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Casani AP, Albera R, Piras C, Albera A, Noto A, Ducci N, Atzori L, Lucisano S, Mussap M, Fanos V. Clinical Efficacy and Metabolomics Modifications Induced by Polyphenol Compound Supplementation in the Treatment of Residual Dizziness following Semont Maneuver in Benign Paroxysmal Positional Vertigo (BPPV) of the Posterior Semicircular Canal (PSC): Preliminary Results. Metabolites 2024; 14:86. [PMID: 38392978 PMCID: PMC10890690 DOI: 10.3390/metabo14020086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/14/2024] [Accepted: 01/22/2024] [Indexed: 02/25/2024] Open
Abstract
Benign paroxysmal positional vertigo (BPPV) represents the most frequent cause of peripheral vertigo. In most cases, it is successfully treated using the canalith repositioning procedure, but it is often followed by continuous lightheadedness in the absence of vertigo or nystagmus (residual dizziness, RD). Our aim is to describe the clinical effectiveness and the urine metabolomics profile of treating these patients with polyphenol compound supplementation. We enrolled 30 patients reporting RD after BPPV of the posterior semicircular canal (PSC) successfully treated using the Semont maneuver. Supplementation with a polyphenol compound was administered for 60 days, and patients were evaluated after 30 and 60 days of treatment using self-administered questionnaires (Visual Analog Scales for Dizziness and Nausea, Dizziness Handicap Inventory, DHI) and urine metabolomics analysis performed using 1H-NMR spectroscopy and multivariate followed by univariate analysis. Most patients reported excellent or good efficacy in the treatment of RD with a significant decrease in VAS and DHI values. The metabolomics analysis identified six significant metabolites related to the treatment, namely 1-methylnicotinamide, anserine, hippurate, lysine, methyl succinate and urea, indicating the inflammatory activities and antioxidant properties of the polyphenol compound. These preliminary data suggest that supplementation with a polyphenol compound could induce some metabolic changes that can help in recovery from RD. However, future steps will require confirmation with a more significant cohort of patients and an extension of the metabolomics evaluation to other problems concerning the different clinical aspects of BPPV, such as the high rate of relapse.
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Affiliation(s)
- Augusto Pietro Casani
- Department of Medical and Surgical Pathology, Otorhinolaryngology Section, Pisa University Hospital, 56024 Pisa, Italy
| | - Roberto Albera
- Department of Surgical Sciences, University of Turin, 10024 Turin, Italy
| | - Cristina Piras
- Department of Biomedical Sciences, University of Cagliari, 09121 Cagliari, Italy
| | - Andrea Albera
- Department of Surgical Sciences, University of Turin, 10024 Turin, Italy
| | - Antonio Noto
- Department of Biomedical Sciences, University of Cagliari, 09121 Cagliari, Italy
| | - Nicola Ducci
- Department of Medical and Surgical Pathology, Otorhinolaryngology Section, Pisa University Hospital, 56024 Pisa, Italy
| | - Luigi Atzori
- Department of Biomedical Sciences, University of Cagliari, 09121 Cagliari, Italy
| | - Sergio Lucisano
- Department of Surgical Sciences, University of Turin, 10024 Turin, Italy
| | - Michele Mussap
- Department of Surgical Sciences, University of Cagliari, 09121 Cagliari, Italy
| | - Vassilios Fanos
- Department of Surgical Sciences, University of Cagliari, 09121 Cagliari, Italy
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Sun J, Ma X, Yang Y, He K, Wang W, Shen J, Wang L, Chen X, Jin Y, Yang J, Chen J. Associations between cognition, anxiety, depression, and residual dizziness in elderly people with BPPV. Front Aging Neurosci 2023; 15:1208661. [PMID: 37719876 PMCID: PMC10500068 DOI: 10.3389/fnagi.2023.1208661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 08/17/2023] [Indexed: 09/19/2023] Open
Abstract
Objective To investigate the associations between cognition, anxiety, depression, and residual dizziness after successful repositioning maneuvers in the elderly with benign paroxysmal positional vertigo (BPPV). Methods We enrolled 40 elderly patients with BPPV in our outpatient department. We used the Dizziness Handicap Inventory (DHI), Visual Analog Scale (VAS), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder Questionnaire-7 (GAD-7) to assess the degree of dizziness, anxiety, and depression of participants before repositioning therapy, respectively. At the 1-week follow-up after BPPV treatment, each participant will be reassessed and divided into a group with residual dizziness (RD) and a group without residual dizziness (NRD) based on the follow-up DHI score. The Mini-Mental State Examination (MMSE) evaluated the cognitive function of the participants. Results The age, gender, duration of BPPV, and involved semicircular canals in the two groups did not show a significant difference. The RD group scored significantly higher on the DHI (p = 0.006), GAD-7 (p < 0.001), and PHQ-9 (p = 0.002) before the repositioning treatment than the NRD group. The two groups had no significant difference in MMSE score (p = 0.381). Anxiety and depression scores before repositioning treatment significantly and positively correlated with follow-up DHI scores (r = 0.678 and 0.522, respectively), but the MMSE score did not significantly relate to it. The univariate linear regression showed that the DHI (p < 0.001), GAD-7 (p < 0.001), and PHQ-9 (p = 0.002) scores before treatment could predict residual dizziness. The multivariate linear regression showed that GAD-7 before treatment was the only significant predictor of residual dizziness (p < 0.001). Conclusion The level of dizziness, anxiety, and depression before treatment can predict residual dizziness after successful repositioning maneuvers in the elderly with BPPV. Anxiety may be the strongest predictor of residual dizziness after successful repositioning treatment in elderly BPPV patients.
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Affiliation(s)
- Jin Sun
- Department of Otorhinolaryngology-Head and Neck Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine Ear Institute, Shanghai, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Xiaobao Ma
- Department of Otorhinolaryngology-Head and Neck Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine Ear Institute, Shanghai, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Ying Yang
- Department of Otorhinolaryngology-Head and Neck Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine Ear Institute, Shanghai, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Kuan He
- Department of Otorhinolaryngology-Head and Neck Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine Ear Institute, Shanghai, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Wei Wang
- Department of Otorhinolaryngology-Head and Neck Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine Ear Institute, Shanghai, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Jiali Shen
- Department of Otorhinolaryngology-Head and Neck Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine Ear Institute, Shanghai, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Lu Wang
- Department of Otorhinolaryngology-Head and Neck Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine Ear Institute, Shanghai, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Xiangping Chen
- Department of Otorhinolaryngology-Head and Neck Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine Ear Institute, Shanghai, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Yulian Jin
- Department of Otorhinolaryngology-Head and Neck Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine Ear Institute, Shanghai, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Jun Yang
- Department of Otorhinolaryngology-Head and Neck Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine Ear Institute, Shanghai, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
| | - Jianyong Chen
- Department of Otorhinolaryngology-Head and Neck Surgery, Xinhua Hospital Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Shanghai Jiao Tong University School of Medicine Ear Institute, Shanghai, China
- Shanghai Key Laboratory of Translational Medicine on Ear and Nose Diseases, Shanghai, China
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Pauwels S, Casters L, Lemkens N, Lemmens W, Meijer K, Meyns P, van de Berg R, Spildooren J. Gait and Falls in Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-analysis. J Neurol Phys Ther 2023; 47:127-138. [PMID: 36897200 PMCID: PMC10521788 DOI: 10.1097/npt.0000000000000438] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
BACKGROUND AND PURPOSE Benign paroxysmal positional vertigo (BPPV) is one of the most common vestibular disorders, and is treated effectively with particle repositioning maneuvers (PRM). The aim of this study was to assess the influence of BPPV and treatment effects of PRM on gait, falls, and fear of falling. METHODS Three databases and the reference lists of included articles were systematically searched for studies comparing gait and/or falls between (1) people with BPPV (pwBPPV) and controls and (2) pre- and posttreatment with PRM. The Joanna Briggs Institute critical appraisal tools were used to assess risk of bias. RESULTS Twenty of the 25 included studies were suitable for meta-analysis. Quality assessment resulted in 2 studies with high risk of bias, 13 with moderate risk, and 10 with low risk. PwBPPV walked slower and demonstrated more sway during tandem walking compared with controls. PwBPPV also walked slower during head rotations. After PRM, gait velocity during level walking increased significantly, and gait became safer according to gait assessment scales. Impairments during tandem walking and walking with head rotations did not improve. The number of fallers was significantly higher for pwBPPV than for controls. After treatment, the number of falls, number of pwBPPV who fell, and fear of falling decreased. DISCUSSION AND CONCLUSIONS BPPV increases the odds of falls and negatively impacts spatiotemporal parameters of gait. PRM improves falls, fear of falling, and gait during level walking. Additional rehabilitation might be necessary to improve gait while walking with head movements or tandem walking.Video Abstract available for more insights from the authors (see the Supplemental Digital Content Video, available at: http://links.lww.com/JNPT/A421 ).
