Prevention of recurrent benign paroxysmal positional vertigo with vitamin D supplementation: a meta-analysis

Journal of Neurology - Vitamin D insufficiency/deficiency is known to be related to occurrences and recurrences of benign paroxysmal positional vertigo (BPPV). However, the efficacy of vitamin D...     

Decreased serum vitamin D in idiopathic benign paroxysmal positional vertigo

Previous studies have demonstrated an association of osteopenia/osteoporosis with idiopathic benign paroxysmal positional vertigo (BPPV). Since vitamin D takes part in the regulation of calcium and phosphorus found in the body and plays an important role in maintaining proper bone structure, decreased bone mineral density in patients with BPPV may be related to decreased serum vitamin D. We measured the serum levels of 25-hydroxyvitamin D in 100 patients (63 women and 37 men, mean age ± SD = 61.8 ± 11.6) with idiopathic BPPV and compared the data with those of 192 controls (101 women and 91 men, mean age ± SD = 60.3 ± 11.3) who had lived in the same community without dizziness or imbalance during the preceding year. The selection of the controls and acquisition of clinical information were done using the data from the Fourth Korean National Health and Nutrition Examination Survey, 2008. The serum level of 25-hydroxyvitamin D was lower in the patients with BPPV than in the controls (mean ± SD = 14.4 ± 8.4 versus 19.1 ± 6.8 ng/ml, p = 0.001). Furthermore, patients with BPPV showed a higher prevalence of decreased serum vitamin D (<20 ng/ml, 80.0 vs. 60.1 %, p < 0.001) than the controls. Multiple logistic regression analyses adjusted for age, sex, body mass index, hypertension, diabetes, proteinuria, regular exercise and the existence of decreased bone mineral density demonstrated that vitamin D insufficiency (10–20 ng/ml) and deficiency (<10 ng/ml) were associated with BPPV with the odds ratios of 3.8 (95 % confidence interval = 1.51–9.38, p = 0.004) and 23.0 (95 % confidence interval = 6.88–77.05, p < 0.001). Our study demonstrated an association between idiopathic BPPV and decreased serum vitamin D. Decreased serum vitamin D may be a risk factor of BPPV.     

Assessment of sleep quality in benign paroxysmal positional vertigo recurrence

Abstract

Objective: Despite the availability of highly effective treatments, there is a significant recurrence rate of benign paroxysmal positional vertigo (BPPV). This study is aimed to quantitatively measure sleep quality in BPPV patients and correlate it with the recurrence of BPPV.

Methods: In this longitudinal cohort study, the clinical records of 67 elderly or middle-aged adult patients who were diagnosed with BPPV at Neurology Clinic, Beijing Chaoyang Hospital affiliated to Capital Medical University between 2013 and 2014. The ‘recurrent’ and ‘non-recurrent’ BPPV were respectively defined. Primary data collection included the medical history, blood test and Pittsburgh Sleep Quality Index measurement.

Results: Among the total 67 patients after successful treatment, recurrent BPPV is observed in 37.31% patients (n?=?25) within 2 years. Among all 11 variables analyzed between recurrent and non-recurrent groups, only the Pittsburgh Sleep Quality Index (PSQI) scores showed significant difference (p<.001). In details, these differences were also measured in five individual sleep items, including the subjective assessment of sleep quality, sleep latency, sleep duration, the use of sleep-aid medication and daytime dysfunctions (all p<.05). Regression analysis showed patients with higher PSQI score (lower sleep quality) had higher risk of BPPV recurrence [odds ratio (OR)=1.17, 95% confidence interval (CI): 1.04–1.32, p=.0082].

Conclusions: The sleep quality in patients with BPPV recurrence is significantly poorer compared to non-recurrent patients. Our result suggested sleep quality as measured by PSQI is an independent risk factor of BPPV recurrence.     

Does benign paroxysmal positional vertigo explain age and gender variation in patients with vertigo by mechanical assistance maneuvers?

