Abstract
Objective
The prevalence of benign paroxysmal positional vertigo (BPPV) is becoming more frequent in elderly population. The presence of comorbid factors has to be considered before assessment as well as before commencing any repositioning treatment. Our aims were evaluation of the maneuvers efficacy and evaluation of the applicability of hybrid maneuver (HM) in patients with physical limitation.
Study design and setting
This is a randomized study in 2 tertiary referral centers.
Intervention
This is a therapeutic intervention.
Patients
All consecutive patients with diagnosis of BPPV of posterior canal matching the inclusion criteria were enrolled. Patients underwent treatment soon after the initial diagnosis in all cases with a repositioning maneuver. The maneuver was casually selected among Semont, Epley, and hybrid. Patients were divided into 3 groups according to the maneuver adopted.
Results
Eighty-eight patients with posterior canal BPPV were enrolled for treatment. Fisher exact test showed that no statistical differences exist between HM and other maneuvers in terms of efficacy. Latency of repositioning nystagmus appeared longer in HM in comparison with other maneuvers ( P < .05). Efficacy of maneuvers used for BPPV decreases in case of cupulolithiasis ( P < .0001). We found no relationship between age, sex, and length of disturbance on response to maneuvers.
Conclusions
All maneuvers evaluated demonstrated similar efficacy. The HM, as our data showed, allows us to obtain a good percentage of success similar to most maneuvers used. It is also more comfortable for the patients with hip or neck functional limitation allowing an effective treatment of the posterior canal BPPV.
1
Introduction
Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo. It accounts for approximately 24% of all cases of peripheral vestibular disorders , and the incidence is approximately 64 of 100 000 per year . Patients present with a history of vertigo arising in certain head positions or during some movements of the head with respect to the horizontal plane.
Symptoms of this inner ear disease are thought to arise when otoconia move from the utricle into semicircular canals. Displacement of such debris, called otoconia, determines an endolymphatic fluid movement leading to a stimulation of ampullar receptors, thereby eliciting vertigo.
Classic BPPV involves the posterior semicircular canal (PSC) and represents the most common type of BPPV . Lateral semicircular canal BPPV accounts approximately for only 10% to 20% of all the patients presenting with BPPV . Development of an anterior semicircular canal BPPV does not occur frequently because of the anatomical position of the semicircular canal, which is anterior with respect to the utricle.
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. A whiplash injury may be a cause of otoconia detachment with subsequent BPPV . Generally, patients affected by idiopathic BPPV are older than those due to posttraumatic ones. Occasionally, BPPV has been described to be secondary to inner ear disorders , after stapes surgery or other otologic procedures . When an inner ear cause is thought to be the origin of BPPV, it should be described as secondary BPPV . Diagnosis of posttraumatic or secondary BPPV is not different from the idiopathic form, but the treatment may require more canalith repositioning maneuvers (CRM) to achieve satisfactory results . Fortunately, in patients affected by vertigo crisis due to idiopathic BPPV, correct diagnostic evaluation and appropriate management allow, in most cases, to solve the problem quickly, without the need for any medical treatment.
Several effective repositioning maneuvers exist to manage PSC-BPPV. The methods proposed by Semont et al and Epley , although differing in their position and movements, act with the mechanism of displacement of the otoconial debris around the long arm of the posterior canal, through the common crus, and back into the utricle. This rule is well applied with these maneuvers that reach a very good recovery rate. Eighty percent of patients become free of symptoms after a single maneuver .
A hybrid maneuver (HM) for PSC BPPV was recently described to treat those patients who exhibit contraindications to neck hyperextension or patients with hip, back, or other diseases that may affect mobility. This maneuver, until now, has only been reported by the authors who originally described the procedure .
We report a comparative study between 3 types of CRMs to treat PSC BPPV. Our aims were (1) evaluation of the maneuvers efficacy and (2) evaluation of the applicability of maneuvers in patients with physical limitation.
2
Materials and methods
All consecutive patients with diagnosis of BPPV of PSC referred to our centers were enrolled in this study in the period of March 2011 to July 2011. We recorded data of the patients: anagraphic data, history, and symptoms. All patients underwent a complete otoneurologic examination including otoscopy, pure tone audiometry, tympanometry, and nystagmus observation under infrared videonystagmoscopy. The diagnosis was based on clinical examination with a side-lying maneuver to test the involved side . This diagnostic test was adopted to avoid differences between groups.
Patients with multiple semicircular canal involvement, with lateral or anterior semicircular canal BPPV, with neurologic or psychiatric disease, with other forms of peripheral or central vertigo, and with head trauma were excluded from this study. Patients with history of whiplash injury were excluded as well as patients with history of falls due to the vertigo. In addition, patients with unilateral sensorineural hearing loss and with a clinical history highly suspicious for a retrocochlear disease underwent a cerebellopontine angle magnetic resonance imaging evaluation to exclude the presence of tumor causing a malignant paroxysmal positional vertigo .