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Affiliation(s)
- Sara Pauwels
- Faculty of Rehabilitation Sciences, REVAL-Rehabilitation Research Centre, Hasselt University, Diepenbeek, Belgium (S.P., L.C., P.M., J.S.); Department of Otorhinolaryngology and Head & Neck Surgery, School for Mental Health and Neuroscience, Faculty of Health Medicine and Life Sciences, Maastricht University Medical Center+, Maastricht, the Netherlands (S.P., R.v.d.B.); Department of Otorhinolaryngology, Head and Neck Surgery, ZOL Hospital, Genk, Belgium (N.L., W.L.); and Department of Nutrition and Movement Sciences, Maastricht University, Maastricht, the Netherlands (K.M.)
| | - Laura Casters
- Faculty of Rehabilitation Sciences, REVAL-Rehabilitation Research Centre, Hasselt University, Diepenbeek, Belgium (S.P., L.C., P.M., J.S.); Department of Otorhinolaryngology and Head & Neck Surgery, School for Mental Health and Neuroscience, Faculty of Health Medicine and Life Sciences, Maastricht University Medical Center+, Maastricht, the Netherlands (S.P., R.v.d.B.); Department of Otorhinolaryngology, Head and Neck Surgery, ZOL Hospital, Genk, Belgium (N.L., W.L.); and Department of Nutrition and Movement Sciences, Maastricht University, Maastricht, the Netherlands (K.M.)
| | - Nele Lemkens
- Faculty of Rehabilitation Sciences, REVAL-Rehabilitation Research Centre, Hasselt University, Diepenbeek, Belgium (S.P., L.C., P.M., J.S.); Department of Otorhinolaryngology and Head & Neck Surgery, School for Mental Health and Neuroscience, Faculty of Health Medicine and Life Sciences, Maastricht University Medical Center+, Maastricht, the Netherlands (S.P., R.v.d.B.); Department of Otorhinolaryngology, Head and Neck Surgery, ZOL Hospital, Genk, Belgium (N.L., W.L.); and Department of Nutrition and Movement Sciences, Maastricht University, Maastricht, the Netherlands (K.M.)
| | - Winde Lemmens
- Faculty of Rehabilitation Sciences, REVAL-Rehabilitation Research Centre, Hasselt University, Diepenbeek, Belgium (S.P., L.C., P.M., J.S.); Department of Otorhinolaryngology and Head & Neck Surgery, School for Mental Health and Neuroscience, Faculty of Health Medicine and Life Sciences, Maastricht University Medical Center+, Maastricht, the Netherlands (S.P., R.v.d.B.); Department of Otorhinolaryngology, Head and Neck Surgery, ZOL Hospital, Genk, Belgium (N.L., W.L.); and Department of Nutrition and Movement Sciences, Maastricht University, Maastricht, the Netherlands (K.M.)
| | - Kenneth Meijer
- Faculty of Rehabilitation Sciences, REVAL-Rehabilitation Research Centre, Hasselt University, Diepenbeek, Belgium (S.P., L.C., P.M., J.S.); Department of Otorhinolaryngology and Head & Neck Surgery, School for Mental Health and Neuroscience, Faculty of Health Medicine and Life Sciences, Maastricht University Medical Center+, Maastricht, the Netherlands (S.P., R.v.d.B.); Department of Otorhinolaryngology, Head and Neck Surgery, ZOL Hospital, Genk, Belgium (N.L., W.L.); and Department of Nutrition and Movement Sciences, Maastricht University, Maastricht, the Netherlands (K.M.)
| | - Pieter Meyns
- Faculty of Rehabilitation Sciences, REVAL-Rehabilitation Research Centre, Hasselt University, Diepenbeek, Belgium (S.P., L.C., P.M., J.S.); Department of Otorhinolaryngology and Head & Neck Surgery, School for Mental Health and Neuroscience, Faculty of Health Medicine and Life Sciences, Maastricht University Medical Center+, Maastricht, the Netherlands (S.P., R.v.d.B.); Department of Otorhinolaryngology, Head and Neck Surgery, ZOL Hospital, Genk, Belgium (N.L., W.L.); and Department of Nutrition and Movement Sciences, Maastricht University, Maastricht, the Netherlands (K.M.)
| | - Raymond van de Berg
- Faculty of Rehabilitation Sciences, REVAL-Rehabilitation Research Centre, Hasselt University, Diepenbeek, Belgium (S.P., L.C., P.M., J.S.); Department of Otorhinolaryngology and Head & Neck Surgery, School for Mental Health and Neuroscience, Faculty of Health Medicine and Life Sciences, Maastricht University Medical Center+, Maastricht, the Netherlands (S.P., R.v.d.B.); Department of Otorhinolaryngology, Head and Neck Surgery, ZOL Hospital, Genk, Belgium (N.L., W.L.); and Department of Nutrition and Movement Sciences, Maastricht University, Maastricht, the Netherlands (K.M.)
| | - Joke Spildooren
- Faculty of Rehabilitation Sciences, REVAL-Rehabilitation Research Centre, Hasselt University, Diepenbeek, Belgium (S.P., L.C., P.M., J.S.); Department of Otorhinolaryngology and Head & Neck Surgery, School for Mental Health and Neuroscience, Faculty of Health Medicine and Life Sciences, Maastricht University Medical Center+, Maastricht, the Netherlands (S.P., R.v.d.B.); Department of Otorhinolaryngology, Head and Neck Surgery, ZOL Hospital, Genk, Belgium (N.L., W.L.); and Department of Nutrition and Movement Sciences, Maastricht University, Maastricht, the Netherlands (K.M.)
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Fu W, He F, Bai Y, An X, Shi Y, Han J, Wang X. Risk Factors of Residual Dizziness After Successful Treatment for Benign Paroxysmal Positional Vertigo in Middle-Aged and Older Adults. Front Neurol 2022; 13:850088. [PMID: 36176560 PMCID: PMC9514231 DOI: 10.3389/fneur.2022.850088] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 05/30/2022] [Indexed: 11/17/2022] Open
Abstract
Objective The purpose of this study was to analyze risk factors of residual dizziness (RD) after successful treatment for benign paroxysmal positional vertigo (BPPV) in middle-aged and older adults. Methods 181 patients with BPPV, after successful canalith repositioning maneuver (CRM) treatment, were recruited. All patients were divided into the middle-aged group (aged 45–59 years, n = 101) and the older group (over 60 years, n = 80). The clinical characteristics were recorded, including age, gender, numbers of maneuvers, involved canal, affected side, RD, comorbidities, dizziness handicap inventory score, and generalized anxiety disorder's 7-item scale score. Results The incidence of RD in the older group was significantly higher than that of the middle-aged group (p = 0.033). Multivariate logistic regression analysis shows that age (odds ratio = 1.042, p = 0.006), moderate to severe dizziness (odds ratio = 2.017, p = 0.034), and moderate to severe anxiety (odds ratio = 2.228, p = 0.017) were independently associated with RD in middle-aged and older adults. Conclusion Older adults exhibited higher incidence of RD after successful treatment for BPPV. Age, moderate to severe dizziness, and moderate to severe anxiety were independent risk factors of RD in middle-aged and older adults.
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Affiliation(s)
- Wei Fu
- Department of Geriatrics, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Feng He
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Ya Bai
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Xinyue An
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Ying Shi
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Junliang Han
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, China
- *Correspondence: Junliang Han
| | - Xiaoming Wang
- Department of Geriatrics, Xijing Hospital, Air Force Medical University, Xi'an, China
- Xiaoming Wang
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Xie KH, Chen LC, Liu LL, Su CY, Li H, Liu RN, Chen QQ, He JS, Ruan YK, He WK. Elevated red cell distribution width predicts residual dizziness in patients with benign paroxysmal positional vertigo. Front Neurol 2022; 13:857133. [PMID: 36119686 PMCID: PMC9477442 DOI: 10.3389/fneur.2022.857133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/30/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveThe present study aimed to determine whether residual dizziness (RD) after successful repositioning treatment in benign paroxysmal positional vertigo (BPPV) patients could be predicted by red blood cell distribution width (RDW).Materials and methodsIn this study, a total of 303 BBPV patients hospitalized at the neurology department were investigated. The enrolled patients were divided into two groups after successful repositioning treatment: non-RD group included patients who were completely cured, and RD group included patients with RD. We collected data on all subjects, including general information, blood routine examination, blood biochemical examination, and magnetic resonance imaging tests.ResultsThe mean RDW values of patients in the RD group were significantly higher than that in the non-RD group (13.63 ± 1.8 vs. 12.5 ± 0.8; p < 0.001). In subsequent multivariate analysis, elevated RDW levels were a statistically significant risk factor associated with the occurrence of RD [odds ratio = 2.62, 95% confidence interval (CI) 1.88–3.64, p < 0.001]. The area under the ROC curve was 0.723 in terms of its predictive ability to distinguish patients with RD. A cut-off point of 12.95% of RDW predicted RD with a sensitivity of 75.6% and a specificity of 69.5%. Moreover, the AUC for the ability of the RDW to predict recurrence were 0.692 (95% CI = 0.561–0.831; p < 0.014).ConclusionsElevated RDW level was related to increased risk of RD among BPPV patients, requiring further efforts to clarify the actual underlying pathophysiology.
