Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review): [RETIRED]

To compare the recovery rates of modified Epley's against Semont's manoeuvres in patients with posterior canal benign paroxysmal positional vertigo: a randomized clinical trial

INTRODUCTION

Benign paroxysmal positional vertigo (BPPV) is one of the commonest causes of peripheral vertigo. It is treated with various canalolith repositioning manoeuvres by changing the head positions to allow the otoconial debris to fall back from the affected canal back to the utricle. The present study has compared the rate of recovery of vertigo with modified Epley's manoeuvres as compared to Semont's manoeuvre in patients with posterior canal BPPV.

MATERIALS AND METHODS

One hundred and seventy patients diagnosed by positive Dix-Hallpike test as posterior canal BPPV were included in this clinical trial. Subjective analysis of vertigo was done using visual analogue scale. 85 patients each were recruited in two arms by simple randomization using lottery method. Modified Epley's manoeuvre was administered to one group and Semont's manoeuvre to the other. They were recalled after 2 weeks for clinical assessment with repeat Dix-Hallpike and VAS.

RESULTS

Repeat Dix-Hallpike manoeuvres after two weeks revealed that 95.3 and 90.6% patients improved in Modified Epley's and Semont's group, respectively. After the second manoeuvre, the resolution rate was significantly higher in Semont's manoeuvre 100% (8 out of 8 patients), as compared to 25% (1 out of 4 patients) in Modified Epley's manoeuvre. Comparison of the mean values of VAS day 0 and VAS 2 weeks has been found to be statistically significant (p value of < 0.001).

CONCLUSION

Both Epley's and Semont's manoeuvre are equally efficacious in treatment of BPPV. However, use of Semont's manoeuvre required fewer repeat manoeuvres for complete resolution of symptoms in patients. The Semont's manoeuvre is also comparatively easier to perform with less number of position changes, takes less time, and has no requirement of post-manoeuvre mobility restrictions. Hence, it is recommended that Semont's manoeuvre can be routinely used for the management of PC BPPV especially in older population and patients with spinal problems.

Randomized Controlled Trial Assessing Vitamin D's Role in Reducing BPPV Recurrence in Older Adults

OBJECTIVE

To determine if the recurrence rates of BPPV in older adults were lower in the vitamin D-treated group as compared to placebo groups.

STUDY DESIGN

Double-blinded randomized control placebo trial.

SETTING

A single-centre study.

METHODS

Double-blinded randomized controlled trial design with 12 months follow-up. Vitamin D3 deplete participants were randomized into treatment (Group A) or placebo groups (Group B). Treatment group received 13 weeks of 2000 IU vitamin D3 followed by 1000 IU for the next 13 weeks. Patients who were replete were allocated to a control group (Group C) for observation and follow up. All groups had dietary interventions for vitamin D3 and calcium.

RESULTS

Results showed an 87% reduction in recurrence rates of BPPV in the treatment group (Group A), with 0.75 fewer clinical episodes per 1 person-year as compared to placebo (Group B). Time to first recurrence was also significantly longer in Group A. There was no statistically significant difference between Group A and C in both recurrence rates and dizziness handicap scores.

CONCLUSIONS

This clinical trial has laid the foundation to expand the investigation of vitamin D as standard of care treatment in BPPV patients in future phase IIb and III studies.

SUMMARY

A reduction in BPPV episodes in older adults has implications on fall risk, as dizziness from BPPV may cause falls. With fewer BPPV episodes and longer time to recurrence, seniors may have better postural stability and hence reduced risk of falls.

LEVEL OF EVIDENCE: 2

Incidence of Subsequent Injuries Associated with a New Diagnosis of Benign Paroxysmal Positional Vertigo and Effects of Treatment: A Nationwide Cohort Study

Background/Objectives: Benign paroxysmal positional vertigo (BPPV) is the most common cause of recurrent vertigo and the most common peripheral vestibular disorder. It is characterized by intense vertigo triggered by head and position changes. This study investigates the risk of subsequent injury in BPPV patients and the effects of treatment. Methods: A population-based retrospective cohort study was conducted using data from the Longitudinal Health Insurance Database 2005 in Taiwan. Patients with and without BPPV were identified between 2000 and 2017. The study outcomes were diagnoses of all-cause injuries. The Kaplan-Meier method determined the cumulative incidence rates of injury in both cohorts, and a log-rank test analyzed the differences. Cox proportional hazard models calculated each cohort's 18-year hazard ratios (HRs). Results: We enrolled 50,675 patients with newly diagnosed BPPV and 202,700 matched individuals without BPPV. During follow-up, 47,636 patients were diagnosed with injuries (13,215 from the BPPV cohort and 34,421 from the non-BPPV cohort). The adjusted HR for injury in BPPV patients was 2.63 (95% CI, 2.49-2.88). Subgroup analysis showed an increased incidence of unintentional and intentional injuries in BPPV patients (aHR 2.86; 95% CI, 2.70-3.13 and 1.10; 95% CI, 1.04-1.21, respectively). A positive dose-response relationship was observed with increasing BPPV diagnoses. Treatment with canalith repositioning therapy (CRT) or medications reduced the risk of injury slightly but not significantly (aHR, 0.78; 95% CI, 0.37-1.29, 0.88; 95% CI, 0.40-1.40, respectively). Conclusions: BPPV is independently associated with an increased risk of injuries. CRT or medications have limited effects on mitigating this risk. Physicians should advise BPPV patients to take precautions to prevent injuries even after treatment.

Do single-session Epley maneuvers treat benign paroxysmal positional vertigo?

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular condition characterized by short-term vertigo attacks that significantly affect quality of life.

OBJECTIVES

Examine how well a single Epley maneuver worked in an outpatient setting for people with posterior canal benign paroxysmal positional vertigo (PC-BPPV) and whether they needed a second Dix-Hallpike maneuver.

DESIGN

Prospective.

SETTINGS

Otorhinolaryngology department of a tertiary care center.

PATIENTS AND METHODS

Sociodemographic data, body mass index (BMI), and systemic disease history of 75 patients diagnosed with PC-BPPV were recorded, and their relationship with success rates after the modified Epley maneuver was analyzed.

MAIN OUTCOME MEASURES

Detect cases that could not be repositioned with the diagnostic control Dix-Hallpike test performed 20 minutes after the modified Epley reposition maneuver in the same session in PC-BPPV patients.

SAMPLE SIZE

75.

RESULTS

Of the 75 patients, 31 were male (41.3%), 44 female (58.6%) with a mean (standard deviation) age of 58.6 (15.9) years age, 54.6% had one or more chronic diseases. BMI was 30 mg/kg2 and above in 31 patients (41.3%). The modified Epley maneuver was successful in 77.3%. No significant relationship was found between additional diseases or BMI in the patient group in whom the maneuver was unsuccessful.

CONCLUSION

The success rates of repositioning maneuvers in treating patients diagnosed with PC-BPPV are high. However, more than a single maneuver is required in some resistant patients. Second diagnostic and repositioning maneuvers performed in the same session will reduce multiple hospital admissions. While it is helpful to repeat the maneuver in the patient group where it was unsuccessful, other factors causing the failure should be investigated.

LIMITATIONS

Lack of follow-up results of patients after 7-10 days.

Multimodal deep learning-based diagnostic model for BPPV

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is a prevalent form of vertigo that necessitates a skilled physician to diagnose by observing the nystagmus and vertigo resulting from specific changes in the patient's position. In this study, we aim to explore the integration of eye movement video and position information for BPPV diagnosis and apply artificial intelligence (AI) methods to improve the accuracy of BPPV diagnosis.

METHODS

We collected eye movement video and diagnostic data from 518 patients with BPPV who visited the hospital for examination from January to March 2021 and developed a BPPV dataset. Based on the characteristics of the dataset, we propose a multimodal deep learning diagnostic model, which combines a video understanding model, self-encoder, and cross-attention mechanism structure.

RESULT

Our validation test on the test set showed that the average accuracy of the model reached 81.7%, demonstrating the effectiveness of the proposed multimodal deep learning method for BPPV diagnosis. Furthermore, our study highlights the significance of combining head position information and eye movement information in BPPV diagnosis. We also found that postural and eye movement information plays a critical role in the diagnosis of BPPV, as demonstrated by exploring the necessity of postural information for the diagnostic model and the contribution of cross-attention mechanisms to the fusion of postural and oculomotor information. Our results underscore the potential of AI-based methods for improving the accuracy of BPPV diagnosis and the importance of considering both postural and oculomotor information in BPPV diagnosis.

