Abstract
Objective
The aim of the study was to evaluate the true incidence, diagnosis, and treatment of benign paroxysmal positional vertigo (BPPV) arising after whiplash injury and to distinguish this type of posttraumatic vertigo from other types of dizziness complained after trauma.
Methods
This was a retrospective study comprising patients referred to our center after whiplash injury. The patients were evaluated with neurotologic examination including bedside and instrumental tests. A Dizziness Handicap Inventory evaluating the symptoms of patients was submitted before and after treatment and was evaluated. The BPPV patients were separately evaluated from those with cervicogenic vertigo, and a comparison between our data about idiopathic BPPV was done.
Results
Eighteen patients of whiplash who had BPPV were evaluated. The mean age was 38.2 years. BPPV was the cause of vertigo in 33.9% of total whiplash patients. In 16 cases, the posterior semicircular canal was involved; the lateral semicircular canal was involved in 2 cases. The instrumental neurotologic assessment did not show any alteration of either vestibulospinal reflexes or dynamic ocular movements. Duration of symptoms before treatment ranged from 3 to 26 days. A total of 55.5% of patients had relief from their symptoms after first repositioning maneuver. The Dizziness Handicap Inventory score improved in all patients treated with repositioning maneuvers, but no difference emerged with idiopathic BPPV data.
Conclusion
BPPV after whiplash injury could be unveiled with a simple bedside examination of peripheral vestibular system, and a treatment could be done in the same session. The diagnosis of posttraumatic BPPV is not different from the idiopathic form, but the treatment may require more maneuvers to achieve satisfactory results.
1
Introduction
The equilibrium is the result of a perfect integration of input from eyesight, proprioceptive receptors, and labyrinths. The whiplash injury is a traumatic lesion due to rapid flexion-extension movement of the cervical column. This causes disturbance signals reaching from the cervical proprioceptive system to the central vestibular system and thus has an adverse effect on equilibrium. Balance problems affect 5% to 50% of patients of whiplash injury . The whiplash injury is generally due to car collision and is the first cause of insurance claims. About 15% to 20% of cases develop the so-called late whiplash syndrome with persistent complaints including headache, vertigo, instability, nausea, and tinnitus .
The cervical trauma may increase the discharge of muscles’ proprioceptive receptors of the neck and may interfere with normal activity of vestibular system, resulting in an alteration of vestibular-ocular reflexes . The neck pain, and related balance impairment, is the most common symptom and may be the cause of the symptoms complained by patients that is generally called cervicogenic vertigo .
The quantification of vestibular damage is difficult in forensic cases. For these reasons, it is mandatory to detect maligners and distinguishing them from patients with true disequilibrium disturbance .
Labyrinthine vertigo and auditory disturbances are present in 25% and 17% of subjects, respectively . The incidence of dizziness with even mild head injury ranges from 15% to 78%, probably because of an unclear definition of the trauma and of the concept of dizziness .
Benign paroxysmal positional vertigo (BPPV) is the most frequent cause of peripheral vertigo . It accounts for approximately 24% of all cases of peripheral vestibular disorders . This type of vertigo is generally seen in individuals 40 years and older, with the highest incidence between 50 and 70 years .
The exact etiology of BPPV is still debatable. More than 50% of all reported cases are idiopathic in nature . Adler was the first to describe manifestations of BPPV in posttraumatic cases. Classic BPPV involves the posterior semicircular canal (PSC) and represents the most common type of BPPV .
Diagnosis of BPPV is based mainly on history of characteristic positional vertigo along with the classic clinical signs. Symptoms are characterized by rotating vertigo with nausea and vomiting, elicited by movements of the head. The nystagmus typically has a latency (of few seconds) and is of limited duration (10–20 seconds), transient, and fatigable .
In patients of BPPV, correct diagnostic evaluation and appropriate management, in the great number of cases, solve the problem quickly, without the need for any medical treatment .
Our work’s aims were to analyze the patients affected by BPPV after whiplash injury and to evaluate differences between idiopathic BPPV and so-called cervicogenic vertigo.
2
Materials and methods
A retrospective study of patients of whiplash injury who visited our department between January 2008 and September 2009 was conducted. Patients with a diagnosis of BPPV following the trauma, occurring within 1 week before presentation, were evaluated. The exclusion criteria were history of vertigo before the whiplash injury, history of ear diseases or hearing loss, central nervous system pathology, psychiatric diseases, and history of vascular diseases. The evaluation included clinical history, complete head and neck examination, clinical vestibular tests, pure tone audiometry, and videoculography/videonystagmography with infrared system (ULMER, Synapsis Inc, Marseille, France). The smooth-pursuit function was evaluated by following an oscillating lighted target on a 29-in screen. The target velocity was regular (18°/s); and the oscillating movements were from center to right, back to the center, and center to left. Each trial was of 20 cycles of 57 seconds each. The saccadic test was performed by watching the target on a horizontal plane; the frequency was 0.4 Hz, and the amplitude was ±20°. The parameters analyzed in saccadic movement evaluation were latency, velocity, and accuracy. Our cutoff parameters to consider results as pathologic were as follows: value more than 200 milliseconds for latency, a score less than 77% for accuracy, and a highest velocity less than 530°/s. The smooth-pursuit movement analysis was evaluated measuring the gain (eye velocity/target velocity), and the parameter of normality was a value of 0.88 ± 0.2.
The same operator performed all instrumental tests.
The Dizziness Handicap Inventory (DHI) was used as reference for clinical improvement and was submitted at first contact and during the follow-up.