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Affiliation(s)
- Ke-Hang Xie
- Department of Neurology, Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine, Zhuhai, China
- *Correspondence: Ke-Hang Xie
| | - Li-Chun Chen
- Department of Encephalopathy, Shantou Hospital of Traditional Chinese Medicine, Shantou, China
| | - Ling-Ling Liu
- Department of Nephrology, The Fifth Affiliated Hospital of Sun Yat-sen University, Zhuhai, China
| | - Chu-Yin Su
- Department of Neurology, Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine, Zhuhai, China
| | - Hua Li
- Department of Neurology, Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine, Zhuhai, China
| | - Run-Ni Liu
- Department of Neurology, Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine, Zhuhai, China
| | - Qing-Qing Chen
- Department of Neurology, Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine, Zhuhai, China
| | - Jia-Sheng He
- Department of Neurology, Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine, Zhuhai, China
| | - Yong-Kun Ruan
- Department of Neurology, Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine, Zhuhai, China
| | - Wang-Kai He
- Department of Neurology, Zhuhai Hospital of Integrated Traditional Chinese and Western Medicine, Zhuhai, China
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Jiang CY, Wu J, Shu L, Sun XH, Pan H, Xu Q, Wu SC, Liu JR, Li Y, Chen W. Clinical and cVEMP Evaluation Predict Short-Term Residual Dizziness After Successful Repositioning in Benign Paroxysmal Positional Vertigo. Front Med (Lausanne) 2022; 9:881307. [PMID: 35685419 PMCID: PMC9170995 DOI: 10.3389/fmed.2022.881307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/12/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Residual dizziness (RD) is a frequent symptom with unknown pathogenesis, often complained about by the patients with benign paroxysmal positional vertigo (BPPV), even after a successful canalith repositioning procedure (CRP). This study aims to quantitatively evaluate the short-term RD severity and its risk factors in patients with BPPV after successful CRPs. Methods In total two hundred and twenty patients with BPPV after successful CRPs (W0) were prospectively followed up for 1 week (W1). Besides demographics and serial neuropsychological assessments (including dizziness handicap inventory-DHI, etc.), patients also received cervical/ocular vestibular evoked myogenic potential (c/oVEMP) evaluation. RD was defined as patients with dizziness or imbalance, dizziness visual analog scale (VAS) >1, and without positional vertigo or nystagmus at W1. Demographic, clinical, and VEMPs differences were compared among the three groups: patients with minor (dizziness VAS 1-3) and moderate-to-severe RD (dizziness VAS > 3) and without RD. Results The total frequency of RD at W1 was 49.1% (n = 108), with 32.3% (n = 71) minor, and 16.8% (n = 37) moderate-to-severe RD. Logistic regression analyses revealed that RD was closely associated with DHI status (OR = 2.101, P = 0.008) at W0, this effect was not present for minor RD. In addition to DHI score > 30 (OR = 4.898, P < 0.001) at W0, bilateral cVEMP absence (OR = 4.099, P = 0.005) was also an independent influential factor of moderate-to-severe RD. Conclusion Our study highlights the importance of RD quantified evaluation. DHI score >30 and bilateral cVEMP absence could increase the risk of short-term moderate-to-severe RD.
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Affiliation(s)
- Chun-Yan Jiang
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Department of Neurology, Huangpu Branch, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Wu
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liang Shu
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xu-Hong Sun
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hui Pan
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qian Xu
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Si-Cheng Wu
- Biostatistics Office of Clinical Research Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jian-Ren Liu
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yun Li
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.,Hearing and Speech Center, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Chen
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Hui J, Lei Q, Ji Z, Zi D. Betahistine alleviates benign paroxysmal positional vertigo (BPPV) through inducing production of multiple CTRP family members and activating the ERK1/2-AKT/PPARy pathway. Biol Res 2022; 55:16. [PMID: 35379352 PMCID: PMC8981858 DOI: 10.1186/s40659-022-00385-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 03/21/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Betahistine is a clinical medication for the treatment of benign paroxysmal positional vertigo (BPPV). Otolin, a secreted glycoprotein with a C-terminal globular domain homologous to the immune complement C1q, has been identified as a biomarker for BPPV. However, the role of complement C1q/TNF-related proteins (CTRPs) with a C-terminal globular domain in BPPV is unclear, so we explored the change of CTRPs in betahistine treated BPPV. METHODS We treated BPPV patients with Betahistine (12 mg/time, 3 times/day) for 4 weeks and observed the clinical efficacy and the expression of CTRP family members in BPPV patients. Then, we constructed a vertigo mice model of vestibular dysfunction with gentamicin (150 mg/Kg) and a BPPV model of Slc26a4loop/loop mutant mice. Adenoviral vectors for CTRP expression vector and small interfering RNA were injected via the intratympanic injection into mice and detected the expression of CTRP family members, phosphorylation levels of ERK and AKT and the expression of PPARγ. In addition, we treated mice of vestibular dysfunction with Betahistine (10 mg/Kg) and/or ERK inhibitor of SCH772984 (12 mg/Kg) and/or and PPARγ antagonist GW9662 (1 mg/Kg) for 15 days, and evaluated the accuracy of air righting reflex, the time of contact righting reflex and the scores of head tilt and swimming behavior. RESULTS After treatment with Betahistine, the residual dizziness duration and the score of the evaluation were reduced, and the expression of CTRP1, 3, 6, 9 and 12 were significantly increased in BPPV patients. We also found that Betahistine improved the accuracy of air righting reflex, reduced the time of contact righting reflex and the scores of head tilt and swimming behavior in gentamicin-treated mice and Slc26a4loop/loop mutant mice. The expression levels of CTRP1, 3, 6, 9 and 12, phosphorylation levels of ERK and AKT, and PPARγ expression were significantly increased, and the scores of head tilt and swimming behavior were decreased in vestibular dysfunction mice with overexpression of CTRPs. Silencing CTRPs has the opposite effect. SCH772984 reversed the effect of Betahistine in mice with vestibular dysfunction. CONCLUSION Betahistine alleviates BPPV through inducing production of multiple CTRP family members and activating the ERK1/2-AKT/PPARy pathway.
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Affiliation(s)
- Jing Hui
- Department of Neurology, The Second Affiliated Hospital of Xi'an Medical College, Xi'an, 710038, China
| | - Qi Lei
- Shaanxi Normal University Hospital, Xi'an, 710119, China
| | - Zhi Ji
- Department of Neurology, The Second Affiliated Hospital of Xi'an Medical College, Xi'an, 710038, China
| | - Dingjing Zi
- Department of Otolaryngology, The Second Affiliated Hospital of Air Force Medical University, No. 1 Xinsi Road, Xi'an , 710038, China.
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Ke Y, Ma X, Jing Y, Diao T, Yu L. Risk factors for residual dizziness in patients with benign paroxysmal positional vertigo after successful repositioning: a systematic review and meta-analysis. Eur Arch Otorhinolaryngol 2022; 279:3237-3256. [PMID: 35218384 DOI: 10.1007/s00405-022-07288-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/24/2022] [Indexed: 11/03/2022]
Abstract
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.
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Affiliation(s)
- Yujie Ke
- Department of Otorhinolaryngology, Peking University People's Hospital, Beijing, China
| | - Xin Ma
- Department of Otorhinolaryngology, Peking University People's Hospital, Beijing, China
| | - Yuanyuan Jing
- Department of Otorhinolaryngology, Peking University People's Hospital, Beijing, China
| | - Tongxiang Diao
- Department of Otorhinolaryngology, Peking University People's Hospital, Beijing, China
| | - Lisheng Yu
- Department of Otorhinolaryngology, Peking University People's Hospital, Beijing, China.
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Heydari M, Ahadi M, Jalaei B, Maarefvand M, Talebi H. The Additional Effect of Vestibular Rehabilitation Therapy on Residual Dizziness After Successful Modified Epley Procedure for Posterior Canal Benign Paroxysmal Positional Vertigo. Am J Audiol 2021; 30:535-543. [PMID: 34191552 DOI: 10.1044/2021_aja-20-00171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Purpose The aim of the study was to evaluate the additional effect of vestibular rehabilitation therapy (VRT) compared with the modified Epley procedure alone on residual dizziness after a successful modified Epley procedure in patients with posterior canal benign paroxysmal positional vertigo (BPPV). Method In this cross-sectional analytical comparative study, 47 patients (35 women and 12 men) aged 18-80 years with posterior canal BPPV were randomly assigned to one of two following groups: the control group, who received the modified Epley procedure only, and the VRT group, who received the modified Epley procedure plus vestibular rehabilitation for 4 weeks. Outcome measures, including the Dizziness Handicap Inventory (DHI), the Vertigo Symptom Scale-Long Version (VSS-L), and the Vertigo Symptom Scale-Short Form (VSS-SF), were conducted on the same session before initial therapy (T1), at 48 hr later (T2), and at 4 weeks later (T3). Presence or absence of residual dizziness was evaluated at T2. Results Residual dizziness was found in 20 (42.6%) patients after a successful modified Epley procedure. There was no statistically significant difference between the mean DHI, VSS-L, and VSS-SF scores at T1, T2, and T3 in patients who manifested with residual dizziness and those without residual dizziness in both groups. The average DHI, VSS-L, and VSS-SF score reduced during the time in both groups. These results were demonstrated that the VRT group and the control group have similar reductions in symptoms after treatment with the VRT plus modified Epley procedure and the modified Epley procedure only, respectively. Conclusions Residual dizziness is a common condition after a successful modified Epley procedure for BPPV. The VRT plus modified Epley procedure is as effective as modified Epley procedure alone in the management of residual dizziness. Further studies with supervised and customized VRT and longer follow-up periods are needed. Supplemental Material https://doi.org/10.23641/asha.14825508.