NADPH Oxidase 3: Beyond the Inner Ear

Reactive oxygen species (ROS) were formerly known as mere byproducts of metabolism with damaging effects on cellular structures. The discovery and description of NADPH oxidases (Nox) as a whole enzyme family that only produce this harmful group of molecules was surprising. After intensive research, seven Nox isoforms were discovered, described and extensively studied. Among them, the NADPH oxidase 3 is the perhaps most underrated Nox isoform, since it was firstly discovered in the inner ear. This stigma of Nox3 as "being only expressed in the inner ear" was also used by me several times. Therefore, the question arose whether this sentence is still valid or even usable. To this end, this review solely focuses on Nox3 and summarizes its discovery, the structural components, the activating and regulating factors, the expression in cells, tissues and organs, as well as the beneficial and detrimental effects of Nox3-mediated ROS production on body functions. Furthermore, the involvement of Nox3-derived ROS in diseases progression and, accordingly, as a potential target for disease treatment, will be discussed.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Epley manoeuvre's efficacy for benign paroxysmal positional vertigo (BPPV) in primary-care and subspecialty settings: a systematic review and meta-analysis

BACKGROUND

Although previous studies have reported general inexperience with the Epley manoeuvre (EM) among general physicians, no report has evaluated the effect of EM on benign paroxysmal positional vertigo (BPPV) in primary care by using point estimates or certainty of evidence. We conducted this systematic review and meta-analysis and clarified the efficacy of EM for BPPV, regardless of primary-care and subspecialty settings.

METHODS

Systematic review and meta-analysis of randomised sham-controlled trials of EM for the treatment of posterior canal BPPV in primary-care and subspecialty settings. A primary-care setting was defined as a practice setting by general practitioners, primary-care doctors, or family doctors. A systematic search was conducted in January 2022 across databases, including Cochrane Central Resister of Controlled Trial, MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. Primary outcomes were the disappearance of subjective symptoms (vertigo), negative findings (Dix-Hallpike test), and all adverse events. We evaluated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

Twenty-seven randomised controlled trials were identified. In primary-care settings, EM reduced the subjective symptoms [risk ratio (RR), 3.14; 95% confidence interval (CI), 1.96-5.02]; however, there was no applicable article for all adverse events. In the subspeciality setting, EM reduced the subjective symptoms (RR, 2.42; 95% CI, 1.64-3.56), resulting in an increase in negative findings (RR, 1.81; 95% CI, 1.40-2.34). The evidence exhibited uncertainty about the effect of EM on negative findings in primary-care settings and all adverse events in subspecialty settings.

CONCLUSIONS

Regardless of primary-care and subspecialty settings, EM for BPPV was effective. This study has shown the significance of performing EM for BPPV in primary-care settings. EM for BPPV in a primary-care setting may aid in preventing referrals to higher tertiary care facilities and hospitalisation for follow-up.

TRIAL REGISTRATION

The study was registered in protocols.io (PROTOCOL INTEGER ID: 51,464) on July 11, 2021.

Climatic variations and pollution on benign paroxysmal positional vertigo in Kars, Türkiye

Benign paroxysmal positional vertigo (BPPV) is the most common diagnosis for peripheral vertigo. Although pathophysiological mechanisms remain unclear, BPPV is mostly idiopathic and factors related to BPPV are still being investigated. Knowing these factors can contribute to the prevention and management of BPPV. In this study, we investigated the correlations between climatic variations, pollution, and BPPV retrospectively. 262 patients diagnosed with BPPV between 2019 and 2021 in Kars, Türkiye, were included in our study. Meteorological parameters were obtained from Turkish State Meteorological Service. Horizontal BPPV increased significantly with the humidity (p < 0.05). In addition, carbon monoxide levels significantly increased the potantial of BPPV (p < 0.05). Surprisingly, BPPV increased in the summertime and showed a significant relationship with humidity. We believe this change is related with the city-specific features as it is the coldest place in the country, emigrant province and crowded in the summer times.

When Particle Repositioning Maneuvers Just Will Not Stick: Clinical Considerations for Persistent Benign Paroxysmal Positional Vertigo

PURPOSE

Although benign paroxysmal positional vertigo (BPPV) is often considered benign and easily treatable, aberrant cases of persistent BPPV can be challenging to manage. Detailed differential diagnosis is essential as central-, vascular-, and cervical-related etiologies may mirror the presentation of persistent BPPV. In addition, an understanding of alternative noninvasive treatment options is important as persistent BPPV is often refractory to traditional particle repositioning maneuvers (PRMs). This article reviews clinical considerations for persistent BPPV.

METHOD

A case of a 68-year-old male diagnosed with posterior semicircular canal BPPV (PC-BPPV) and received various unsuccessful PRMs treatments is described. His clinical presentation is referenced alongside various possible etiologies to discern the most likely diagnosis. Nonsurgical treatment options for intractable PC-BPPV will also be reviewed.

CONCLUSIONS

BPPV recalcitrant to PRM treatment warrants investigation of other etiologies; however, key elements of the case history and objective examination are helpful for differential diagnosis. Brandt-Daroff exercises may facilitate habituation of symptoms secondary to persistent BPPV. More research is needed to understand the use of multiaxial repositioning chairs for the treatment of intractable BPPV.

Early treatment for benign paroxysmal positional vertigo secondary to sudden sensorineural hearing loss

Sudden sensorineural hearing loss (SSNHL) accompanied by benign paroxysmal positional vertigo (BPPV) is relatively common in the clinic. There are unified standards for the treatment of primary BPPV with good reduction effect, while there are few studies on the treatment of BPPV secondary to SSNHL within 1 week of onset. The study was to investigate the treatment of BPPV secondary to SSNHL and compare its manual reduction with that of primary BPPV. We selected 90 patients with BPPV accompanied by SSNHL within a week of onset and 210 primary BPPV patients at Hebei Provincial Eye Hospital from June 2020 to December 2022. The former group was divided into the medicine group and manual reduction plus medicine group. The medicines used were extract of Ginkgo biloba leaves injection, betahistine hydrochloride injection and oral prednisone. We contrasted the efficacy respectively for posterior semicircular canal BPPV (psc-BPPV), horizontal semicircular canal BPPV (hsc-BPPV) and multiple semicircular canal BPPV (msc-BPPV). In addition, we compared the manual reduction effect for primary BPPV and manual reduction group, and the evaluation of efficacy are the intensity of nystagmus and the clinical symptoms. In the secondary BPPV group, there was no difference in efficacy between the medicine group and manual reduction group at the 7th-day after reduction for psc-BPPV, hsc-BPPV, and msc-BPPV (P > .05). The immediate effect of reduction was significantly different between the primary BPPV group and the group with SSNHL and BPPV for both psc-BPPV and hsc-BPPV (P < .05), and the effect of the primary BPPV group was better, but it was no difference for msc-BPPV (P > .05). For the treatment of BPPV accompanied by SSNHL within 1 week of onset, the additional reduction therapy showed no benefit, so we need to apply medication for SSNHL.

Prevalence of Horizontal Canal Variant in 3,975 Patients With Benign Paroxysmal Positional Vertigo: A Cross-sectional Study

Background and Objectives

Current understanding based on older studies is that pc-BPPV is far more common than hc-BPPV. Such studies are limited by small sample sizes, and often the supine roll test for hc-BPPV is not performed. To better estimate the prevalence of hc-BPPV, we studied a large cross-section of patients with VOG-diagnosed BPPV.

Methods

Using a cross-sectional study of patients with BPPV, we investigated patients referred to NeuroEquilibrium specialty clinics throughout India between January 1, 2021, and December 31, 2021. All patients were evaluated with video oculography (VOG) during positional tests, and all diagnoses were confirmed by a neurotologist and neurologist.

Results

Of 3,975 patients with VOG-confirmed and specialist-diagnosed BPPV (median age, 51 years; 56.6% women), pc-BPPV accounted for 1,901 (47.8%), hc-BPPV was seen in 1,842 (46.3%), and anterior canal BPPV was found in 28 (0.7%) patients.