All diagnostic tests and evaluations were done before group assignments. The posttreatment tests were scheduled 1 week after first treatment and control diagnostic tests were programmed after 2 and 4 weeks.
Patients underwent treatment soon after the initial diagnosis in all cases with one of CRMs. The maneuver was randomly selected among Semont repositioning maneuver (SRM), Epley repositioning maneuver (ERM), and HM. We repeated the CRM once in the same session in the event of no response. The criterion to deem success or failure of the CRM done was the response to side-lying position repeated at the end of each CRM by an operator blinded to the treatment entourage. A new session was scheduled after 3 days in case of no response in the first session. Patients were divided into 3 groups according to the maneuver adopted: group A, SRM; group B, ERM; group C, HM. Patients with neck motion limitations, hip or back disease, and obese patients were grouped separately and were always treated with HM. The value of discomfort felt by patients (with and without comorbidity) treated with CRMs was obtained adopting a visual analog scale (VAS) consisting of a black line of 10-cm length on which the patients indicate the subjective sensation of pain or discomfort related to movement and holding positions, specifying to not include vertigo-related distress.
All subjects were instructed to avoid taking vestibular suppressant medications before their first visit and during the week before the control visit, when a side-lying position was repeated to exclude a recurrence. No postural restrictions after the canalith repositioning maneuvers were counseled to the patients in accordance with our published data . The procedures followed were in accordance with the ethical standards of the Helsinki Declaration and with our institutional review board.
2
Materials and methods
All consecutive patients with diagnosis of BPPV of PSC referred to our centers were enrolled in this study in the period of March 2011 to July 2011. We recorded data of the patients: anagraphic data, history, and symptoms. All patients underwent a complete otoneurologic examination including otoscopy, pure tone audiometry, tympanometry, and nystagmus observation under infrared videonystagmoscopy. The diagnosis was based on clinical examination with a side-lying maneuver to test the involved side . This diagnostic test was adopted to avoid differences between groups.
Patients with multiple semicircular canal involvement, with lateral or anterior semicircular canal BPPV, with neurologic or psychiatric disease, with other forms of peripheral or central vertigo, and with head trauma were excluded from this study. Patients with history of whiplash injury were excluded as well as patients with history of falls due to the vertigo. In addition, patients with unilateral sensorineural hearing loss and with a clinical history highly suspicious for a retrocochlear disease underwent a cerebellopontine angle magnetic resonance imaging evaluation to exclude the presence of tumor causing a malignant paroxysmal positional vertigo .
All diagnostic tests and evaluations were done before group assignments. The posttreatment tests were scheduled 1 week after first treatment and control diagnostic tests were programmed after 2 and 4 weeks.
Patients underwent treatment soon after the initial diagnosis in all cases with one of CRMs. The maneuver was randomly selected among Semont repositioning maneuver (SRM), Epley repositioning maneuver (ERM), and HM. We repeated the CRM once in the same session in the event of no response. The criterion to deem success or failure of the CRM done was the response to side-lying position repeated at the end of each CRM by an operator blinded to the treatment entourage. A new session was scheduled after 3 days in case of no response in the first session. Patients were divided into 3 groups according to the maneuver adopted: group A, SRM; group B, ERM; group C, HM. Patients with neck motion limitations, hip or back disease, and obese patients were grouped separately and were always treated with HM. The value of discomfort felt by patients (with and without comorbidity) treated with CRMs was obtained adopting a visual analog scale (VAS) consisting of a black line of 10-cm length on which the patients indicate the subjective sensation of pain or discomfort related to movement and holding positions, specifying to not include vertigo-related distress.
All subjects were instructed to avoid taking vestibular suppressant medications before their first visit and during the week before the control visit, when a side-lying position was repeated to exclude a recurrence. No postural restrictions after the canalith repositioning maneuvers were counseled to the patients in accordance with our published data . The procedures followed were in accordance with the ethical standards of the Helsinki Declaration and with our institutional review board.
3
Results
During the period of study, 88 patients with PSC BPPV were enrolled for treatment. Forty-eight of the patients were females, whereas the remaining 40 patients were males. The patients belonged to the age range between 32 and 80 years with a mean of 52.56 years. The symptom period varied between 5 days to 2 months. No patients included in the study were treated previously for BPPV. All patients of the series matched the inclusion criteria stated above. The groups’ subdivision is summarized in Table 1 . Fisher exact test showed that no statistical differences exist between HM and other CRMs ( P = .23) in terms of efficacy in resolution of the signs and symptoms of BPPV. Although the numbers of failures were higher in ERM group, there was no statistical difference noted after the Fisher exact test ( P = .22). Latency of repositioning nystagmus appeared longer in HM in comparison with SRM and ERM with an average duration of 14.66 seconds ( t test, P < .05). The number of required maneuvers to achieve repositioning of the debris was higher in ERM group. All data have been summarized in Table 1 .
