Clinical characteristics and associated factors of canal switch in benign paroxysmal positional vertigo

Mechanical rotational chair-assisted multiple canalith repositioning procedures for benign paroxysmal positional vertigo: enhanced vertigo relief, comparable adverse effects, and decreased incidence of residual dizziness

Objectives

This retrospective study aimed to assess the effectiveness and adverse effects of mechanical rotational chair-assisted multiple canalith repositioning procedures (CRPs) to treat benign paroxysmal positional vertigo (BPPV).

Materials and methods

A retrospective analysis of 1,273 BPPV patients was conducted, with 241 patients included in the final study. The participants diagnosed with BPPV, unresolved by a single previous CRP, were categorized into either the single or multiple CRP groups. In both groups, on days 1, 4, and 7 after the initial treatment, the participants were re-evaluated after a single CRP; if positional vertigo was resolved, the treatment was regarded as successful. The remission rate, adverse effects (such as canal switch (CS), falls, and vomiting), residual dizziness (RD) rate, and RD duration were compared between the two groups.

Results

The resolution rates for the single and multiple CRP groups were significantly different on days 1 and 4 (55.7% vs. 85.1%, 75.5% vs. 91.9%; P < 0.05) but not on day 7 (93.3% vs. 94.8%; P > 0.05). There were no significant differences between the single and multiple CRP groups in terms of CS and falls (3.8% vs. 5.2%, 10.3% vs. 8.9%; P > 0.05). However, there was a significant difference in the incidence of vomiting (6.6% vs. 14.8%; P < 0.05). RD such as head heaviness, imbalance, and non-specific dizziness is more common in the single CRP group than in the multiple CRP group (34.9% vs. 20.7%, 42.5% vs. 26.7%, 47.2% vs. 32.6%; P < 0.05). The incidence and duration of RD were notably diminished in the group undergoing multiple CRPs compared to the single CRP group, with incidence rates of 41.5% and 57.5%, respectively (P < 0.05).

Conclusion

For patients with BPPV, multiple CRPs offer greater benefits than a single CRP.

Canal switch: a possible complication of physical therapeutic manoeuvers for posterior canal benign paroxysmal positional vertigo

Objective

To study the frequency of canal switch in posterior canal benign paroxysmal positional vertigo (BPPV) treated by canalith repositioning manoeuver (CRP), quick liberatory rotation manoeuver (QLR) or Semont manoeuver (SM).

Methods

Retrospective study on 1158 patients, 637 women and 521 men suffering from geotropic posterior canal BPPV treated by CRP, QLR, or SM, retested after 15 minutes and about seven days.

Results

1146 patients recovered from the acute phase; treatments failed in 12 patients treated with CRP. We observed 12 canal switches from posterior to lateral canal and 2 from posterior to anterior canal during or after CRP in 13/879 cases (1.5%) and after QLR in 1/158 (0.6%) with no significant difference between CRP vs SM and QLR. We did not consider slight positional downbeat nystagmus after the therapeutic manoeuvers as a sign of canal switch into the anterior canal, but as a sign of persistent small debris in the non-ampullar arm of the posterior canal.

Conclusions

Canal switch is rare for any manoeuver and it does not belong to the criteria to choose one manoeuver over another. Notably, due to the canal switching criteria, SM and QLR cannot be preferred over those with a more prolonged extension of the neck.

Comparison of the efficacy of the Epley maneuver and repeated Dix-Hallpike tests for eliminating positional nystagmus: A multicenter randomized study

Background and objectives

Patients with benign paroxysmal positional vertigo of the posterior canal (pc-BPPV) exhibit BPPV fatigue, where the positional nystagmus diminishes with the repeated performance of the Dix-Hallpike test (DHt). BPPV fatigue is thought to be caused by the disintegration of lumps of otoconial debris into smaller parts and can eliminate positional nystagmus within a few minutes [similar to the immediate effect of the Epley maneuver (EM)]. In this study, we aimed to show the non-inferiority of the repeated DHt to the EM for eliminating positional nystagmus after 1 week.

Methods

This multicenter, randomized controlled clinical trial was designed based on the CONSORT 2010 guidelines. Patients who had pc-BPPV were recruited and randomly allocated to Group A or Group B. Patients in Group A were treated using the EM, and patients in Group B were treated using repeated DHt. For both groups, head movements were repeated until the positional nystagmus had been eliminated (a maximum of three repetitions). After 1 week, the patients were examined to determine whether the positional nystagmus was still present. The groups were compared in terms of the percentage of patients whose positional nystagmus had been eliminated, with the non-inferiority margin set at 15%.