Discussion

This study found that hc-BPPV is far more common than previously reported. It is important to perform the supine roll test in addition to the Dix-Hallpike in all patients suspected with BPPV. Better training to diagnose patients with BPPV and to accurately recognize the nystagmus pattern of hc-BPPV should be a priority.

Surveying physical therapists' understanding of benign paroxysmal positional vertigo

Introduction

Benign paroxysmal positional vertigo (BPPV) is a common condition with disabling symptoms that is diagnosed and effectively treated at the bedside. Our encounter with patients experiencing prolonged BPPV who may not have received appropriate physical therapy prompted us to explore barriers to the diagnosis and treatment for BPPV among physical therapists, which has not been extensively investigated. We hypothesize that a potential barrier may be a lack of understanding of subtle symptoms of BPPV that deviate from the classical presentation. The gold standard for diagnosing definite BPPV is subjective dizziness or vertigo with nystagmus in response to positional testing. There are variants of BPPV including subjective BPPV (subjective dizziness or vertigo without nystagmus) and vestibular agnosia (nystagmus without subjective dizziness or vertigo) that do not meet the diagnostic criteria for definite BPPV but are equally responsive to the same repositioning maneuvers. The purpose of this project was to survey physical therapists for their understanding of BPPV including subjective BPPV and vestibular agnosia.

Methods

A panel of experts created a 16-question survey, designed for physical therapists, with three categories: (1), inquiring if they treat persons with BPPV, (2) three clinical vignettes for definite BPPV, subjective BPPV, and BPPV with vestibular agnosia, and (3) demographic information. Data collection occurred at two large physical therapy meetings, one of which was a national professional meeting and the other was a professional continuing medical education course geared towards advancing vestibular rehabilitation skills.

Results

There were 426 people who completed the survey, 364 of whom treat BPPV in their practice. In the first clinical vignette created to assess the respondents' understanding of definite BPPV, 229 (62%) of respondents would always assess a patient for BPPV based on complaints of a "room spinning" vertigo from head movement. When asked if the complaint was lingering "lightheadedness or feelings of imbalance" from head movement, only 158 (43%) reported they would perform positional testing to reassess. In the BPPV variant vignettes, 187 (51%) identified the patient with subjective BPPV as having BPPV and 305 (85%) identified the patient with vestibular agnosia as having BPPV.

Discussion

The results of this survey demonstrate gaps in knowledge regarding BPPV across practice settings and experience, with opportunities to bridge these gaps to improve treatment for BPPV.

[Patient with cervical spinal cord injury and benign paroxysmal positional vertigo treated with particle repositioning maneuvers]

Benign paroxysmal positional vertigo (BPPV) is characterized by short, sudden episodes of vertigo when the head moves in specific positions. The treatment is particle repositioning maneuvers. BPPV usually is underdiagnosed, unreported and therefore not adequately treated. We present the case of a patient with spinal cord injury and BPPV. A 72-year-old patient who suffered a C5 fracture with spinal cord injury C5 AIS C that required surgical fixation. In the spinal cord injury unit BPPV of the left lateral semicircular canal was documented and treated using specific repositioning maneuvers, the patient progressively improved and was able to complete the rehabilitation treatment. The spinal cord injury unit with access to vestibular rehabilitation units can carry out the diagnosis and specific treatment of BPPV, minimizing the risks for the patient.

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department

This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").

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.

Evaluation of a questionnaire as a screening tool for benign paroxysmal position vertigo

OBJECTIVE

To determine the value of a questionnaire as a screening tool for benign paroxysmal position vertigo (BPPV).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care centers.

METHODS

A total of 520 vertigo adults completed the questionnaire before the diagnosis was confirmed. After vestibular function examination and other diagnostic examination, the diagnosis of all participants was confirmed by experts. By validating valuable items from the questionnaire with 47 items, a new questionnaire of 5 items was formed to quickly diagnose BPPV. The internal consistency of the new questionnaire and validity were evaluated. The correlation between the score obtained from the new questionnaire and diagnosis was investigated. The mean score was also compared between groups with and without BPPV and diagnostic precision measures were calculated.

RESULTS

520 vertigo participants answered all the question completely and BPPV was identified in 138 participants (26.5%). The responses to questionnaire revealed preferable reproducibility (r = 0.898, P < 0.05) and internal consistency (Cronbach's α = 0.702) as well as the validity (Kaiser-Meyer-Olkin, KMO = 0.731). The higher the individual score, the more likely to be BPPV (B = 2.082; P < 0.05). The mean score of answers was greater in the group with a clinical diagnosis of BPPV compared to those without BPPV (F = 58.459, P < 0.05). The sensitivity of the screening tool was 92.8% and specificity was 88.5%, with an area under the ROC curve of 0.946 (95% confidence interval 0.926-0.965; P < 0.05).

CONCLUSION

The questionnaire proved to be of great value to screen for individuals with possible BPPV.

The relationship between psychological conditions and recurrence of benign paroxysmal positional vertigo: a retrospective cohort study

BACKGROUND

Psychological conditions have been found to be associated with an increased risk of incident benign paroxysmal positional vertigo (BPPV). However, much less is known on whether and how psychological conditions such as anxiety, insomnia and obsessive-compulsive disorder (OCD) affect the recurrence of BPPV.

METHODS

A retrospective cohort study of 2,612 outpatients and inpatients diagnosed with BPPV between September 2012 and August 2020. BPPV recurrence was followed up until February 2021. The Cox proportional hazard regression was used to analyze the association between psychological conditions and the risk of the first recurrence. Poisson regression was applied to analyze the association between psychological conditions and the number of recurrences in patients with at least one relapse.

RESULTS

During the follow-up, 391 patients had at least one BPPV recurrence. Female BPPV patients were more likely than male patients to experience relapses than male patients, but the characteristics of BPPV recurrence (number of recurrences and duration between recurrences) did not differ between men and women. After adjustment for sex, age and comorbidities, a heightened risk of first BPPV recurrence was found to be associated with anxiety (hazard ratio [HR]: 1.30, 95% confidence interval [CI]: 1.01, 1.68) and OCD (HR: 2.15, 95% CI: 1.31, 3.52). An increased risk of first BPPV recurrence associated with insomnia was only observed in male patients (HR: 2.22, 95% CI: 1.24, 3.98) but not in female patients (HR: 0.91, 95% CI: 0.63, 1.31). None of these psychological conditions were associated with the number of recurrences in patients who experienced recurrence.

CONCLUSIONS

The presence of anxiety and OCD increased the risk of first BPPV recurrence, as well as insomnia for male patients. These psychological conditions were not associated with the number of BPPV recurrences. Diagnosis and treatment of these psychological conditions could be a useful strategy to prevent the recurrence of BPPV.

Effect of Self-treatment of Recurrent Benign Paroxysmal Positional Vertigo: A Randomized Clinical Trial

Importance

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo with frequent recurrences.

Objective

To determine the efficacy of a web-based diagnosis and treatment of BPPV when it recurs in patients with confirmed and treated BPPV.

Design, Setting, and Participants

This randomized, controlled, parallel-group, double-blind trial took place in multiple referral-based university hospitals in South Korea between July 2017 and February 2020. Of 728 patients (age ≥20 years) with diagnosed and treated BPPV, 585 were enrolled after excluding 143 who declined participation, could not use the internet, or had spinal problems, multicanal BPPV, or cognitive dysfunction. Patients were followed up for recurrence at least for 2 years until February 2022.

Interventions

Patients were randomly assigned (1:1) to the treatment or control group. The patients in the treatment group completed a questionnaire for diagnosis and received a video clip for self-administration of canalith repositioning maneuver (CRM) according to the type of BPPV diagnosed when they experienced positional vertigo again. Patients in the control group received a video clip for self-administration of CRM according to the type of BPPV that had been diagnosed on enrollment.

Main Outcomes and Measures

The primary outcome was self-reported resolution of positional vertigo post-CRM. Secondary outcomes included difficulties and requirement for assistance when using the program and any falls or other adverse events related to CRM. The primary outcome was analyzed using both intention-to-treat and per-protocol methods.