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Affiliation(s)
- Maryam Heydari
- Department of Audiology, Rehabilitation Research Center, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mohsen Ahadi
- Department of Audiology, Rehabilitation Research Center, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Bahram Jalaei
- Department of Audiology, Rehabilitation Research Center, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Maarefvand
- Department of Audiology, Rehabilitation Research Center, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Hossein Talebi
- Department of Audiology, School of Rehabilitation, Isfahan University of Medical Sciences, Iran
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Çetin YS, Çağaç A, Düzenli U, Bozan N, Elasan S. Residual Dizziness in Elderly Patients after Benign Paroxysmal Positional Vertigo. ORL J Otorhinolaryngol Relat Spec 2021; 84:122-129. [PMID: 34237746 DOI: 10.1159/000516961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 04/30/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The aim of this study was to compare the effects of Brandt-Daroff (BD) exercise and shopping exercise (SE) on the resolution of residual dizziness (RD) in patients with benign paroxysmal positional vertigo (BPPV) following a successful modified Epley canalith repositioning maneuver (CRP). METHODS This single-blind, randomized clinical trial included patients with posterior semicircular canal type of BPPV. Following the modified Epley maneuver, patients that experienced RD were randomly assigned to 3 groups: (i) BD, (ii) SE, and (iii) control groups. Primary outcomes were quantified using the Dizziness Handicap Inventory (DHI). RESULTS Following CRP, 240 (63%) participants experienced RD. All these patients were followed up weekly for RD. After the resolution of RD, patients were followed up monthly for recurrence. Mean time to recovery was 16.4 ± 10 (range, 5-49) days in the BD group, 11.5 ± 4.6 (range, 6-32) days in the SE group, and 23.4 ± 16.8 (range, 6-89) days in the control group. The SE group recovered significantly faster than the BD and control groups (p < 0.001). Baseline emotional DHI (E-DHI) scores were significantly correlated with the duration of pre-CRP symptoms (p < 0.001). Correlation analysis indicated that patients with obesity and diabetes mellitus (DM) recovered later than patients without these comorbidities. CONCLUSION We found that RD improved significantly in the SE group compared to the BD and control groups. Additionally, a significant relationship was established between RD and high anxiety levels and DM, and obesity had a negative impact on the resolution of RD.
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Affiliation(s)
- Yaser Said Çetin
- Department of Otorhinolaryngology, Faculty of Medicine, Van Yüzüncü Yıl University, Van, Turkey
| | - Aydın Çağaç
- Department of Neurology, Faculty of Medicine, Van Yüzüncü Yıl University, Van, Turkey
| | - Ufuk Düzenli
- Department of Otorhinolaryngology, Faculty of Medicine, Van Yüzüncü Yıl University, Van, Turkey
| | - Nazım Bozan
- Department of Otorhinolaryngology, Faculty of Medicine, Van Yüzüncü Yıl University, Van, Turkey
| | - Sadi Elasan
- Department of Biostatistics, Faculty of Medicine, Van Yüzüncü Yıl University, Van, Turkey
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Dyukova GM, Kryukov AI, Makarov SA, Guseva AL, Olimpieva SP. [A method for prediction functional dizziness after benign paroxysmal positional vertigo]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:120-125. [PMID: 34184487 DOI: 10.17116/jnevro2021121051120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To identify risk factors for functional vertigo (FV) in patients with benign paroxysmal positional vertigo (BPPV) based on the analysis of emotional and personality disorders at the time of the occurrence of BPPV and to develop a method for predicting its development. MATERIAL AND METHODS The study included 93 people, 81 women (87.1%), with benign paroxysmal positional vertigo (BPPV), aged 18 to 65 years, mean age 50 [41.5; 59]). After successful treatment with repositioning maneuvers, patients were re-examined 1 month later. Fifty-three patients underwent a semi-structured interview to identify a history of panic attacks (PA) using DSM-5 diagnostic criteria. After successful BPPV treatment, patients completed the following scales and questionnaires: Dizziness Handicap Inventory (DHI), Vertigo Symptom Scale Short form (VSS-SF), Numeric analog scale of fear (from 0 to 10), Depersonalization-Derealization Inventory (DDI), PHQ-9, GAD-7, PHQ-15, Holmes-Rahe Stress Inventory, Anxiety Sensitivity Index (ASI). RESULTS The cohort was divided into two groups according to the presence (group 1, n=17) or absence (group 2, n=76) of complaints for dizziness 1 month after BPPV. The frequency of PA history in group 1 was higher than in group 2 (80 vs 29.3%). Patients from group 1 had higher rates in all scales: DHI (57 vs 49, p=0.048), subscale DHI-E (18 vs 12, p=0.006), and subscale A VSS-SF (9 vs 5, p=0.03); DDI (18 vs 11, p=0.01), GAD-7 (13 vs 4), p=0.0002), Numeric analog scale of fear (10 vs 5, p<0.00005), ASI (55.5 vs 36.5, p<0.005). We developed a predictive method for diagnosis FD after BPPV, which sensitivity is 78.9% (95% CI 67.80-86.94) and specificity 94.12% (95% CI 71.31-99.85). CONCLUSION The likelihood of developing FV after BPPV can be predicted using the proposed predictive method. Early screening for FV can be used to prevent persistent postural-perceptual dizziness.
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Affiliation(s)
- G M Dyukova
- Loginov Moscow Clinical Scientific and Practical Center Moscow, Russi, Loginov Moscow Clinical Scientific and Practical Center Moscow, Russia
| | - A I Kryukov
- Pirogov Russian National Research Medical University, Moscow, Russia.,Sverzhevsky Research Institute of Clinical Otorhinolaryngology, Moscow, Russia
| | - S A Makarov
- Sechenov First Moscow State Medical University, Moscow, Russia
| | - A L Guseva
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - S P Olimpieva
- Pirogov Russian National Research Medical University, Moscow, Russia
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Abstract
The number of older people has been increasing over recent decades in Western populations. Dizziness, imbalance, and vertigo constitute some of the most common complaints in older patients, and risk of falling is the most frequent and worrying consequence. It has been reported that 15–20% of the adult population experiences these debilitating symptoms. Among the diseases that may be associated with vertigo, the three classes of otological, central, and functional (psychological) dizziness may be distinguished. Overall, vestibular disorders account for 48% of vertiginous complaints in the older population. The main focus of this article is to review the forms of pharmacotherapy for vertigo, especially with regard to older patients, who may be treated simultaneously with other drugs for different comorbidities. Interactions with other drugs should be considered in the choice of a particular course of treatment. Moreover, overuse of pharmacotherapy for the management of vertigo in the elderly may prevent the development of the central compensatory mechanism that sustains both static and dynamic imbalance after a vertiginous crisis. In the majority of patients, vestibular and physical rehabilitation are strongly advised and rarely contraindicated.
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13
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Gan Z, Zhou S, Yang H, He F, Wei D, Bai Y, Wang Y, Wang Y, Fu W, Han J. Self-Treatment of Posterior Canal Benign Paroxysmal Positional Vertigo: A Preliminary Study. Front Med (Lausanne) 2021; 8:654637. [PMID: 33996859 PMCID: PMC8116577 DOI: 10.3389/fmed.2021.654637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 03/15/2021] [Indexed: 12/04/2022] Open
Abstract
Objectives: The purpose of this study is to investigate a modified Epley maneuver for self-treatment of posterior canal benign paroxysmal positional vertigo (PC-BPPV). Methods: The study recruited 155 patients with PC-BPPV. All patients were randomized into the Epley maneuver group (n = 77) and modified Epley maneuver group (n = 78). We analyzed the resolution rate (1 day and 1 week), residual symptoms after the maneuver, and adverse effects. Results: It was found that the modified Epley maneuver group had a higher resolution rate than that of the Epley maneuver group in the treatment of PC-BPPV after 1 day of the initial maneuver (p < 0.05). However, there was no difference in resolution rate between the Epley maneuver group and the modified Epley maneuver group in resolution rate after 1 week of the initial maneuver (p > 0.05). The modified Epley maneuver group had fewer residual symptoms than that of the Epley maneuver group 1 week after treatment of PC-BPPV (p < 0.05). Significant improvements were also observed in average DHI scores in patients who underwent the modified Epley maneuver compared to the Epley maneuver (p < 0.05). There was no significant difference in adverse effects between the two groups (p > 0.05). Conclusions: The modified Epley maneuver has a satisfactory therapeutic efficacy with less residual symptoms and could be recommended as a self-treatment for patients with PC-BPPV.
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Affiliation(s)
- Zhuangqin Gan
- Department of Neurology, Qionghai People's Hospital, Qionghai, China
| | - Shiling Zhou
- Department of Neurology, Qionghai People's Hospital, Qionghai, China
| | - Hui Yang
- Department of Neurology, Qionghai People's Hospital, Qionghai, China
| | - Feng He
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Dong Wei
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ya Bai
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yuanyuan Wang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Yingxia Wang
- Department of Neurology, Qionghai People's Hospital, Qionghai, China
| | - Wei Fu
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Junliang Han
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Yildiz MG, Bilal N, Kara I, Sagiroglu S, Orhan I, Doganer A. Characteristics of Benign Paroxysmal Positional Vertigo Following an Earthquake. Ann Otol Rhinol Laryngol 2021; 130:1236-1244. [PMID: 33715462 DOI: 10.1177/0003489421996914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Benign Paroxysmal Positional Vertigo (BPPV) is a commonly encountered peripheral vestibular disorder. People exposed to massive earthquakes experience intense and long-term problem associated with dizziness. The purpose of our study is to investigate this relationship and to demonstrate the efficacy of the treatment modalities used in the management of patients with post-earthquake dizziness. METHODOLOGY The study was carried out by examining the retrospective records of patients who presented with dizziness to the otorhinolaryngological outpatient unit before and after the Elazig earthquake that occurred on 24th Jan 2020. Parameters evaluated include patients' age and gender, onset of dizziness, accompanying symptoms and comorbidities, videonystagmography (VNG) findings, pre- and post-treatment Visual Analogue Scale (VAS), Dizziness Handicap Inventory (DHI), and Hospital Anxiety and Depression Scale (HADS). RESULTS The number of patients who presented with dizziness to our outpatient clinic after the earthquake and were included in our study totaled 84. The number of patients who visited the outpatient clinic before the earthquake was identified to be 75. In the earthquake related group, while there was a statistically significant difference between residual symptoms (RS) and the need for repetitive repositioning maneuvers, there was no statistically significant difference detected for age, gender, and comorbidities. Also, no statistically significant difference was found in the pre- and post-treatment assessments of VAS, DHI, and HADS median values in the earthquake group. CONCLUSION There was a remarkable increase in the number of patients presenting with dizziness in the early post-earthquake period. Management of these patients may differ from the classic BPPV. Residual symptoms appearing after performing repositioning maneuvers can be more commonly seen among these patients.