Results

Data for a total of 180 patients were analyzed (90 patients per group). Positional nystagmus had been eliminated in 50.0% of the patients in Group A compared with 47.8% in Group B. The upper limit of the 95% confidence interval for the difference was 14.5%, which was lower than the non-inferiority margin.

Discussion

This study showed the non-inferiority of repeated DHt to the EM for eliminating positional nystagmus after 1 week in patients with pc-BPPV and that even the disintegration of otoconial debris alone has a therapeutic effect for pc-BPPV. Disintegrated otoconial debris disappears from the posterior canal because it can be dissolved in the endolymph or returned to the vestibule via activities of daily living.

Classification of evidence

This study provides Class II evidence of the non-inferiority of repeated DHt to the EM for eliminating positional nystagmus after 1 week.

Registration number

UMIN000016421.

Canal switch in benign paroxysmal positional vertigo: Clinical characteristics and possible mechanisms

BACKGROUND

Canal switch-benign paroxysmal positional vertigo (CS-BPPV) refers to the phenomenon in which otolith particles move from one canal to another (on the ipsilateral side) during or after canalith repositioning procedure (CRP). However, the clinical characteristics of CS-BPPV and the underlying pathological mechanisms remain unclear. In this study, we investigated the incidence of canal switch (CS) for the different semicircular canals in benign paroxysmal positional vertigo (BPPV), examined nystagmus characteristics, and explored the underlying mechanisms.

METHODS

Clinical data for 1,099 patients with single-canal BPPV were collected and retrospectively analyzed. The incidences of CS in the different types of BPPV were analyzed. Patients were divided into CS-BPPV and non-CS (NCS)-BPPV groups according to whether they exhibited CS after CRP. The baseline characteristics and nystagmus characteristics of patients were compared between the two groups.

RESULTS

Patients with BPPV who developed or did not develop CS accounted for 4.6% (51/1,099) and 95.4% (1,048/1,099), respectively, of the patients included in the study. There were no statistically significant differences between the two groups in terms of sex, age, side of the canals involved, hypertension, or diabetes. CS was observed in 3.7% (25/677) of patients with PC-BPPV, including conversion between posterior canal (PC) and horizontal canal (HC) (1.6%, 11/677), and between PC and anterior canal (AC) (2.1%, 14/677). CS was observed in 5.2% (17/327) of patients with HC-BPPV, including from HC to PC (4.3%, 14/327), and from HC to AC (0.9%, 3/327). CS was found in 9.5% (9/95) of patients with AC-BPPV, including from AC to PC (8.4%, 8/95), and from AC to HC (1.1%, 1/95). The intensity of nystagmus was significantly greater in the CS-BPPV group compared with that in the NCS-BPPV group [24.00 (11-39) vs. 12.00 (7-24), P < 0.001]. Furthermore, the incidence of direction-reversing nystagmus was significantly higher in the CS-BPPV group than in the NCS-BPPV group [31.4% (16/51) vs. 4.3% (45/1,048), P < 0.001].

CONCLUSIONS

CS in BPPV is uncommon. Patients with AC-BPPV are more likely to develop CS, followed by patients with HC-BPPV and PC-BPPV. The occurrence of CS-BPPV may be related to the anatomical structure of the semicircular canals. When the canals contain large/heavy accumulations of otolith particles, CS may be more common during re-examination after CRP.

A comparative study of two methods for treatment of benign paroxysmal positional vertigo in the emergency department

Introduction

Posterior canal benign paroxysmal positional vertigo (PC-BPPV) is considered the most common cause of peripheral vertigo in the emergency department (ED). Although the canalith repositioning maneuver (CRM) is the standard of care, the most effective method to deliver it in the ED has been poorly studied.

Objective

To compare two protocols of the Epley maneuver for the treatment of PC-BPPV.

Patients and methods

We prospectively recruited 101 patients with unilateral PC-BPPV on physical examination, randomizing them to either a single Epley maneuver (EM) (n = 46) or multiple maneuvers (n = 55) on the same visit. Measured outcomes included presence/absence of positional nystagmus, resolution of vertigo, and score on the dizziness handicap inventory (DHI) at follow-up evaluations. The DHI was stratified into mild (≤30) and moderate-severe (>30).