Results

Of 585 patients enrolled, 292 were randomized to the treatment group (mean [SD] age, 60.3 [12.8] years, 37 [64%] women) and 293 were randomized to the control group (mean [SD] age, 61.1 [13.2] years; 50 [71%] women). Overall, 128 (21.9%) had recurrence (58 in the treatment group and 70 in the control group), and 109 (85.2%) successfully used the web-based system. In the intention-to-treat analysis, 42 of 58 individuals (72.4%) in the treatment group and 30 of 70 individuals (42.9%) in the control group reported vertigo resolution (χ2 test: 95% CI, 0.13-0.46; P < .001).

Conclusions and Relevance

This trial proved the efficacy of a web-based system for the diagnosis and treatment of recurrent BPPV. Use of this system may play an important role in telemedicine for vestibular disorders.

Trial Registration

Clinical Research Information Service Identifier: KCT0002364.

The Impact of the Angular Head Movement's Velocity during Diagnostic Maneuvers on Proper Benign Positional Paroxysmal Vertigo Diagnosis and Therapy

Based on the current state of the BPPV field, there are no guidelines that specify an angular head movement's velocity (AHMV) during diagnostic maneuvers of BPPV. The aim of this study was to evaluate the impact of AHMV during diagnostic maneuvers on proper BPPV diagnosis and therapy. The analysis covered the results obtained in 91 patients with a positive result of the Dix-Hallpike (D-H) maneuver or the roll test. The patients were divided into four groups based on values of AHMV (high 100-200°/s and low 40-70°/s) and the BPPV type (posterior: PC-BPPV or horizontal: HC-BPPV). The parameters of the obtained nystagmuses were analyzed and compared to AHMV. There was a significant negative correlation between AHMV and latency of nystagmus in all study groups. Furthermore, there was a significant positive correlation between AHMV and both maximum slow phase velocity and average frequency of nystagmus in the PC-BPPV groups, whereas it was not observed in the HC-BPPV patients. Complete relief of symptoms was reported after 2 weeks and was better in patients diagnosed with maneuvers performed with high AHMV. High AHMV during the D-H maneuver allows the nystagmus to be more visible, increasing the sensitivity of diagnostic tests and is crucial for a proper diagnosis and therapy.

Outcome for dizzy patients in a physiotherapy practice: an observational study

BACKGROUND

Dizziness is a common reason for referral to physiotherapy. Additional information on clinical characteristics, treatment effect and prognostic indicators in physiotherapy practice are needed.

METHODS

A retrospective observational study. Based on a standardised clinical evaluation patients were labelled as having Benign Paroxysmal Positioning Vertigo (BPPV) or not (no-BPPV). BPPV was treated with repositioning manoeuvres and exercises. In no-BPPV, treatment was based on additional clinical tests. Treatment was provided once per week and considered successful when the patient was free of symptoms confirmed by negative positional tests.

RESULTS

From 148 referred patients, 88 were labelled as having BPPV, 60 as no-BPPV. The symptom of a short-lasting spinning sensation provoked by head movements was highly suggestive of BPPV. On average, in BPPV treatment was completed after 2.27 ± 1.68 treatments, in no-BPPV this was after 4.91 ± 3.46 treatments. The delayed outcome was related to higher 'age' and 'concomitant neck pain' in BPPV and with higher 'age' only in no-BPPV. Favourable outcome was related to the feature 'dizziness provoked by movements in the horizontal plane' in BPPV.

CONCLUSIONS

Clinical evaluation and treatment in physiotherapy practice can be an effective and safe option for patients with dizziness. Several clinical variables with prognostic values were identified.Key messagesClinical evaluation and treatment in physiotherapy practice can be part of low threshold care for dizzy patients.Despite prior medical screening, one-third of patients without signs of BPPV were sent back for further evaluation, illustrating the need for interdisciplinary collaboration.Based on the description of the dizziness symptom (vertigo rather than light-headedness), provocation of the dizziness by movements, and a short duration of the dizziness attack, and positive clinical vestibular tests, BPPV treatment could be initiated.

Implementing specialised vestibular physiotherapy in an emergency department: a process evaluation

Background

Dizziness and vertigo-like symptoms, often caused by common peripheral vestibular disorders such as benign paroxysmal positional vertigo (BPPV), may significantly impact function and quality of life. These symptoms often result in emergency department (ED) presentations. Evidence-based clinical practice guidelines strongly recommend using physical assessment and treatment manoeuvres for the assessment, diagnosis and treatment of these symptoms. This study aimed to evaluate the process of implementing specialised vestibular physiotherapy (SPV) in an emergency department from the clinician’s perspective.

Methods

This implementation study utilised a retrospective mixed-methods process evaluation to understand how SVP operated in an Australian emergency department. The i-PARiHS framework was embedded within the methodology and analytical approach of the study to ensure a comprehensive approach closely aligned to implementation science. Nine clinicians retrospectively completed the Organisational Readiness for Change Assessment (ORCA), Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM) and Feasibility of Intervention Measure (FIM). Seven clinicians also participated in a focus group or interview.

Results

A range of barriers and facilitators to the implementation process were identified by participants, some of which spanned multiple domains of the i-PARiHS framework. Relationships with service leaders, champions and medical staff were pivotal facilitators to implementation, along with a generally held perception that SVP was acceptable and feasible. The main barrier identified was a lack of capacity to deliver and facilitate this innovation within the physiotherapy workforce and the broader multidisciplinary recipients.

Conclusions

This study demonstrates that the process of implementing an SVP service in an ED context was generally well-received by clinicians but also involved some challenges and barriers. Services looking to implement SVP in the ED should aim to build stakeholder relationships; develop a shared vision with clear goals and intended outcomes; embed the innovation in organisation processes, procedures and policies; and increase workforce capacity to deliver and facilitate SVP to guide their approach to this innovation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00313-2.

Dynamic changes of otolith organ function before and after repositioning in patients with benign paroxysmal positional vertigo detected by virtual reality auxiliary technology: A cohort study

Objectives

To dynamically investigate otolith function in patients with benign paroxysmal positional vertigo (BPPV) before, after, and 1 month after repositioning, and explore the possible compensation mechanisms.

Methods

Thirty-six patients confirmed with BPPV (canal lithiasis) treated in our hospital between August 2020 and March 2021, as well as 36 health controls matched for age and gender (normal control group, NC group) were enrolled. For NC group, the virtual reality (VR) auxiliary static subjective visual vertical (SVV), subjective visual horizontal (SVH), and SVV of dynamic unilateral centrifugation (DUC), were measured at inclusion. For the BPPV group, visual analog scale (VAS) was used to assess the vertigo degree, while static SVV, SVH, and DUC were performed before, after, and 1 month after repositioning. First, we compare the deviations of SVV0/SVH0° when the subject's head is in the positive position, and SVV of DUC between BPPV and NC groups before repositioning, after which we compared the deviations in SVV45, SVV90, SVH45, SVH90°, and SVV of DUC between the affected and unaffected sides before repositioning. Finally, paired t-test was used to compare the VAS score, deviations in static SVV0, SVV45, SVV90, SVH0, SVH45, and SVH90°, and deviations in SVV of DUC before, after, and 1 month after repositioning. (Here, 0, 45, and 90° refer to the angle which the center axis of head deviates from the gravity line.)

Results

SVV0 SVH0°, and SVV of DUC at 120 and 180°/s 0 significantly differed between BPPV and NC group before repositioning. The deviations in SVV45, SVV90, SVH45, SVH90°, and SVV of DUC at 120°/s-2 and 180°/s-4.5 did not significantly differ between bilateral sides in BPPV patients before repositioning. The deviation in SVH90° was significantly lower after repositioning than before. The deviation in SVH45° was significantly higher 1 month after repositioning than before. The deviation angle of SVV of DUC at 180°/s-0 was significantly lower after repositioning than before. The vertigo VAS score of patient with BPPV continued to decrease after repositioning.

Conclusion

Before repositioning, the otolithic organ function of BPPV patients was obviously impaired, with no significant difference between the healthy and affected ear. After repositioning, there was a transient recovery of otolithic organ dysfunction followed by a sustained decline to similar levels to before repositioning.