The clinical vestibular tests used to investigate the positioning nystagmus were the Dix-Hallpike and McClure-Pagnini tests (nystagmus observed in a supine position while turning the head to the left and right). The vestibulospinal function was evaluated by the Romberg test, index deviation test, and Unterberger test . The dynamic ocular bedside examination included the head-shaking test and Halmagyi test. The evaluation of nystagmus and vestibular reflexes was done after a period of at least 5 days from last dosage of vestibular suppressant drugs.
Imaging is generally included in those patients with uncommon clinical presentation or those with lack of response to treatment .
After diagnosing BPPV, all patients were promptly treated with canalith repositioning maneuver (CRM) according to the affected semicircular canal. The Semont maneuver or the Epley maneuver was used to treat a PSC BPPV; the Gufoni maneuver was used to manage the lateral semicircular canal (LSC) BPPV The persistence of nystagmus and vertigo spells after CRM was indicative of treatment failure, and repetition of maneuver was done in the same session or in the following 3 days. No medical treatment was prescribed to patients after CRM. The follow-up was done at 1 week, 3 weeks, and 1 month; the patients were examined, and a DHI questionnaire was submitted at the second and sixth months after the treatment.
The patients with cervicogenic vertigo were treated with a combination of physiotherapy, habituation exercises, and analgesics.
Finally, the data where matched with our result in treating idiopathic BPPV and with patients complaining a “cervicogenic vertigo” following a whiplash injury to evaluate the differences.
Our Institutional Board reviewed and approved the study.
2
Materials and methods
A retrospective study of patients of whiplash injury who visited our department between January 2008 and September 2009 was conducted. Patients with a diagnosis of BPPV following the trauma, occurring within 1 week before presentation, were evaluated. The exclusion criteria were history of vertigo before the whiplash injury, history of ear diseases or hearing loss, central nervous system pathology, psychiatric diseases, and history of vascular diseases. The evaluation included clinical history, complete head and neck examination, clinical vestibular tests, pure tone audiometry, and videoculography/videonystagmography with infrared system (ULMER, Synapsis Inc, Marseille, France). The smooth-pursuit function was evaluated by following an oscillating lighted target on a 29-in screen. The target velocity was regular (18°/s); and the oscillating movements were from center to right, back to the center, and center to left. Each trial was of 20 cycles of 57 seconds each. The saccadic test was performed by watching the target on a horizontal plane; the frequency was 0.4 Hz, and the amplitude was ±20°. The parameters analyzed in saccadic movement evaluation were latency, velocity, and accuracy. Our cutoff parameters to consider results as pathologic were as follows: value more than 200 milliseconds for latency, a score less than 77% for accuracy, and a highest velocity less than 530°/s. The smooth-pursuit movement analysis was evaluated measuring the gain (eye velocity/target velocity), and the parameter of normality was a value of 0.88 ± 0.2.
The same operator performed all instrumental tests.
The Dizziness Handicap Inventory (DHI) was used as reference for clinical improvement and was submitted at first contact and during the follow-up.
The clinical vestibular tests used to investigate the positioning nystagmus were the Dix-Hallpike and McClure-Pagnini tests (nystagmus observed in a supine position while turning the head to the left and right). The vestibulospinal function was evaluated by the Romberg test, index deviation test, and Unterberger test . The dynamic ocular bedside examination included the head-shaking test and Halmagyi test. The evaluation of nystagmus and vestibular reflexes was done after a period of at least 5 days from last dosage of vestibular suppressant drugs.
Imaging is generally included in those patients with uncommon clinical presentation or those with lack of response to treatment .
After diagnosing BPPV, all patients were promptly treated with canalith repositioning maneuver (CRM) according to the affected semicircular canal. The Semont maneuver or the Epley maneuver was used to treat a PSC BPPV; the Gufoni maneuver was used to manage the lateral semicircular canal (LSC) BPPV The persistence of nystagmus and vertigo spells after CRM was indicative of treatment failure, and repetition of maneuver was done in the same session or in the following 3 days. No medical treatment was prescribed to patients after CRM. The follow-up was done at 1 week, 3 weeks, and 1 month; the patients were examined, and a DHI questionnaire was submitted at the second and sixth months after the treatment.
The patients with cervicogenic vertigo were treated with a combination of physiotherapy, habituation exercises, and analgesics.
Finally, the data where matched with our result in treating idiopathic BPPV and with patients complaining a “cervicogenic vertigo” following a whiplash injury to evaluate the differences.
Our Institutional Board reviewed and approved the study.
3
Results
Out of 53 patients of whiplash injury who were referred to our department, 33 were male. The mean age was 40.77 (range, 18–66) years. In all patients, the head trauma occurred within 1 week before presentation.
In 20 patients, the history revealed the presence of rotating vertigo after trauma. An unspecified imbalance or dizziness was the chief complaint in 33 patients, which were labeled as having cervicogenic vertigo. These patients did not show any alteration on neurotologic examination. The hearing was normal in all patients.
In 18 of 20 patients, the vertigo was related to head position and movement on the bed. In the remaining 2 cases, a labyrinthine concussion was diagnosed; and these 2 patients were excluded from present analysis. No patient reported history of vertigo before the head trauma.
The result of the Dix-Hallpike diagnostic maneuver was positive in 16 of 18 patients, whereas the result of the McClure-Pagnini maneuver for the LSC was positive in 2 cases.
Out of 18 whiplash patients with BPPV, 11 were male. The mean age of the group was 38.2 (range, 25–66) years. The BPPV was the cause of vertigo in 33.9% of whiplash patients. In 16 cases, PSC was involved, the right side in 9 patients and left side in 7 cases. The left LSC was involved in the remaining 2 cases. The neurotologic assessment did not show any alteration of either vestibulospinal reflexes or dynamic ocular movement ( Table 1 ).