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Affiliation(s)
- Muhammed Gazi Yildiz
- Department of ENT, Kahramanmaras Sütcü Imam University Faculty of Medicine, Kahramanmaras,Turkey
| | - Nagihan Bilal
- Department of ENT, Kahramanmaras Sütcü Imam University Faculty of Medicine, Kahramanmaras,Turkey
| | - Irfan Kara
- Department of ENT, Kahramanmaras Sütcü Imam University Faculty of Medicine, Kahramanmaras,Turkey
| | - Saime Sagiroglu
- Department of ENT, Kahramanmaras Sütcü Imam University Faculty of Medicine, Kahramanmaras,Turkey
| | - Israfil Orhan
- Department of ENT, Kahramanmaras Sütcü Imam University Faculty of Medicine, Kahramanmaras,Turkey
| | - Adem Doganer
- Department of Biostatistics, Kahramanmaras Sütcü Imam University Faculty of Medicine, Kahramanmaras, Turkey
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Efficacy of combined canalith-repositioning procedure and supine to prolonged lateral position in treating posterior canal benign paroxysmal positional vertigo. Auris Nasus Larynx 2021; 48:834-840. [PMID: 33468353 DOI: 10.1016/j.anl.2021.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/27/2020] [Accepted: 01/07/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Posterior benign paroxysmal positional vertigo (p-BPPV) is the most common type of BPPV, and canalith-repositioning procedure (CRP) is frequently applied for treatment. Supine to prolonged lateral position (SPLP), a simple home-based maneuver, can be performed for treatment of p-BPPV. The purpose of this study was to investigate whether combination of CRP and SPLP could be more effective in symptom alleviation compared with CRP alone and reduce times of repeated CRP for patients with p-BBPV. METHODS A retrospective chart review enrolled 96 patients diagnosed with primary p-BPPV. Of these patients, 64 patients were included in the CRP group and 32 patients, in the CRP+SPLP group. The outcome was determined according to days required to reach negative result in Dix-Hallpike test, duration of vertigo and dizziness following the first repositioning procedure, and times of CRP performed to reach resolution of p-BPPV. RESULTS Of patients in the CRP and CRP+SPLP groups, 38% and 16% received CRP at least twice to reach resolution, respectively (P = 0.034). Patients in the CRP group and CRP+SPLP group spent an average of 9.8 ± 6.1 days and 7.9 ± 3.4 days, respectively reaching a negative result in Dix-Hallpike test (P = 0.050). In terms of duration for relieving vertigo and dizziness, the CRP+SPLP group achieved symptom relief with shorter duration (P = 0.036 and P = 0.025, respectively). CONCLUSION Compared with CRP alone, combination of CRP and SPLP improved the therapeutic effectiveness and shortened the duration of suffering from vertigo and dizziness in patients with p-BPPV.
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Kim HA, Bisdorff A, Bronstein AM, Lempert T, Rossi-Izquierdo M, Staab JP, Strupp M, Kim JS. Hemodynamic orthostatic dizziness/vertigo: Diagnostic criteria. J Vestib Res 2020; 29:45-56. [PMID: 30883381 PMCID: PMC9249281 DOI: 10.3233/ves-190655] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 02/25/2019] [Indexed: 11/15/2022]
Abstract
This paper presents the diagnostic criteria for hemodynamic orthostatic dizziness/vertigo to be included in the International Classification of Vestibular Disorders (ICVD). The aim of defining diagnostic criteria of hemodynamic orthostatic dizziness/vertigo is to help clinicians to understand the terminology related to orthostatic dizziness/vertigo and to distinguish orthostatic dizziness/vertigo due to global brain hypoperfusion from that caused by other etiologies. Diagnosis of hemodynamic orthostatic dizziness/vertigo requires: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) orthostatic hypotension, postural tachycardia syndrome or syncope documented on standing or during head-up tilt test; and C) not better accounted for by another disease or disorder. Probable hemodynamic orthostatic dizziness/vertigo is defined as follows: A) five or more episodes of dizziness, unsteadiness or vertigo triggered by arising or present during upright position, which subsides by sitting or lying down; B) at least one of the following accompanying symptoms: generalized weakness/tiredness, difficulty in thinking/concentrating, blurred vision, and tachycardia/palpitations; and C) not better accounted for by another disease or disorder. These diagnostic criteria have been derived by expert consensus from an extensive review of 90 years of research on hemodynamic orthostatic dizziness/vertigo, postural hypotension or tachycardia, and autonomic dizziness. Measurements of orthostatic blood pressure and heart rate are important for the screening and documentation of orthostatic hypotension or postural tachycardia syndrome to establish the diagnosis of hemodynamic orthostatic dizziness/vertigo.
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Affiliation(s)
- Hyun Ah Kim
- Department of Neurology, Keimyung University Dongsan Hospital, Daegu, South Korea
| | - Alexandre Bisdorff
- Department of Neurology, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg
| | - Adolfo M. Bronstein
- Department of Neuro-otology, Division of Brain Sciences, Imperial College London, Charing Cross Hospital Campus, London, UK
| | - Thomas Lempert
- Department of Neurology, Schlosspark-Klinik, Berlin, Germany
| | | | - Jeffrey P. Staab
- Departments of Psychiatry and Psychology and Otorhinolaryngology – Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA
| | - Michael Strupp
- Department of Neurology and German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Dizziness Center, Seoul National University Bundang Hospital, Seongnam, South Korea
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Jalali MM, Gerami H, Saberi A, Razaghi S. The Impact of Betahistine versus Dimenhydrinate in the Resolution of Residual Dizziness in Patients with Benign Paroxysmal Positional Vertigo: A Randomized Clinical Trial. Ann Otol Rhinol Laryngol 2020; 129:434-440. [DOI: 10.1177/0003489419892285] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Objectives: The aim of this study was to compare the effects of betahistine with dimenhydrinate on the resolution of residual dizziness (RD) of patients with benign paroxysmal positional vertigo (BPPV) after successful Epley maneuver. Methods: In this double-blind, randomized clinical trial, patients with posterior semicircular canal type of BPPV were included. After execution of the Epley maneuver, patients were assigned randomly to one group for 1 week: betahistine, dimenhydrinate or placebo. The primary outcomes were scores of the Dizziness Handicap Inventory (DHI) and the modified Berg balance scale (mBBS). All patients were asked to describe the characteristics of their subjective residual symptoms. Binary logistic regression analysis was performed to examine the predictors of improved RD. All analyses were conducted using SPSS 19.0. Results: In total, 117 patients (age range: 20-65 years) participated in this study. After the Epley maneuver, 88 participants had RD. After the intervention, 38 patients exhibited an improved RD. Less than 50% of participants in the three groups showed mild to moderate dizziness handicap. However, there was no significant difference between mBBS scores of groups before or after the intervention. Logistic regression was shown that patients with receiving betahistine were 3.18 times more likely to have no RD than the placebo group. Increasing age was associated with a decreased likelihood of improving RD ( P = .05). Conclusion: The analysis of data showed that the use of betahistine had more effect on improving RD symptoms. We recommended future studies using objective indicators of residual dizziness.
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Affiliation(s)
- Mir Mohammad Jalali
- Professor of Otology/Neurotology, Otorhinolaryngology Research Center, Otorhinolaryngology Department, Medical Faculty, Guilan University of Medical Sciences, Rasht, Iran
| | - Hooshang Gerami
- Associate professor of Otorhinolaryngology, Otorhinolaryngology Research Center, Otorhinolaryngology Department, Medical Faculty, Guilan University of Medical Sciences, Rasht, Iran
| | - Alia Saberi
- Professor of Neurology, Neurosciences Research Center, Neurology Department, Medical Faculty, Guilan University of Medical Sciences, Rasht, Iran
| | - Siavash Razaghi
- Otrhinolaryngology Research Center, Otorhinolaryngology Department, Medical Faculty, Guilan University of Medical Sciences, Rasht, Iran
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Is drug consumption correlated with benign paroxysmal positional vertigo (BPPV) recurrence? Eur Arch Otorhinolaryngol 2020; 277:1609-1616. [DOI: 10.1007/s00405-020-05855-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 02/06/2020] [Indexed: 10/25/2022]
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Casani AP, Navari E, Albera R, Agus G, Asprella Libonati G, Chiarella G, Lombardo N, Marcelli V, Ralli G, Scotto di Santillo L, Teggi R, Viola P, Califano L. Approach to residual dizziness after successfully treated benign paroxysmal positional vertigo: effect of a polyphenol compound supplementation. Clin Pharmacol 2019; 11:117-125. [PMID: 31534374 PMCID: PMC6681902 DOI: 10.2147/cpaa.s210763] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 06/25/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess if a polyphenol compound supplementation (Vertigoval®) could improve residual dizziness earlier after benign paroxysmal positional vertigo (BPPV) and relieve patients from this disabling symptomatology. Methods In this prospective, multicentric study, 127 patients were randomized in the treatment group (TG), who received a 60-day supplementation, while 131 patients were randomized in the control group (CG), who did not receive any medication. The dizziness handicap inventory (DHI) score, static posturography, and the visual analog scale (VAS) for both dizziness (D-VAS) and nausea/vomit (N/V-VAS) were used as measures of outcome at baseline and after 30 and 60 days. Patients were asked about efficacy and tolerance to the treatment. Side effects were examined. Results A statistically significant greater decrease was established in the TG for DHI, D-VAS, and N/V-VAS compared to the CG. On the other hand, static posturography did not show statistical differences between the two groups, though a better clinical improvement after 60-day supplementation was shown in the TG in comparison to the CG. We counted mild side effects in only 2 patients. Most patients reported an excellent or good efficacy and tolerance to the treatment. Conclusion Residual dizziness is a frequent condition of unknown origin that manifests as persistent disabling imbalance after successful repositioning maneuvers for BPPV. The decreasing postural control can affect the quality of life, contributing to falling and psychological problems. The supplementation with the polyphenol compound used in our study is safe, manageable, and appeared to be able to reduce subjective symptoms and improve instability earlier, decreasing the risk of potential complications.