Benign paroxysmal positional vertigo with congenital nystagmus: A case report

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is a form of temporary vertigo induced by moving the head to a specific position. It is a self-limited, peripheral, vestibular disease and can be divided into primary and secondary forms. Congenital nystagmus (CN), an involuntary, rhythmic, binocular-symmetry, conjugated eye movement, is found at birth or within 3 mo of birth. According to the pathogenesis, CN can be divided into sensory-defect nystagmus and motor-defect nystagmus. The coexistence of BPPV and CN is rarely seen in the clinic.

CASE SUMMARY

A 62-year-old woman presented to our clinic complaining of a 15-d history of recurrent positional vertigo. The vertigo lasting less than 1 min occurred when she turned over, sometimes accompanied by nausea and vomiting. Both the patient and her father had CN. Her spontaneous nystagmus was horizontal to right; however, the gaze test revealed variable horizontal nystagmus with the same degree when the eyes moved. The patient’s Dix-Hallpike test was normal, except for persistent nystagmus, and the roll test showed severe variable horizontal nystagmus, which lasted for about 20 s in the same direction as her head movement to the right and left, although the right-side nystagmus was stronger than the left-side. Since these symptoms were accompanied by nausea, she was diagnosed with BPPV with CN and treated by manual reduction.

CONCLUSION

Though rare, if BPPV with CN is correctly identified and diagnosed, reduction treatment is comparably effective to other vertigo types.

Vestibular suppressants for benign paroxysmal positional vertigo: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is a common cause of acute dizziness. Medication use for its treatment remains common despite guideline recommendations against their use.

OBJECTIVES

The objective was to evaluate the efficacy and safety of vestibular suppressants in patients with BPPV compared to placebo, no treatment, or canalith repositioning maneuvers (CRMs).

METHODS

We searched MEDLINE, Cochrane, EMBASE, and ClinicalTrials.gov from inception until March 25, 2022. for randomized controlled trials (RCTs) comparing antihistamines, phenothiazines, anticholinergics, and/or benzodiazepines to placebo, no treatment, or a CRM.

RESULTS

Five RCTs, enrolling 296 patients, were included in the quantitative analysis. We found that vestibular suppressants may have no effect on symptom resolution at the point of longest follow-up (14-31 days in four studies) when evaluated as a continuous outcome (standardized mean difference -0.03 points, 95% confidence interval [CI] -0.53 to 0.47). Conversely, CRMs may improve symptom resolution at the point of longest follow-up as a dichotomous outcome when compared to vestibular suppressants (relative risk [RR] 0.63, 95% CI 0.52 to 0.78). Vestibular suppressants had an uncertain effect on symptom resolution within 24 h (mean difference [MD] 5 points, 95% CI -16.92 to 26.94), repeat emergency department (ED)/clinic visits (RR 0.37, 95% CI 0.12 to 1.15), patient satisfaction (MD 0 points, 95% CI -1.02 to 1.02), and quality of life (MD -1.2 points, 95% CI -2.96 to 0.56). Vestibular suppressants had an uncertain effect on adverse events.

CONCLUSIONS

In patients with BPPV, vestibular suppressants may have no effect on symptom resolution at the point of longest follow-up; however, there is evidence toward the superiority of CRM over these medications. Vestibular suppressants have an uncertain effect on symptom resolution within 24 h, repeat ED/clinic visits, patient satisfaction, quality of life, and adverse events. These data suggest that a CRM, and not vestibular suppressants, should be the primary treatment for BPPV.

Falls at advanced age - The importance to search for benign paroxysmal positional vertigo (BPPV)

INTRODUCTION

One of the most important geriatric syndromes is dizziness in conjunction with gait disorder and consequent falls. There are various differential diagnoses for dizziness, one of them is benign paroxysmal positional vertigo (BPPV).

OBJECTIVES

A targeted diagnostic work-up and treatment of BPPV can prevent subsequent falls and a decline in the patients' quality of life, prolonged hospitalization with unnecessary examinations and medication.

DESIGN

Prospective examination of patients with a positive medical history of BPPV.

SETTING AND PARTICIPANTS

All patients treated within the Department of Geriatrics between 05/2015 and 03/2018 were included. A total of n = 5166 patients were screened (n = 2651 geriatrics; n = 2515 controls).

METHODS

All patients from other wards subjected to a neurological examination due to vertigo served as controls. Patients with typical hints in the medical history for a BPPV were subjected to the diagnostic Dix-Hallpike maneuver and, if positive, subsequent canalith repositioning maneuvers. The percentage of successful positional treatments was determined in both groups.

RESULTS

N = 254 patients (4.9 %) had indications in the medical history for a BPPV. For 71 of n = 254 patients (28 %; in total 1.4 %; mean age: 78.4 ± 12.3 years) the diagnosis of BPPV was proven by a positive Dix-Hallpike maneuver. N = 39 (54.9 %) patients belong to the geriatric group (mean age 82 years) and n = 32 (45.1 %) to the control group (mean age 73.9 years). The frequency of BPPV was similar in both groups (1.3-1.5 %). In 91.9 % of patients the BPPV was localized in the posterior semicircular canal. Up to 93 % were asymptomatic after one or repeated canalith repositioning maneuvers.

CONCLUSIONS AND IMPLICATIONS

The BPPV should be considered as an important differential diagnosis for geriatric patients with dizziness and falls. After therapeutic repositioning maneuvers most of the patients are asymptomatic. Therefore, targeted screening and therapy ("theragnostic") of BPPV at an advanced age increases diagnostic accuracy and prevents unnecessary examinations, medications and future falls.

Benign Paroxysmal Positional Vertigo: A Practical Approach for Emergency Physicians

Benign paroxysmal positional vertigo (BPPV) is a very common condition in the population and an important cause of acute vertigo or dizziness in patients presenting to an emergency department (ED). Despite this, abundant evidence shows that current ED management of patients with BPPV is suboptimal. Common ED management processes include brain imaging and treatment with vestibular suppressant medications such as meclizine, neither of which is recommended by current guidelines. The most efficient management of BPPV is to perform a bedside test (Dix-Hallpike test) and then to treat the patients with a bedside positional (the Epley) maneuver. In this practical review we emphasize the efficient management for the most common form of BPPV-posterior canal BPPV. Using this management will reduce resource utilization (laboratory testing, brain imaging, specialist consultation), reduce ED length of stay, and reduce use of ineffective mediations that have side effects but little therapeutic effect. Application of these practices would improve important patient-centered outcomes such as symptom reduction, radiation exposure, side effects from medications, and less need for urgent follow-up with another health care provider. The article also discusses the approach to patients in whom the Dix-Hallpike and/or Epley maneuvers do not seem to work. This includes a discussion the second most common variant of BPPV (horizontal canal BPPV) and criteria for safe discharge of patients. Another important advantage of learning BPPV best practices is that it is enormously satisfying for the clinician, not unlike treating a child with a nursemaid's elbow.

Risk factors for residual dizziness in patients with benign paroxysmal positional vertigo after successful repositioning: a systematic review and meta-analysis

PURPOSE

To investigate the risk factors for residual dizziness (RD) in patients with benign paroxysmal positional vertigo (BPPV) after successful repositioning.

METHODS

Searches were performed in PubMed, Embase, Cochrane library, Web of Science, Chinese National Knowledge Infrastructure, and Sino Med up to March 7, 2021 and references of relevant articles were screened. Data from eligible studies were meta-analyzed using Stata version 16.0 and Review Manager 5.4.

RESULTS

In this systematic review and meta-analysis of 4487 patients from 31 studies, the prevalence of RD was 43.0% (95% CI 39.0-48.0%). Age (MD 4.17; 95% CI 2.13-6.21, P = 0.000), female gender (OR = 1.28, 95% CI 1.11-1.47, P = 0.001), secondary BPPV (OR 1.88; 95% CI 1.27-2.77, P = 0.001), a longer duration of BPPV before treatment (MD 3.45; 95% CI 1.87-5.02, P = 0.000), abnormal ocular vestibular evoked myogenic potential (OVEMP, OR 4.34; 95% CI 2.78-6.78, P = 0.000), abnormal cervical vestibular evoked myogenic potential (CVEMP, OR 2.48; 95% CI 1.54-3.99, P = 0.000), higher Dizziness Handicap Index (DHI) score before treatment (MD 10.88; 95% CI 5.96-15.80, P = 0.000), anxiety (OR 9.58; 95% CI 6.32-14.52, P = 0.000), osteopenia (OR = 4.40, 95% CI 2.17-8.96, P = 0.000), onset in winter (OR 7.27; 95% CI 2.38-22.24, P = 0.001) and with a history of BPPV (OR 1.79; 95% CI 1.06-3.04, P = 0.03) are the risk factors for RD in patients with BPPV after successful repositioning. The affected side, location or type of semicircular involvement, hyperlipidemia, diabetes, hypertension, heart disease, migraine, sleep disorders, canalolithiasis/cupulolithiasis, the number of times the canalith repositioning procedures (CRPs) were performed and number of vertigo attacks did not correlate with the occurrence of RD.