Benign paroxysmal positional vertigo (BPPV) is one of the most common peripheral vestibular diseases. The aim of this study was to explore the prevalence of BPPV in vertigo patients and the characteristics of BPPV in diagnosis and repositioning using mechanical assistance maneuvers and to analyze and summarize the reasons showing these characteristics. Seven hundred and twenty-six patients with vertigo were enrolled in this study. All patients were inspected by TRV armchair (SYNAPSYS, model TRV, France). BPPV patients were identified by the examination results. The characteristics and results using TRV armchair in diagnosis and treatment of BPPV were compared and analyzed. Of 726 vertigo patients, 209 BPPV patients were diagnosed, including 58 men and 151 women, aged from 16 to 87 (mean 52.90 ± 11.93) years. There were significant differences in the proportion of BPPV in male and female vertigo patients (P = 0.0233), but no differences among all age groups (P = 0.3201). Of 209 BPPV patients, 208 cases were repositioned by TRV armchair and no one appeared to have otolithic debris relocated into another canal in the repositioning procedures. 202 cases (97.12 %) were successful and six cases (2.87 %) were effective. None of them failed. This study suggests that BPPV is one of the most common diseases in the young vertigo patients, just like that in the old ones. Female of the species has predilection for BPPV and the site of predilection is the right posterior semicircular canals (PC-BPPV). The results of repositioning are perfect using mechanical assistance maneuvers.     

Epidemiology of benign paroxysmal positional vertigo: a population based study

Objectives

To examine the prevalence and incidence, clinical presentation, societal impact and comorbid conditions of benign paroxysmal positional vertigo (BPPV) in the general population.

Methods

Cross‐sectional, nationally representative neurotological survey of the general adult population in Germany with a two stage sampling design: screening of 4869 participants from the German National Telephone Health Interview Survey 2003 (response rate 52%) for moderate or severe dizziness or vertigo, followed by validated neurotological interviews (n = 1003; response rate 87%). Diagnostic criteria for BPPV were at least five attacks of vestibular vertigo lasting <1 min without concomitant neurological symptoms and invariably provoked by typical changes in head position. In a concurrent validation study (n = 61) conducted in two specialised dizziness clinics, BPPV was detected by our telephone interview with a specificity of 92% and a sensitivity of 88% (positive predictive value 88%, negative predictive value 92%).

Results

BPPV accounted for 8% of individuals with moderate or severe dizziness/vertigo. The lifetime prevalence of BPPV was 2.4%, the 1 year prevalence was 1.6% and the 1 year incidence was 0.6%. The median duration of an episode was 2 weeks. In 86% of affected individuals, BPPV led to medical consultation, interruption of daily activities or sick leave. In total, only 8% of affected participants received effective treatment. On multivariate analysis, age, migraine, hypertension, hyperlipidaemia and stroke were independently associated with BPPV.

Conclusion

BPPV is a common vestibular disorder leading to significant morbidity, psychosocial impact and medical costs.Benign paroxysmal positional vertigo (BPPV) is probably the most common cause of vestibular vertigo accounting for approximately 20–30% of diagnoses in specialised dizziness clinics.^1,2 The evolution of highly effective positioning manoeuvres^3,4 has made BPPV the most successfully treatable cause of vertigo.Thus far, however, the epidemiology of BPPV in the general population is not known. The aim of this study was to estimate the prevalence and incidence of BPPV in the general adult population in Germany and to characterise the clinical features, impact and risk factors of BPPV in a nationally representative sample.     

Validation of 5-item and 2-item questionnaires in Chinese version of Dizziness Handicap Inventory for screening objective benign paroxysmal positional vertigo