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Affiliation(s)
- Augusto Pietro Casani
- Department of Medical and Surgical Pathology, Otorhinolaryngology Section, Pisa University, Pisa, Italy
| | - Elena Navari
- Department of Medical and Surgical Pathology, Otorhinolaryngology Section, Pisa University, Pisa, Italy
| | - Roberto Albera
- Division of Otorhinolaryngology, Department of Surgical Sciences, University of Turin School of Medicine, Turin, Italy
| | - Giuseppe Agus
- Otorhinolaryngology, Private Practice, Cagliari, Italy
| | - Giacinto Asprella Libonati
- Ear, Nose and Throat Department, Unit of Audiology, Vestibology and Phoniatry, Madonna delle Grazie Hospital, Matera, Italy
| | - Giuseppe Chiarella
- Department of Experimental and Clinical Medicine, Unit of Audiology and Phoniatrics, Magna Græcia University, Catanzaro, Italy
| | - Nicola Lombardo
- Otorhinolaryngology Section, Mater Domini University, Catanzaro, Italy
| | - Vincenzo Marcelli
- Department of Neuroscience, Vestibular and Audiology Unit, University of Naples "Federico II", Naples, Italy
| | - Giovanni Ralli
- Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | | | - Roberto Teggi
- Ear, Nose and Throat Department, San Raffaele Scientific Hospital, Milan, Italy
| | - Pasquale Viola
- Department of Experimental and Clinical Medicine, Unit of Audiology and Phoniatrics, Magna Græcia University, Catanzaro, Italy
| | - Luigi Califano
- Audiovestibology Unit, G. Rummo Hospital, Benevento, Italy
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Effects of treatment on anxiety levels among patients with benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol 2019; 276:711-718. [DOI: 10.1007/s00405-019-05297-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 01/14/2019] [Indexed: 10/27/2022]
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Oh KH, Suh KD, Lee YH, Lee SY, Chang MY, Mun SK. Clinical utility of cervical vestibular-evoked myogenic potentials in predicting residual dizziness after benign paroxysmal positional vertigo. Clin Neurophysiol 2018; 130:95-100. [PMID: 30497047 DOI: 10.1016/j.clinph.2018.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 11/06/2018] [Accepted: 11/13/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In the present study, the value of cervical vestibular-evoked myogenic potential (cVEMP) as a predictive factor for residual dizziness after recovery of benign paroxysmal positional vertigo (BPPV) was evaluated. METHODS The present study included 65 patients who had BPPV and underwent cVEMP testing. Patients were divided into two groups depending on the presence or absence of residual dizziness after recovery of BPPV. Univariate and multivariate analyses were performed to determine the factors associated with residual dizziness using age, gender, affected semicircular canal, affected side, BPPV duration, and cVEMP parameters. RESULTS In univariate analysis, cVEMP-modified interaural amplitude difference (IAD) ratio and p13 latency showed a relatively significant association (p < 0.20) with residual dizziness. Based on multivariate analysis, increased cVEMP-modified interaural amplitude difference (IAD) ratio at the affected side (≥25%; p = 0.018, OR 6.623) remained as an associated factor. CONCLUSIONS Increased cVEMP-modified IAD ratio at the affected side is associated with residual dizziness. BPPV patients with increased cVEMP-modified IAD ratio at the affected side are more likely to have residual dizziness after recovery of BPPV. SIGNIFICANCE cVEMP testing could be used for the prediction of residual dizziness. An increased cVEMP-modified IAD ratio at the affected side may be used as a predictor of residual dizziness.
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Affiliation(s)
- Kyung Hyun Oh
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Kang Duk Suh
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Yang Ho Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Sei Young Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Mun Young Chang
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Republic of Korea.
| | - Seog-Kyun Mun
- Department of Otorhinolaryngology-Head and Neck Surgery, Chung-Ang University College of Medicine, Seoul, Republic of Korea.
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Wan TJ, Yu YC, Zhao XG, Tang P, Gong YS. Efficacy of betahistine plus cognitive behavioral therapy on residual dizziness after successful canalith repositioning procedure for benign paroxysmal positional vertigo. Neuropsychiatr Dis Treat 2018; 14:2965-2971. [PMID: 30464481 PMCID: PMC6223332 DOI: 10.2147/ndt.s182809] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Some patients still complain of residual dizziness after successful canalith repositioning procedure (CRP) for benign paroxysmal positional vertigo (BPPV). Previous study found that compared to the low-dose betahistine, the high-dose betahistine could yield better efficacy in treating residual dizziness. Therefore, this study was conducted to assess whether the addition of cognitive behavioral therapy (CBT) could make low-dose betahistine produce similar results to high-dose betahistine in treating residual dizziness. METHODS The recruited patients were randomly assigned to receive either low-dose betahistine (6 mg/time, three times/day) or high-dose betahistine (12 mg/time, three times/day). Patients in the low-dose group also received CBT (twice a week, 1 hour per time). The treatment was continued for 4 weeks. The duration of residual dizziness, 25-item Dizziness Handicap Inventory (DHI), Hamilton Anxiety Rating Scale (HARS), and Hamilton Depression Rating Scale (HDRS) were recorded and analyzed. The duration of residual dizziness and DHI score were the primary outcomes, and the HARS and HDRS scores were the secondary outcomes. RESULTS Each group had 50 patients. After treatment, the average DHI scores, HDRS scores, and HARS scores were significantly decreased in both groups. The duration of residual dizziness and average DHI score were nonsignificantly different (P=0.08; P=0.06) between the two groups, although they were lower in the low-dose group. Compared to the high-dose group, the low-dose group had the significantly lower average HDRS score (P=0.007) and HARS score (P=0.02). Meanwhile, four patients in the high-dose group experienced intolerable stomach upset. CONCLUSION These results demonstrated that the addition of CBT could make low-dose beta-histine produce similar results to high-dose betahistine in treating residual dizziness. Moreover, the low-dose betahistine plus CBT showed some advantages over high-dose betahistine in relieving depressive and anxiety symptoms and should be further explored.
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Affiliation(s)
- Tian-Ju Wan
- Department of Emergency, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Yi-Chuan Yu
- Department of Emergency, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Xiao-Gang Zhao
- Department of Emergency, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Ping Tang
- Department of Emergency, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Yong-Shu Gong
- Department of Pediatrics, Yongchuan Hospital of Chongqing Medical University, Chongqing, China,
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Chen CC, Cho HS, Lee HH, Hu CJ. Efficacy of Repositioning Therapy in Patients With Benign Paroxysmal Positional Vertigo and Preexisting Central Neurologic Disorders. Front Neurol 2018; 9:486. [PMID: 30013505 PMCID: PMC6037198 DOI: 10.3389/fneur.2018.00486] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 06/04/2018] [Indexed: 11/17/2022] Open
Abstract
With the exception of migraines, benign paroxysmal positional vertigo (BPPV) in patients with preexisting central neurologic disorders (CND) is rarely discussed in the literature. Demographic features of this patient group and the efficacy of repositioning therapy are still unknown. We hypothesized that a CND may alter the function of the central vestibular pathway, thus changing the pattern of BPPV and outcomes of repositioning. In this study, we enrolled 93 consecutive idiopathic BPPV patients and categorized them into two groups according to the presence or absence of a CND. In our series, 31.2% of BPPV cases had a CND. The most common associated CNDs were cerebrovascular disease and migraines. The two groups showed similar age distributions, canal involvement, success rates of repositioning, and cycles of treatment used to achieve complete resolution. The major differences were the proportion of females (89.7%) and a right-side predominance (75.9%) in the CND group. There was a trend of more residual dizziness (RD) after successful repositioning in the CND group, but the difference was not significant. The reason for the female and right-side predominance in the CND group is unclear. We concluded that the efficacy of repositioning therapy was excellent (with a success rate of 80.6% with one cycle and 93.5% within two cycles of treatment) for BPPV with or without a preexisting CND. Clinicians are encouraged to diagnose and treat BPPV in patients with a preexisting CND as early as possible to improve patients' quality of life, avoid complications, and reduce medical costs.
