intensity, VAS scores decreased from 6.48 to 1.65 after the Epley maneuver and from 6.53 to 2.18 after the Semont maneuver. Statistical analysis revealed that the Epley maneuver was superior to the Semont maneuver (P = .009) in reducing dizziness intensity.

CONCLUSIONS

The Epley and Semont maneuvers had similar efficacy in curing posterior canal BPPV. Regarding the severity of dizziness after treatment, the Epley maneuver produced significantly better results than did the Semont maneuver.Level of Evidence: II.

Lateral Modified Brandt-Daroff Exercises: A Novel Home Treatment Technique for Horizontal Canal BPPV

OBJECTIVES

Brandt-Daroff exercises (BDEs) are commonly used as an at-home treatment for posterior canalithiasis, but their efficacy in the treatment of benign paroxysmal positional vertigo (BPPV) of the horizontal canal (HC-BPPV) has not been previously studied. Using biomechanical model simulation, we investigated modifications that may optimize BDE use for HC-BPPV treatment.

MATERIALS AND METHODS

The BPPV Viewer, a three-dimensional model of the human labyrinth, was used to analyze BDE for HC-BPPV treatment. While moving the model through sequential BDE positions, the expected position of otoliths was demonstrated. Treatment steps were adjusted to maximize otolith movement around the canal circumference without compromising otolith repositioning into the semicircular duct's anterior arm. All adjustments were integrated into lateral modified BDEs (LMBDEs) presented here.

RESULTS

By implementing several modifications, BDE can effectively treat HC-BPPV. Model simulation indicates tilting the head 20° upward in the lateral position, instead of 45° specified by the original technique, which significantly increases displacement of otoliths originating from the horizontal duct's anterior and intermediate segments. LMBDE can be performed as a direct two-step sequence without pausing in the upright position before switching sides. If the affected ear is known, positioning the head 45° below horizontal on the unaffected side as a third treatment step can promote actual canal evacuation. These treatment enhancements increase circumferential otolith movement around the canal and may promote horizontal canal evacuation.

CONCLUSION

LMBDEs are a modification of BDE that may increase their effectiveness for use in patients with HC-BPPV. This safe treatment adjunct between office visits may promote long-term symptom reduction.

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

Diagnostic value of repeated Dix-Hallpike and roll maneuvers in benign paroxysmal positional vertigo

Introduction

Benign Paroxysmal Positional Vertigo (BPPV) is the most common peripheral vestibular disorder. The Dix-Hallpike and Roll maneuvers are used to diagnose BPPV.

Objective

This study aims to investigate the diagnostic value of repeated Dix-Hallpike and Roll maneuvers in BPPV.

Methods

We performed Dix-Hallpike and roll maneuvers in patients who admitted with peripheral vertigo anamnesis and met our criteria. The present study consists of 207 patients ranging in age from 16 to 70 (52.67 ± 10.67). We conducted the same maneuvers sequentially one more time in patients with negative results. We detected patients who had negative results in first maneuver and later developed symptom and nystagmus. We evaluated post-treatment success and patient satisfaction by performing Dizziness Handicap Inventory (DHI) at first admittance and two weeks after treatment in all patients with BPPV.

Results

Of a total of 207 patients, we diagnosed 139 in first maneuver. We diagnosed 28 more patients in sequentially performed maneuvers. The remaining 40 patients were referred to imaging. There was a significant difference between pre- and post-treatment DHI scores in patients with BPPV (p < 0.001).

Conclusion

Performing the diagnostic maneuvers only one more time in vertigo patients in the first clinical evaluation increases the diagnosis success in BPPV. Canalith repositioning maneuvers are effective and satisfactory treatment methods in 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.

Predictors for benign paroxysmal positional vertigo with positive Dix-Hallpike test

OBJECTIVE

Patient medical history is important for making a diagnosis of causes of dizziness, but there have been no studies on the diagnostic value of individual items in the history. This study was performed to identify and validate useful questions for suspecting a diagnosis of benign paroxysmal positional vertigo (BPPV).