CONCLUSIONS

Despite successful treatment, nearly half of the BPPV patients developed RD. RD seems to be a syndrome caused by multiple factors. The pathogenesis of most factors can be explained by psychological and/or physical disorders. Early recognition of these risk factors contributes to the prevention and treatment of RD.

Patient Self-Management of Benign Paroxysmal Positional Vertigo: Instructional Video Development and Preliminary Evaluation of Behavioral Outcomes

IMPORTANCE

Benign paroxysmal positional vertigo of the posterior canal (PC-BPPV) is a common disorder that is diagnosed using the Dix-Hallpike test (DHT) and treated with the canalith repositioning maneuver (CRM). Patients often seek out information about BPPV self-management, but studies to develop and evaluate patient-centered instructional resources are limited.

OBJECTIVE

To develop and preliminarily evaluate a patient-oriented PC-BPPV self-management instructional video.

METHODS

We assembled a multidisciplinary team and used an iterative process to develop a theory-based instructional video for self-performing the DHT and CRM. We recruited individuals searching online for information about dizziness to complete a survey and review the video. Patients rated the video by scoring seven questions that measure behavioral intent to perform the DHT or CRM (attitudes/acceptability, perceived self-efficacy, and social norms) using a 10-point scale (higher scores = more favorable ratings). A multilevel linear regression model was used to determine the association of age, sex, race, and education with video ratings.

RESULTS

Of the 771 participants who completed the survey, 124 (16%) also reviewed and evaluated the PC-BPPV instructional video. The video review participants were typically more than or equal to 55 years old (70%; 93/124), women (70%; 87/124), and White (70%; 88/124). These participants also generally reported acute-subacute and moderate-to-severe dizziness, and 60% (75/124) reported typical BPPV triggers. The median scores for the seven questions about attitudes/acceptability, self-efficacy, and social norms on the PC-BPPV instructional video were all more than or equal to 9 out of 10 with interquartile ratios that ranged from 7 to 9 at the 25th percentile to 10 at the 75th percentile. Female sex was the only demographic variable associated with higher video ratings (coefficient, 1.21, 95% CI 0.60-1.83).

CONCLUSION

This study found that participants rated the PC-BPPV self-management video favorably on measures that contribute to behavioral intent to perform the DHT or CRM. The findings provide support that the video is appropriate to use in future studies that evaluate patient self-performance accuracy and outcomes.

Nystagmus Parameters of Supine Roll Test Correlates With Prognosis After Repositioning Maneuver in Horizontal Semicircular Canal Benign Paroxysmal Positional Vertigo

Background: Positional nystagmus induced by supine roll test is characteristic for diagnosing horizontal semicircular canal benign paroxysmal positional vertigo (HC-BPPV). In this study, we aimed to explore the value of nystagmus parameters in by supine roll test (SRT) as prognostic factors in HC-BPPV.

Methods: We retrospectively analyzed the nystagmus parameters of 813 patients diagnosed with HC-BPPV by the SRT model in the SRM-IV system through video nystagmography. Then we used the computer-controlled canalith repositioning procedure (CCRP) mode for treatment. Based on the outcomes, patients were divided into either the cured group or the resistant group. The 1:1 propensity score matching (PSM) was applied to minimize potential selection bias. Then univariable and multivariable analyses were performed to identify the association of nystagmus parameters and the efficacy of CCRP.

Results: Among the 813 patients, 99 (12.2%) were classified in the resistant group. The right side of HC-BPPV patients was twice the number of the left side patients (537 vs. 276). PSM is used to pair resistant patients to the cured patients, in which 99 pairs were successfully matched. Results of univariate and multivariate analyses showed that patients in the resistant group have longer latency in the affected side [odds ratio (OR) = 1.231 (1.110–1.366); P < 0.001] and slower slow phase velocity (SPV) in the healthy side [OR = 0.957 (0.917–0.999); P = 0.045].

Conclusion: Nystagmus parameters may represent the characteristics of canalith. HC-BPPV patients with a longer latency in the affected side and slower SPV on the healthy side during SRT have a higher risk of HC-BPPV persisting after a single CCRP.

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.

Responses to the Dix-Hallpike test in primary care: A comparison between subjective and objective benign paroxysmal positional vertigo

Patients who experience both vertigo and nystagmus in the Dix-Hallpike test (DHT) are diagnosed with objective benign paroxysmal positional vertigo (BPPV). This test provokes only vertigo in between 11% and 48% of patients, who are diagnosed with subjective BPPV. Detection of nystagmus has important diagnostic and prognostic implications. To compare the characteristics of patients diagnosed with objective and subjective BPPV in primary care. Cross-sectional descriptive study. Two urban primary care centers. Adults (≥18 years) diagnosed with objective or subjective BPPV between November 2012 and January 2015. DHT results (vertigo or vertigo plus nystagmus; dependent variable: nistagmus as response to DHT), age, sex, time since onset, previous vertigo episodes, self-reported vertigo severity (Likert scale, 0-10), comorbidities (recent viral infection, traumatic brain injury, headache, anxiety/depression, hypertension, diabetes mellitus, dyslipidemia, cardiovascular disease, altered thyroid function, osteoporosis, cervical spondylosis, neck pain). In total, 134 patients (76.1% women) with a mean age of 52 years were included; 59.71% had subjective BPPV. Objective BPPV was significantly associated with hypertension, antihypertensive therapy, and cervical spondylosis in the bivariate analysis and with cervical spondylosis (OR=3.94, p=0.021) and antihypertensive therapy (OR 3.02, p=0.028) in the multivariate analysis. Patients with subjective BPPV were more likely to be taking benzodiazepines [OR 0.24, p=0.023]. The prevalence of subjective BPPV was higher than expected. Cervical spondylosis and hypertensive therapy were associated with objective BPPV, while benzodiazepines were associated with subjective BPPV.

Unilateral mimicking bilateral BPPV- a forgotten entity? Characteristics of a large cohort of patients, comparison with posterior canal BPPV and clinical implications

Objective

Unilateral mimicking bilateral benign paroxysmal positional vertigo (umb-BPPV) was attributed to inappropriate head positioning during testing of the posterior canal. Despite its inclusion in the Diagnostic criteria for the classification of vestibular disorders of the Bárány Society, the clinical characteristics and treatment responsiveness of this BPPV subtype have not been intensively studied.

Methods

Records of patients with BPPV seen at a single outpatient dizziness clinic during the years 2000–2020 were reviewed. Eighty seven patients with umb-BPPV and 86 random patients with posterior canal BPPV (p-BPPV) were retrieved. Their demographics and BPPV characteristics were analyzed.

Results

Patients' and BPPV characteristics were similar in umb- and p-BPPV except for the prevalence of males in the umb-BPPV group. No differences were found between treatment responsiveness and recurrences in both groups. The recurrence rate of umb-BPPV was not influenced by age, gender, BPPV side, duration of symptoms or treatment responsiveness during the first attack.

Conclusions

In accordance with our hypothesis about mixed canalo- and cupulolithiasis as the underlying mechanism of umb-BPPV, patients did not differ in characteristics and treatment responsiveness from p-BPPV patients. Recognition of umb-BPPV is important since inappropriate treatment can cause an unnecessary delay in therapy success.