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Affiliation(s)
- Chih-Chung Chen
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan.,Dizziness and Balance Disorder Center, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
| | - Hsiao-Shan Cho
- Department of Neurology, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
| | - Hsun-Hua Lee
- Department of Neurology, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan.,Dizziness and Balance Disorder Center, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan.,Graduate Institute of Clinical Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chaur-Jong Hu
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Neurology, Taipei Medical University-Shuang Ho Hospital, New Taipei City, Taiwan
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25
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Akin FW, Riska KM, Williams L, Rouse SB, Murnane OD. Characteristics and Treatment Outcomes of Benign Paroxysmal Positional Vertigo in a Cohort of Veterans. Am J Audiol 2017; 26:473-480. [PMID: 28973090 DOI: 10.1044/2017_aja-16-0118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/24/2017] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND The Mountain Home Veterans Affairs (VA) Medical Center has been diagnosing and treating veterans with benign paroxysmal positional vertigo (BPPV) for almost 2 decades. The clinic protocol includes a 2-week follow-up visit to determine the treatment outcome of the canalith repositioning treatment (CRT). To date, the characteristics of BPPV and treatment efficacy have not been reported in a cohort of veterans with BPPV. PURPOSE To determine the prevalence and characteristics of veterans diagnosed with BPPV in a Veterans Affairs Medical Center Audiology Clinic and to examine treatment outcomes. RESEARCH DESIGN Retrospective chart review. STUDY SAMPLE A total of 102 veterans who tested positive for BPPV in the Vestibular Clinic at the Mountain Home VA Medical Center from March 2010 to August 2011. RESULTS In 102 veterans who were diagnosed with BPPV, the posterior semicircular canal was most often involved (75%), motion-provoked vertigo was the most common symptom (84%), and the majority (43%) were diagnosed with BPPV in their sixth decade. The prevalence of BPPV in the Audiology Vestibular Clinic was 15.6%. Forty-one percent of veterans reported a symptom onset within 12 months of treatment for BPPV; however, 36% reported their symptoms began > 36 months prior to treatment. CRT was effective (negative Dix-Hallpike/roll test) in most veterans (86%) following 1 treatment appointment (M = 1.6), but more than half reported incomplete symptom resolution (residual dizziness) at the follow-up appointment. Eighteen percent of veterans experienced a recurrence (M = 1.8 years; SD = 1.7 years). CONCLUSIONS The characteristics and treatment outcomes of BPPV in our veteran cohort was similar to what has been reported in the general population. Future work should focus on improving the timeliness of evaluation and treatment of BPPV and examining the time course and management of residual dizziness.
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Affiliation(s)
- Faith W. Akin
- Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, James H. Quillen VA Veterans Affairs Medical Center, Mountain Home, TN
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
| | - Kristal M. Riska
- Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, James H. Quillen VA Veterans Affairs Medical Center, Mountain Home, TN
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
| | - Laura Williams
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
- Audiology and Speech Pathology Service, San Diego VA Medical Center, La Jolla, CA
| | - Stephanie B. Rouse
- Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, James H. Quillen VA Veterans Affairs Medical Center, Mountain Home, TN
| | - Owen D. Murnane
- Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, James H. Quillen VA Veterans Affairs Medical Center, Mountain Home, TN
- Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
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Kahraman SS, Arli C, Copoglu US, Kokacya MH, Colak S. The evaluation of anxiety and panic agarophobia scores in patients with benign paroxysmal positional vertigo on initial presentation and at the follow-up visit. Acta Otolaryngol 2017; 137:485-489. [PMID: 27809643 DOI: 10.1080/00016489.2016.1247986] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
CONCLUSION Patients with BPPV experienced short but intense anxiety and/or panic disorder, especially at the initial visit, but most patients recovered without medication with successful treatment. OBJECTIVE Recent studies have shown that people with dizziness report some psychological problems such as panic and agoraphobia and anxiety. The aim of this study was to evaluate anxiety and panic agorophobia levels in patients with benign paroxysmal positional vertigo on initial presentation and at the follow-up visit and compare the scores with the control group. METHODS All the 32 patients in the study had a diagnosis of BPPV confirmed by their history, typical subjective symptom reports, and characteristic positional nystagmus during the Dix-Hallpike test and/or Roll test. The patients were instructed to complete the standard forms of Beck anxiety inventory and panic agoraphobia scale questionnaire before and at 7 and 14 days after the canalith repositioning treatment. RESULTS The validity scores of panic agoraphobia were statistically significantly higher in patients with BPPV than in the control group in each period (p < .001) and the validity scores of the Beck anxiety inventory were statistically significantly higher in patients with BPPV than in the control group at the first and second evaluation (p < .001).
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Affiliation(s)
- Serif Samil Kahraman
- Department of Otolaryngology – Head and Neck Surgery, Mustafa Kemal University Faculty of Medicine, Hatay, Turkey
| | - Cengiz Arli
- Department of Otolaryngology – Head and Neck Surgery, Mustafa Kemal University Faculty of Medicine, Hatay, Turkey
| | - Umit Sertan Copoglu
- Department of Psychiatry, Mustafa Kemal University Faculty of Medicine, Hatay, Turkey
| | - Mehmet Hanifi Kokacya
- Department of Psychiatry, Mustafa Kemal University Faculty of Medicine, Hatay, Turkey
| | - Sait Colak
- Department of Otolaryngology – Head and Neck Surgery, Mustafa Kemal University Faculty of Medicine, Hatay, Turkey
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Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, Holmberg JM, Mahoney K, Hollingsworth DB, Roberts R, Seidman MD, Steiner RWP, Do BT, Voelker CCJ, Waguespack RW, Corrigan MD. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg 2017; 156:S1-S47. [DOI: 10.1177/0194599816689667] [Citation(s) in RCA: 363] [Impact Index Per Article: 51.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Neil Bhattacharyya
- Department of Otolaryngology, Harvard Medical School, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Samuel P. Gubbels
- Department of Otolaryngology, School of Medicine and Public Health, University of Colorado, Aurora, Colorado, USA
| | - Seth R. Schwartz
- Department of Otolaryngology, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Jonathan A. Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Hussam El-Kashlan
- Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
| | - Terry Fife
- Barrow Neurological Institute and College of Medicine, University of Arizona, Phoenix, Arizona, USA
| | | | | | | | - Richard Roberts
- Alabama Hearing and Balance Associates, Inc, Birmingham, Alabama, USA
| | - Michael D. Seidman
- Department of Otolaryngology–Head and Neck Surgery, College of Medicine, University of Central Florida, Orlando, Florida, USA
| | - Robert W. Prasaad Steiner
- Department of Health Management and Systems Science and Department of Family and Geriatric Medicine, School of Public Health and Information Science, University of Louisville, Louisville, Kentucky, USA
| | - Betty Tsai Do
- Department of Otorhinolaryngology, Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma, USA
| | - Courtney C. J. Voelker
- Department of Otolaryngology–Head and Neck Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Richard W. Waguespack
- Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Maureen D. Corrigan
- American Academy of Otolaryngology–Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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Giommetti G, Lapenna R, Panichi R, Mobaraki PD, Longari F, Ricci G, Faralli M. Residual Dizziness after Successful Repositioning Maneuver for Idiopathic Benign Paroxysmal Positional Vertigo: A Review. Audiol Res 2017; 7:178. [PMID: 28603599 PMCID: PMC5452628 DOI: 10.4081/audiores.2017.178] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 04/19/2017] [Indexed: 01/31/2023] Open
Abstract
The benign paroxysmal positional vertigo (BPPV) is a vestibular disorder cause of vertigo. The BPPV may be corrected mechanically by repositioning maneuvers but even after successful maneuvers, some patients report residual dizziness for a certain period afterward. Early recognition and treatment might decrease the incidence of residual dizziness in patients with BPPV, especially in those patients with psychiatric comorbidities and in the elderly, lowering the risk of falling. Many pathogenetic hypotheses for residual dizziness are under debate. The purpose of this review was to identify, evaluate and review recent researches about possible causal factors involved in residual dizziness and the implications on clinical practice. A literature search was performed using different databases such as Pubmed and Scopus. The following search terms were used: residual dizziness, otolithic membrane and BPPV. The search found a total of 1192 titles, which were reduced to 963 after a procedure of de-duplication of the found titles. The research was then restricted to an interval of time comprised between 2000 and 2016 for a total of 800 titles. Among these titles, only those including the terms benign paroxysmal positional vertigo were considered eligible for this review. Only publications in English language were taken into consideration and we excluded those with not available abstract. Finally, 90 abstracts were obtained and critically evaluated by two different Authors, and additional studies were identified by hand searching from the references of artiche of interest. Only 53 were included in this work.