METHODS

Construction and validation of a disease prediction model was performed at the outpatient clinic in the Department of General Medicine of Chiba University Hospital. Patients with dizziness were enrolled (145 patients for construction of the disease prediction model and 61 patients for its validation). This study targeted BPPV of the posterior semicircular canals only with a positive Dix-Hallpike test (DHT + BPPV) to avoid diagnostic ambiguity. Binomial logistic regression analysis was performed to identify the items that were useful for diagnosis or exclusion of DHT + BPPV.

RESULTS

Twelve patients from the derivation set and six patients from the validation set had DHT + BPPV. Binomial logistic regression analysis selected a "duration of dizziness ≤15 seconds" and "onset when turning over in bed" as independent predictors of DHT + BPPV with an odds ratio (95% confidence interval) of 4.36 (1.18-16.19) and 10.17 (2.49-41.63), respectively. Affirmative answers to both questions yielded a likelihood ratio of 6.81 (5.11-9.10) for diagnosis of DHT + BPPV, while negative answers to both had a likelihood ratio of 0.19 (0.08-0.47).

CONCLUSION

A "duration of dizziness ≤15 seconds" and "onset when turning over in bed" were the two most important questions among various historical features of BPPV.

Benign Paroxysmal Positional Vertigo (BPPV): History, Pathophysiology, Office Treatment and Future Directions

BPPV is the most common cause of vertigo. It most often occurs spontaneously in the 50 to 70 year age group. In younger individuals it is the commonest cause of vertigo following head injury. There is a wide spectrum of severity from inconsistent positional vertigo to continuous vertigo provoked by any head movement. It is likely to be a cause of falls and other morbidity in the elderly. Misdiagnosis can result in unnecessary tests. The cardinal features and a diagnostic test were clarified in 1952 by Dix and Hallpike. Subsequently, it has been established that the symptoms are attributable to detached otoconia in any of the semicircular canals. BPPV symptoms can resolve spontaneously but can last for days, weeks, months, and years. Unusual patterns of nystagmus and nonrepsonse to treatment may suggest central pathology. Diagnostic strategies and the simplest "office" treatment techniques are described. Future directions for research are discussed.

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.

Efficacy of the barbecue manoeuvre in benign paroxysmal vertigo of the horizontal canal

Five to ten percent of benign paroxysmal positional vertigo are caused by the horizontal semi-circular variant (h-BPPV). In this study, we reviewed the efficacy of the Barbecue repositioning manoeuvre in h-BPPV, and we assessed the possible effect of different factors on the outcome. Barbecue manoeuvre consists in turning the supine patient around his longitudinal axis toward the unaffected side until 360 degrees are accomplished. After every 90 degrees step the patient is maintained in the new position for 30 s. We reviewed 46 patients with h-BPPV, treated by barbecue rotation from 2003 to 2005. After the first Barbecue manoeuvre, the patients were followed-up at intervals of approximately 1 week and the rotation was repeated if h-BPPV persisted (up to three rotations). Factors assessed were age, gender, duration of symptoms before treatment and type of h-BPPV (canalolithiasis vs. cupulolithiasis). Fisher's exact test was used for the analysis.

RESULTS

85% of patients (39/46) were cured after a maximum of 3 rotations. 74% (34/46) were cured after the first manoeuvre and 80% (37/46) after the second one. None of the evaluated factors did significantly affect the efficacy (P > 0.05). The Barbecue manoeuvre is an efficient treatment of h-BPPV demonstrating 85% cure rate after a maximum of three sessions. 74% of the patients are healed after one manoeuvre. The efficacy is not affected by the evaluated factors.