Nystagmus Estimation for Dizziness Diagnosis by Pupil Detection and Tracking Using Mexican-Hat-Type Ellipse Pattern Matching

The detection of nystagmus using video oculography experiences accuracy problems when patients who complain of dizziness have difficulty in fully opening their eyes. Pupil detection and tracking in this condition affect the accuracy of the nystagmus waveform. In this research, we design a pupil detection method using a pattern matching approach that approximates the pupil using a Mexican hat-type ellipse pattern, in order to deal with the aforementioned problem. We evaluate the performance of the proposed method, in comparison with that of a conventional Hough transform method, for eye movement videos retrieved from Gifu University Hospital. The performance results show that the proposed method can detect and track the pupil position, even when only 20% of the pupil is visible. In comparison, the conventional Hough transform only indicates good performance when 90% of the pupil is visible. We also evaluate the proposed method using the Labelled Pupil in the Wild (LPW) data set. The results show that the proposed method has an accuracy of 1.47, as evaluated using the Mean Square Error (MSE), which is much lower than that of the conventional Hough transform method, with an MSE of 9.53. We conduct expert validation by consulting three medical specialists regarding the nystagmus waveform. The medical specialists agreed that the waveform can be evaluated clinically, without contradicting their diagnoses.

Downregulation of VDR in benign paroxysmal positional vertigo patients inhibits otolith‑associated protein expression levels

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vertigo‑associated disease. Vitamin D (VD) helps maintain normal otolith function and may be associated with BPPV. VD exerts its biological functions primarily via the VD receptor (VDR). The present study demonstrated that serum VD levels were significantly decreased in patients with BPPV compared with in controls. VDR, otolith‑associated protein otoconin‑90 (OC90) and NADPH oxidase 3 (NOX3) expression levels were also significantly decreased in patients with BPPV compared with in controls. Furthermore, a positive correlation was observed between VD levels and VDR expression. Receiver operating characteristic curve analysis identified VDR expression levels as a potential diagnostic marker for BPPV. OC90 and NOX3 expression levels were notably lower in the inner ear tissue of VDR knockout mice compared with in those of wild‑type mice. In mice overexpressing VDR, OC90 and NOX3 were also overexpressed. Following intravenous injection of VD in VDR knockout mice, expression levels of OC90 and NOX3 were not significantly different from those in VDR knockout mice injected with saline. This indicated that VDR may be underexpressed in patients with BPPV and was associated with the expression levels of otolith‑associated proteins. Moreover, VDR mediated VD activation, leading to otolith protein formation. The present study provided a novel theoretical basis for BPPV onset that may facilitate the development of more effective diagnostic and treatment options.

Episodic Positional Dizziness

PURPOSE OF REVIEW

This article provides a summary of the evaluation and treatment of patients presenting with episodic positional dizziness.

RECENT FINDINGS

Positional components are nearly ubiquitous among diagnoses of dizziness, so it can be challenging to classify patients with episodic positional dizziness simply based on the history of present illness. Overreliance on the presence of a report of positional components has likely resulted in misapplication or misinterpretation of positional testing and negative experiences with maneuvers to treat positional dizziness. The prototypical episodic positional dizziness disorder is benign paroxysmal positional vertigo (BPPV). BPPV is caused by free-floating particles in a semicircular canal that move in response to gravity. The diagnosis is made by identifying the characteristic patterns of nystagmus on the Dix-Hallpike test. Particle repositioning for BPPV is supported by randomized controlled trials, meta-analyses, and practice guidelines. Other disorders that can present with episodic positional dizziness are migraine dizziness, central lesions, and light cupula syndrome.

SUMMARY

Episodic positional dizziness is a common presentation of dizziness. Neurologists should prioritize identifying and treating BPPV; doing so provides an important opportunity to deliver effective and efficient care. Providers should also recognize that positional components are common in most causes of dizziness and, therefore, should not over-rely on this part of the history of presentation when considering the diagnosis and management plan.

Sémont Maneuver for Benign Paroxysmal Positional Vertigo Treatment: Moving in the Correct Plane Matters

HYPOTHESIS

We aimed to investigate the effect of the head excursion angle on the success of the Sémont Maneuver (SM).

BACKGROUND

SM is performed with the head turned by 45 degrees toward the unaffected ear. In clinical routine, it is unlikely that physicians can turn the head to a position of exactly 45 degrees. Moreover, it is unclear how possible deviations from 45 degrees would affect the outcome with SM.

METHODS

We used an in vitro model (upscaled by ×5) of a posterior semicircular canal with canalithiasis to study head excursion angles (0-75 degrees) and minimum waiting times in SM. Additionally, we measured actual head excursion angles performed by trained physicians during SM on a healthy subject.

RESULTS

Successful canalith repositioning to the utricle was possible at head excursion angles between 21 and 67 degrees. Waiting time increased from 16 to 30 seconds with increasing deviation from 45 degrees. Angles larger than 67 degrees or smaller than 21 degrees did not lead to successful repositioning even after a waiting period of 5 minutes. Physicians set head excursion angles of 50 degrees ±SD 4.8 degrees while performing the SM.

CONCLUSION

Angular deviations up to ±20 degrees from the ideal SCC plane (45 degrees) still allows for successful SM. Although the tested physicians tended to underestimate the actual head excursion angle by 5 degrees (and more), the success of SM will not be affected provided that the waiting time is sufficiently long. Further, the results suggest that the Brandt-Daroff maneuver is a form of habituation training rather than a liberatory maneuver.

Quantitative assessment of self-treated canalith repositioning procedures using inertial measurement unit sensors

BACKGROUND

Low success and high recurrence of benign paroxysmal positional vertigo (BPPV) after home-based self-treated Epley and Barbeque (BBQ) roll maneuvers is an important issue.

OBJECTIVE

To quantify the cause of low success rate of self-treated Epley and BBQ roll maneuvers and provide a clinically acceptable criterion to guide self-treatment head rotations.

METHODS

Twenty-five participants without active BPPV wore a custom head-mount rotation monitoring device for objective measurements. Self-treatment and specialist-assisted maneuvers were compared for head rotation accuracy. Absolute differences between the head rotation evaluation criteria (American Academy of Otolaryngology guidelines) and measured rotation angles were considered as errors. Self-treatment and specialist-treated errors in maneuvers were compared. Between-trial variations and age effects were evaluated.

RESULTS

A significantly large error and between-trial variation occurred in step 4 of the self-treated Epley maneuver, with a considerable error in the second trial. The cumulative error of all steps of self-treated BBQ roll maneuver was significantly large. Age effect occurred only in the self-treated BBQ roll maneuver. Errors in specialist-treated maneuvers ranged from 10 to 20 degrees.

CONCLUSIONS

Real-time feedback of head movements during simultaneous head-body rotations could increase success rates of self-treatments. Specialist-treated maneuvers can be used as permissible rotation margin criteria.

Cervical vestibular evoked myogenic potentials in patients with the first episode of posterior canal benign paroxysmal positional vertigo before and after repositioning

BACKGROUND

Cervical vestibular evoked myogenic potentials (cVEMPs) are used to assess the sacculo-collic pathways. Benign paroxysmal positional vertigo (BPPV) is mainly a utricular disorder.

OBJECTIVES

To investigate cVEMPs in BPPV patients before and after repositioning maneuvers.

METHODS

Forty patients with posterior canal BPPV with new onset symptoms underwent cVEMP testing at the time of diagnosis and a month after successful repositioning maneuver. p13, n23 latency and amplitude ratio values were compared with the results of 40 healthy controls.

RESULTS

p13 and n23 latencies of the affected side were significantly longer than the healthy controls more prominent for the p13 latency. Comparison of the affected side with the non-affected side revealed delayed p13 latency on the affected side. Though a significant improvement in p13 latency was observed after repositioning, it was still prolonged when compared with the healthy controls. An abnormality regarding amplitudes was not present.

CONCLUSIONS AND SIGNIFICANCE

cVEMP abnormalities in patients with BPPV indicate saccular dysfunction accompanying utricular dysfunction which seems to be confined to the symptomatic side at least in the early phase of the disease. Partial recovery can be seen after treatment with residual findings following even the first attack.

Vertigo and Balance Disorders - The Role of Osteopathic Manipulative Treatment: A Systematic Review

BACKGROUND

Balance disorders are among the most frequent reasons for consultation and referral to specialist care. Osteopathic Manipulative Treatment (OMT) can influence the proprioceptive system by inducing alterations in the proprioceptive stimuli, hence affecting postural control.

OBJECTIVE

The present systematic review aimed to explore the effects of OMT in managing patients with vertigo and balance disorders.