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Affiliation(s)
- Giorgia Giommetti
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgical and Biomedical Sciences, University of Perugia, Corciano (PG), Italy
| | - Ruggero Lapenna
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgical and Biomedical Sciences, University of Perugia, Corciano (PG), Italy
| | - Roberto Panichi
- Department of Experimental Medicine, University of Perugia, Corciano (PG), Italy
| | - Puya Dehgani Mobaraki
- Section of Otorhinolaryngology, Gubbio-Gualdo Tadino Hospital, ASL Umbria 1, Perugia; and Association “Naso Sano” Onlus, Umbria Regional Registry of Volunteer Activities, Corciano (PG), Italy
| | - Fabrizio Longari
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgical and Biomedical Sciences, University of Perugia, Corciano (PG), Italy
| | - Giampietro Ricci
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgical and Biomedical Sciences, University of Perugia, Corciano (PG), Italy
| | - Mario Faralli
- Section of Otolaryngology-Head and Neck Surgery, Department of Surgical and Biomedical Sciences, University of Perugia, Corciano (PG), Italy
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Martellucci S, Pagliuca G, de Vincentiis M, Greco A, De Virgilio A, Nobili Benedetti FM, Gallipoli C, Rosato C, Clemenzi V, Gallo A. Features of Residual Dizziness after Canalith Repositioning Procedures for Benign Paroxysmal Positional Vertigo. Otolaryngol Head Neck Surg 2016; 154:693-701. [DOI: 10.1177/0194599815627624] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 12/29/2015] [Indexed: 11/15/2022]
Abstract
Objectives To assess factors related to residual dizziness (RD) in patients who underwent successful canalith repositioning procedures (CRPs) for benign paroxysmal positional vertigo (BPPV). Study Design Prospective cohort study. Setting Academic center. Subjects and Methods Ninety-seven consecutive patients with BPPV of the posterior semicircular canal were initially enrolled. Diagnosis was assessed according to clinical history and bedside evaluation. All patients were treated with CRPs until nystagmus disappeared. Three days after the successful treatment, presence of RD was investigated. If RD was present, patients were monitored every 3 days until the symptoms disappeared. Subjects who required ≥4 CRPs or who failed to meet the follow-up visit were excluded. The Dizziness Handicap Inventory (DHI) was obtained from patients at the time of diagnosis and at every subsequent visit. Results At the end of selection, 86 patients were included; 33 (38.36%) reported RD after successful treatment. A significant difference in the incidence of RD was observed in consideration of the age of the subjects ( P = .0003) and the DHI score at the time of diagnosis ( P < .001). A logistic regression analysis showed that the probability of RD occurrence increased with the increase of the emotional subdomain score of the DHI questionnaire. Conclusion RD is a common self-limited disorder, more frequent in the elderly, which may occur after the physical treatment for BPPV. The DHI score at the time of BPPV diagnosis represents a useful tool to quantify the impact of this vestibular disorder on the quality of life and to estimate the risk of RD after CRPs.
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Affiliation(s)
- Salvatore Martellucci
- Department of Surgical Biotechnologies and Science, ENT Section, Sapienza University of Rome, Rome, Italy
| | - Giulio Pagliuca
- Department of Surgical Biotechnologies and Science, ENT Section, Sapienza University of Rome, Rome, Italy
| | - Marco de Vincentiis
- Department of Sensorial Organs, ENT Section, Sapienza University of Rome, Rome, Italy
| | - Antonio Greco
- Department of Sensorial Organs, ENT Section, Sapienza University of Rome, Rome, Italy
| | - Armando De Virgilio
- Department of Sensorial Organs, ENT Section, Sapienza University of Rome, Rome, Italy
- Department of Surgical Science, Sapienza University of Rome, Rome, Italy
| | | | - Camilla Gallipoli
- Department of Surgical Biotechnologies and Science, ENT Section, Sapienza University of Rome, Rome, Italy
| | - Chiara Rosato
- Department of Surgical Biotechnologies and Science, ENT Section, Sapienza University of Rome, Rome, Italy
| | - Veronica Clemenzi
- Department of Surgical Biotechnologies and Science, ENT Section, Sapienza University of Rome, Rome, Italy
| | - Andrea Gallo
- Department of Surgical Biotechnologies and Science, ENT Section, Sapienza University of Rome, Rome, Italy
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Tian L, Sheng HB, Wang J, Luo X, Yu J, Jia XH, Cheng X, Han Z, Chi FL. Comparative Study on the Roles of the Number of Accelerations and Rotation Angle in the Treatment Maneuvers for Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo. ORL J Otorhinolaryngol Relat Spec 2015; 78:36-45. [PMID: 26682914 DOI: 10.1159/000442091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 10/26/2015] [Indexed: 11/19/2022]
Abstract
AIMS This study aims to investigate the roles of the number of accelerations and rotation angle in the treatment of posterior semicircular canal benign paroxysmal positional vertigo (PC-BPPV). METHODS We enrolled 344 patients with unilateral PC-BPPV. Of these, 167 patients in the simple-step maneuver (SSM) group were accelerated twice and rotated 120° per step, whereas 177 patients in the multi-step maneuver (MSM) group were accelerated 4 times and rotated 60° per step. Dix-Hallpike (DH) tests were performed to categorize the treatment outcome as follows: 'symptom free' if the result was negative, 'symptom persistent' if the result remained positive after performing the maneuver 3 times or 'canal conversion' if horizontal nystagmus was evoked. RESULTS Of the patients in the SSM and MSM groups, 78.4 and 91.5% became symptom free, respectively, while canal conversion occurred in 13.8 and 5.1%, respectively (p = 0.003, χ(2) test). The success rate after performing the maneuver once was 57.1% in the MSM and 32.3% in the SSM symptom-free patients (p = 0.001, χ(2) test). One month after the treatment, 22.0 and 9.6% of the SSM and MSM patients had symptom relapse, respectively (p = 0.007, χ(2) test). CONCLUSIONS More accelerations and a smaller rotation angle improved the effectiveness and efficiency of the repositioning maneuvers and reduced canal conversion.
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Affiliation(s)
- Liang Tian
- Department of Otology and Skull Base Surgery, Eye Ear Nose and Throat Hospital, Fudan University, Shanghai Clinical Medical Center of Hearing Medicine, and Key Laboratory of Hearing Science, Ministry of Health, Shanghai, China
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31
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Recent advances in orthostatic hypotension presenting orthostatic dizziness or vertigo. Neurol Sci 2015; 36:1995-2002. [DOI: 10.1007/s10072-015-2363-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Accepted: 08/05/2015] [Indexed: 02/03/2023]
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Kim MB, Lee HS, Ban JH. Vestibular suppressants after canalith repositioning in benign paroxysmal positional vertigo. Laryngoscope 2014; 124:2400-3. [PMID: 24782447 DOI: 10.1002/lary.24741] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 04/15/2014] [Accepted: 04/26/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES/HYPOTHESIS To investigate the characteristics of residual symptoms and to evaluate the effects of adjuvant vestibular suppressants on residual symptoms after successful canalith repositioning procedures (CRPs). STUDY DESIGN Individual randomized controlled trial. METHODS One hundred fifty patients with idiopathic benign paroxysmal positional vertigo who achieved successful CRPs on initial visit participated in this study. Dizziness Handicap Inventory (DHI) questionnaires were completed before CRPs. All study populations were divided into three groups after successful CRPs on the initial visit day: the medication (V) group (treated with a vestibular suppressant [dimenhydrinate 50 mg per day]), the placebo (P) group, and the no medication (N) group. One week after successful CRPs, residual symptoms were checked and repeated DHI questionnaires were completed to compare residual symptoms. RESULTS Among the 138 patients who did not show positional nystagmus at follow-up, 67 (48.5%) complained of residual symptoms. The presence of residual symptoms was more prevalent in the P and N group compared with the V group (P = .035, P = .017, respectively). The most frequent residual symptom was lightheadedness (n = 42). Moreover, in the V group, lightheadedness was significantly reduced compared with the P group (P = .029). However, in the analysis of DHI, total and subscale scores did not differ across the three groups before or after successful CRP. CONCLUSIONS Vestibular suppressants significantly reduced residual symptoms compared to both placebo and no medication after CRP. However, there was no significant reduction in DHI score compared with the control group, suggesting that the residual symptoms could not be evaluated by DHI score alone.
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Affiliation(s)
- Min-Beom Kim
- Department of Otolaryngology-Head and Neck Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medicine, Seoul, Korea
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Autonomic dysfunction as a possible cause of residual dizziness after successful treatment in benign paroxysmal positional vertigo. Clin Neurophysiol 2014; 125:608-14. [DOI: 10.1016/j.clinph.2013.08.008] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 08/20/2013] [Accepted: 08/22/2013] [Indexed: 11/18/2022]
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Teggi R, Quaglieri S, Gatti O, Benazzo M, Bussi M. Residual dizziness after successful repositioning maneuvers for idiopathic benign paroxysmal positional vertigo. ORL J Otorhinolaryngol Relat Spec 2013; 75:74-81. [PMID: 23774304 DOI: 10.1159/000350255] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 02/20/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To establish a possible causal factor for residual dizziness (RD) after successful repositioning maneuvers in patients with benign paroxysmal positional vertigo (BPPV). MATERIALS AND METHOD Ninety consecutive patients with idiopathic BPPV were treated with repositioning maneuvers, and the rate of RD was assessed as well as clinical data. Posturography and assessment of anxiety levels were performed on patients reporting RD. Results were compared with a control group of BPPV patients of the sample after repositioning maneuvers and without RD. RESULTS Twenty-eight subjects (31.1%) reported RD on the second day after successful repositioning maneuvers. The mean duration of RD was 11.6 ± 3.9 days. Patients with RD presented a higher duration of BPPV (14.1 vs. 10.9 days, p = 0.01). A correlation was demonstrated between the duration of BPPV and duration of RD (p < 0.01). Subjects with RD presented increased body sways, above all in eyes-closed conditions. CONCLUSION RD is mainly correlated with duration of vertigo in BPPV patients. Anxiety was demonstrated to play a role in increased body sways.
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Affiliation(s)
- Roberto Teggi
- Department of Otorhinolaryngology, San Raffaele Scientific Institute, Milan, Italy.
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