[Benign paroxysmal positional vertigo of the horizontal semicircular canal]

OBJECTIVE

Assesment of 8 new cases of benign paroxysmal positional vertigo of the horizontal semicircular canal (BPPV-HC), since this variant of benign positional vertigo occurs rarely. An oculographic study of features in the positional response was carried out. Electrooculograpy (EOG) allows an exhaustive study of positional nystagmus.

MATERIAL AND METHODS

We have studied retrospectively 8 patients with BPPV-HC and positive head rotation manoeuvre registered by EOG techniques. Possible alterations in other EOG tests in the group of patients were analyzed.

RESULTS

Most of the patients (7/8) expressed bilateral horizontal geotropic changing-direction nystagmus. One patient exhibited apogeotropic horizontal nystagmus. 5/8 cases showed caloric hypofunction.

CONCLUSIONS

We have proven that BPPV-HC is an uncommon disorder. In most of the cases, provocative manoeuver generates bilateral horizontal geotropic changing-direction nystagmus that probably is due to canalitiasis of the horizontal semicircular canal. The rest, a few cases, exhibit apogeotropic horizontal response that can be secondary to cupulolitiasis or location particles in the anterior portion of the horizontal canal. A caloric test showed abnormal in many and can help to locatize the affected ear.

[Benign paroxysmal positional vertigo of the horizontal canal: A multicenter study]

OBJECTIVE

BPPV localized in the horizontal semicircular canal is an infrequent entity. Nowadays there are controversies about the different treatments available. The objective of this study is to present our results.

MATERIAL AND METHODS

A multicenter and retrospective study was performed in 31 patients diagnosed of BPPV-HSC between January 1996 and May 2004.

RESULTS

cupulolithiasis was diagnosed in 48% on the patients. Symptoms disappeared before signs (p<0.05). Global cure rate was 85%, while relapses were 16% at one year. No relations were found between cure rate and relapses and age, gender, duration of symptoms, canalithiasis and cupulolithiasis.

CONCLUSION

Our results support that there are not differences between the treatments performed in the BPPV-HSC. Symptoms disappeared before signs when canalith repositioning particles (CRP) maneuver was performed.

Clinical characteristics of benign paroxysmal positional vertigo in Korea: a multicenter study

Benign paroxysmal positional vertigo (BPPV) is characterized by episodic vertigo and nystagmus provoked by head motions. To study the characteristics of BPPV in a large group of patients in Korea, we retrospectively analyzed clinical features of 1,692 patients (women: 1,146, 67.7%; men: 54.6, 32.3%; mean age: 54.8+/-14.0 yr), who had been diagnosed as BPPV by trained neuro-otologists Dizziness Clinics. The diagnosis of BPPV was based on typical nystagmus elicited by positioning maneuvers. Posterior semicircular canal was involved in 60.9% of the patients, horizontal canal in 31.9%, anterior canal in 2.2%, and mixed canals in 5.0%. The horizontal canal type of BPPV (HC-BPPV) comprised 49.5% of geotropic and 50.5% of apogeotropic types. We could observe significant negative correlation between the proportion of HC-BPPV of each clinic and the mean time interval between the symptom onset and the first visit to the clinics (r=-0.841, p<0.05). Most patients were successfully treated with canalith repositioning maneuvers (86.9%). The high incidence of HC-BPPV in this study may be explained by relatively shorter time interval between the symptom onset and visit to the Dizziness Clinics in Korea, compared with previous studies in other countries.

Nystagmus: an update on treatment in adults

Recent developments in the treatment of nystagmus in adults have changed the traditional approach to such illnesses as benign paroxysmal positional vertigo, vestibular neuritis, Meniere's disease, superior canal dehiscence syndrome, vestibular paroxysmia, superior oblique myokymia, downbeat/upbeat nystagmus and acquired pendular nystagmus, as well as periodic alternating nystagmus. Treatments reported to suppress nystagmus, with tolerable side effects, are now available for some of these syndromes. Due to the absence of large controlled studies, however, treatment recommendations rest only on class C evidence.