METHODS

MEDLINE (PubMed), ScienceDirect, and Google Scholar were searched. Clinical trials and prospective observational studies were considered. Only studies that considered OMT as the main intervention, provided alone or combined with other interventions, were included. The methodological quality of the evidence was assessed with a modified version of the Newcastle-Ottawa Scale.

RESULTS

Five studies that enrolled a total of 114 subjects met our inclusion criteria. Overall, it has been observed that there is a positive effect on balance disorders through different outcomes in all of the included studies. Only two studies (9 subjects) mentioned low to moderate adverse events after OMT.

CONCLUSIONS

OMT showed weak positive effects on balance function, encouraging the connection of conventional medicine and evidence-based complementary medicine for integrative clinical practice and interprofessional work. However, full-sized adequately powered randomized trials are required to determine the effectiveness of OMT for vertigo and balance disorders.

Effect of the Epley Maneuver and Brandt-Daroff Exercise on Benign Paroxysmal Positional Vertigo Involving the Posterior Semicircular Canal Cupulolithiasis: A Randomized Clinical Trial

Objective: To investigate the therapeutic efficacies of the Epley maneuver and Brandt-Daroff (BD) exercise in patients with benign paroxysmal positional vertigo involving the posterior semicircular canal cupulolithiasis (PC-BPPV-cu).

Methods: We conducted a randomized clinical trial to evaluate the therapeutic effect of the Epley maneuver and BD exercise in patients with PC-BPPV-cu. Patients were randomly assigned to undergo the Epley maneuver (n = 29) or BD exercise (n = 33). The primary outcome was an immediate resolution of positional nystagmus within 1 h after a single treatment of each maneuver on the visit day. Secondary outcomes included the resolution of positional nystagmus at 1 week, the change of maximal slow phase velocity (mSPV) of positional nystagmus, and dizziness handicap inventory (DHI) immediately and at 1 week.

Results: Immediate resolution occurred in none of 29 patients in the Epley maneuver group and only 1 of 33 patients in the BD exercise group. The Epley maneuver and BD exercise had an equivalent effect at 1 week in treating PC-BPPV-cu in terms of resolving positional nystagmus (48 vs. 36%, p = 0.436) and the decrease of mSPV and DHI.

Conclusion: Neither the Epley maneuver nor BD exercise has an immediate therapeutic effect in treating PC-BPPV-cu. Clear classification of PC-BPPV should be required at the time of different pathology and different treatment response.

What diagnosis should we make for long-lasting vertiginous sensation after acute peripheral vertigo?

BACKGROUND

Differential diagnosis of persistent vertigo/dizziness in patients with a past history of vestibular neuritis (VN) and sudden deafness with vertigo (SDV) could sometimes be difficult for physicians due to variable vertiginous symptoms from rotatory to floating sensation.

OBJECTIVES

The main purpose of the present study was to examine the associations between the findings of otology/neurotology examinations in patients at the chronic stage after VN and SDV.

MATERIAL AND METHODS

We encountered 1789 successive vertigo/dizziness patients at the Vertigo/Dizziness Center in Nara Medical University between 2014 and 2018. Eighty-five patients were diagnosed as showing VN and 60 showed SDV according to the diagnostic guideline . The VN and SDV patients included 75 and 45 patients with chronic-stage of persistent vertigo/dizziness, of which 55 and 40 were enrolled into the present study.

RESULTS

Persistent vertigo/dizziness after VN was attributable to delayed vestibular compensation (dVC: 33/55; 60.0%), secondary benign paroxysmal positional vertigo (sBPPV: 20/55; 36.4%), and secondary endolymphatic hydrops (sEH: 2/55; 3.6%), while that after SDV was attributable to sBPPV (20/40; 50.0%), sEH (16/40; 40.0%), and dVC (4/40; 10.0%).

CONCLUSION AND SIGNIFICANCE

The present results could allow to simplify differential diagnosis of persistent vertigo/dizziness after VN and SDV such diseases as dVC, sBPPV, or sEH.

The effects of climate on the incidence of benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is one of the most common vestibular disorders. An investigation into the factors related to BPPV could contribute to its prevention and appropriate management. We investigated the association between climatic factors and incidence of BPPV in this study. A total of 365 patients who were diagnosed with idiopathic BPPV in the emergency room of our hospital in 2015 were included. The number of patients diagnosed with BPPV per week was calculated (every week). Climatic factors, including daily average humidity, temperature, atmospheric pressure, cloud amount, sunshine amount, and daylight time, were documented daily. The weekly mean climatic value in each week was calculated. Simple correlation analysis and multivariate regression analyses were performed to identify climatic factors associated with the number of patients diagnosed with BPPV. Simple correlation analysis revealed a significant association between the humidity (r = 0.276, p = 0.048), temperature (r = 0.275, p = 0.049), and cloud amount (r = 0.293, p = 0.035) and the number of BPPV patients diagnosed per week. Multivariate regression analysis revealed that only the cloud amount was a statistically significant factor associated with the number of BPPV patients diagnosed every week. A significant positive association was discovered between the cloud amount and BPPV incidence. Cloud amount can therefore have an association with the incidence of BPPV.

Update on benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo worldwide. This review considers recent advances in the diagnosis and management of BPPV including the use of web-based technology and artificial intelligence as well as the evidence supporting the use of vitamin D supplements for patients with BPPV and subnormal serum vitamin D.

Acute Benign Paroxysmal Positional Vertigo After Endothelial Keratoplasty-A Unique Cause of Postoperative Nausea and Headache

PURPOSE

To describe a case of new-onset benign paroxysmal positional vertigo (BPPV) after uncomplicated Descemet stripping automated endothelial keratoplasty.

METHODS

Case report and review of literature.

RESULTS

A 61-year-old woman with a history of steroid-induced glaucoma and penetrating keratoplasty for Fuchs endothelial dystrophy, and no history of BPPV or other vertigo, underwent Descemet stripping automated endothelial keratoplasty for penetrating keratoplasty graft failure. On the third postoperative day, she developed acute spinning vertigo, nausea, and headache on sitting up after 3 days of strict supine positioning. Her ophthalmic examination was benign, with no evidence of a pupillary block, and she was diagnosed by an otologist with BPPV. Her symptoms resolved after 1 week without further intervention.

CONCLUSIONS

BPPV is a benign but rare complication of nonotologic surgery and has not been previously reported with ophthalmic surgery. The overlap in symptomatology between BPPV and other serious and potentially vision-threatening causes of postoperative nausea and headache, such as pupillary block glaucoma, makes this a relevant etiology to consider in the spectrum of postendothelial keratoplasty complications.

Congruous Torsional Down Beating Nystagmus in the Third Position of the Semont's Maneuver in Patients Treated for Canalithiasis of Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo: Its Significance and Prognostic Value

Due to its mechanical pathogenesis, benign paroxysmal positional vertigo treatment is mainly physical: when posterior semicircular canal is involved, Semont's maneuver is reported as one of the most effective liberating procedures. In the case of a canalolithiasis, the efficacy of the maneuver is corroborated by the appearance of some nystagmus findings during its performance. Liberating nystagmus, that can occur in the second position of Semont's maneuver and whose direction is congruous with the excitation of the affected posterior semicircular canal has proven to be a favorable prognostic sign. On the other hand, in clinical experience, we've frequently verified the appearance of another nystagmus during the execution of the maneuver: upon reaching the third position, when replacing the patient seated, a torsional down beating nystagmus, with the torsional component “congruous” with the stimulation of the vertical semicircular canals of the affected side, can often be appreciated. Such a sign can occur with or without having had the previous liberating nystagmus in the second position and is almost always associated with an intense vertigo and/or body pulsion. In this study, we describe the incidence and characteristics of the congruous torsional down beating nystagmus that can arise by assuming the third position of Semont's maneuver in a cohort of patients treated for posterior semicircular canal benign paroxysmal positional vertigo due to canalolithiasis. In the best of our knowledge, such a sign has never been described and explained before. On the basis of the pathophysiology and of the possible canal receptors stimulation during the different phases of Semont's maneuver, we formulated different hypothesis on how such a nystagmus can be generated. We observed that such a sign, when elicited, has a very good prognostic meaning for healing purposes, even better than that of liberating nystagmus. Therefore, congruous torsional down beating nystagmus should always be checked when performing Semont's maneuver because it could help in predicting success of physical treatment and in managing patients.