Results

Normalization of the Dix-Hallpike maneuver at day 5 was observed in 38% of the single EM group and 44.4% in the multiple EM group (p = 0.62). The DHI showed reduction from 42.2 (SD 18.4) to 31.9 (SD 23.7) in the single EM group and from 43.7 (SD 22.9) to 33.5 (SD 21.5) in the multiple EM group (p = 0.06). A higher number of patients improved from moderate-severe to mild DHI (p = 0.03) in the single EM group compared to the multi-EM group (p = 0.23).

Conclusion

There was no statistically significant difference between performing a single EM versus multiple EMs for treatment of PC-BPPV in the emergency department. The single EM approach is associated with shorter physical contact between patients and examiner, which is logically safer in a pandemic context.

The Additional Effect of Vestibular Rehabilitation Therapy on Residual Dizziness After Successful Modified Epley Procedure for Posterior Canal Benign Paroxysmal Positional Vertigo

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.

[Benign paroxysmal positional vertigo : Typical and unusual clinical findings]

Benign paroxysmal positional vertigo (BPPV) is the most frequent form of vertigo seen in patients attending emergency departments. Leading symptoms are short attacks of vertigo provoked by head or body rotations. BPPV is caused by small calcium crystals, so-called otoconia, which are dislocated from the macula of the utricle mostly into the posterior semicircular canal. Free floating otoconia can move under the influence of gravity inside the semicircular canal (canalolithiasis) or adhere to the cupula (cupulolithiasis) causing displacement of the cupula. This results in positional nystagmus, whose directions and time courses are characteristic for the affected semicircular canal and the underlying cause. In recent years, however, a number of cases were reported, in which direction and times course of nystagmus differed from typical clinical findings. This may cause diagnostic problems.

[Benign paroxysmal positional vertigo : Typical and unusual clinical findings]

Benign paroxysmal positional vertigo (BPPV) is the most frequent form of vertigo seen in patients attending emergency departments. Leading symptoms are short attacks of vertigo provoked by head or body rotations. BPPV is caused by small calcium crystals, so-called otoconia, which are dislocated from the macula of the utricle mostly into the posterior semicircular canal. Free floating otoconia can move under the influence of gravity inside the semicircular canal (canalolithiasis) or adhere to the cupula (cupulolithiasis) causing displacement of the cupula. This results in positional nystagmus, whose directions and time courses are characteristic for the affected semicircular canal and the underlying cause. In recent years, however, a number of cases were reported, in which direction and times course of nystagmus differed from typical clinical findings. This may cause diagnostic problems.

Treatment Results of Geotropic and Apogeotropic Horizontal Canal Benign Paroxysmal Positional Vertigo in a Tertiary Dizziness Clinic

Purpose: To determine the effectiveness of our treatment protocol for geotropic and apogeotropic horizontal canal benign paroxysmal positional vertigo (h-BPPV).

Methods: We retrospectively evaluated patients with newly diagnosed geotropic and apogeotropic h-BPPV who visited our clinic between July 2017 and December 2019. Patients were treated according to our treatment protocol, which was implemented in 2017. Patients with geotropic h-BPPV were preferably treated with the Gufoni maneuver. In patients with apogeotropic h-BPPV we executed the modified Gufoni maneuver to achieve conversion to the geotropic type. We looked at the number of successful treatments and the number of recurrences within 1 year.

Results: We included 102 patients with h-BPPV, 62 (61%) of whom were treated for geotropic h-BPPV. The ratio of apogeotropic to geotropic h-BPPV was 0.65. After the first visit, we observed resolution of horizontal canal BPPV in 71 and 63% of the geotropic and the apogeotropic group, respectively. After the second visit, this percentage increased to 92% for geotropic h-BPPV and 78% for apogeotropic h-BPPV. After 1 year of follow-up we determined a recurrence rate of 32 and 24% for the geotropic and apogeotropic group, respectively.

Conclusion: With our treatment protocol we managed to achieve high rates of symptom resolution in the geotropic and apogeotropic type of h-BPPV with acceptable recurrence rates. We observed a relatively high ratio of apogeotropic h-BPPV to geotropic h-BPPV.