As possible candidate screening instruments for benign paroxysmal positional vertigo (BPPV), studies to validate the Dizziness Handicap Inventory (DHI) sub-scale (5-item and 2-item) and total scores are rare in China. From May 2014 to December 2014, 108(55 with and 53 without BPPV) patients complaining of episodic vertigo in the past week from a vertigo outpatient clinic were enrolled for DHI evaluation, as well as demographic and other clinical data. Objective BPPV was subsequently determined by positional evoking maneuvers under the record of optical Frenzel glasses. Cronbach’s coefficient α was used to evaluate the reliability of psychometric scales. The validity of DHI total, 5-item and 2-item questionnaires to screen for BPPV was assessed by receiver operating characteristic (ROC) curves. It revealed that the DHI 5-item questionnaire had good internal consistency (Cronbach’s coefficient α = 0.72). Area under the curve of total DHI, 5-item and 2-item scores for discriminating BPPV from those without was 0.678 (95 % CI 0.578–0.778), 0.873(95 % CI 0.807–0.940) and 0.895(95 % CI 0.836–0.953), respectively. It revealed 74.5 % sensitivity and 88.7 % specificity in separating BPPV and those without, with a cutoff value of 12 in the 5-item questionnaire. The corresponding rate of sensitivity and specificity was 78.2 and 88.7 %, respectively, with a cutoff value of 6 in 2-item questionnaire. The present study indicated that both 5-item and 2-item questionnaires in the Chinese version of DHI may be more valid than DHI total score for screening objective BPPV and merit further application in clinical practice in China.     

Exercise therapy for positional vertigo.

We present a common cause of vertigo, benign positional paroxysmal vertigo (BPPV), and its history, diagnosis, and therapy. BPPV is suggested by history, readily diagnosed by office examination, and cured by appropriate exercise therapy. Since the condition is so common and often unrecognized, physicians are encouraged to consider BPPV as a possible cause of treatable dizziness.     

Migrainous vertigo presenting as episodic positional vertigo

Migraine can cause vestibular symptoms including positional vertigo. Of 362 consecutive patients presenting with positional vertigo, 10 with migrainous vertigo mimicking benign paroxysmal positional vertigo (BPPV) were identified. The following factors help to distinguish migrainous positional vertigo from BPPV: short-duration symptomatic episodes and frequent recurrences, manifestation early in life, migrainous symptoms during episodes with positional vertigo, and atypical positional nystagmus.     

中国家族性良性阵发性位置性眩晕临床分析

目的了解中国家族性良性位置性眩晕(benign paroxysmal positional vertigo,BPPV)家系临床特点,提高对BPPV家族性可能的遗传病因认识。方法回顾分析我院诊断的1个家族性BPPV家系,并检索维普电子期刊全文数据库1989~2016年间收录我国的家族性BPPV家系的研究文献,分析中国家族性BPPV的临床特点。结果我院诊断1家系及文献检索出的2个家族性BPPV家系,共计3个家系,包括患者23例,其中男性10例,女性13例,起病年龄最小者7岁,最大者70岁,病程明确者为6 m至36 y,平均病程6.5 y。3个家系中先证者及其他患者均表现为头部位置突然变化后诱发的眩晕,伴视物旋转、恶心、呕吐,Roll-Test滚转试验或Dix-Hallpike试验可诱发眼震,经手法复位及相关药物治疗后患者头晕症状好转,均表现为家族成员多发性,且已排外其他原因所致眩晕,依据BPPV的4条诊断标准,上述成员均为诊断明确的BPPV,根据临床表现为家族聚集性BPPV,考虑诊断为家族性良性阵发性位置性眩晕,但均未检测目前国外已报道的2个与良性阵发性位置性眩晕相关的基因位点(良性复发性眩晕1(Benign Recurrent Vertigo 1,BRV1)定位在6p,BRV2定位在22q12)。结论家族遗传性可能为中国良性阵发性位置性眩晕的罕见病因,目前遗传机制尚不明确,需引起重视及进一步研究。     

Residual Dizziness after Successful Repositioning Treatment in Patients with Benign Paroxysmal Positional Vertigo

Background and purpose

Benign paroxysmal positional vertigo (BPPV) is the most common form of vertigo. Although the repositioning maneuver dramatically improves the vertigo, some patients complain of residual dizziness. We evaluated the incidence and characteristics of persistent dizziness after successful particle repositioning and the clinical factors associated with the residual dizziness.

Methods

We performed a prospective investigation in 49 consecutive patients with confirmed BPPV. The patients were treated with a repositioning maneuver appropriate for the type of BPPV. Success was defined by the resolution of nystagmus and positional vertigo. All patients were followed up until complete resolution of all dizziness, for a maximum of 3 months. We collected data on the characteristics and duration of any residual dizziness and analyzed the clinical factors associated with the residual dizziness.

Results

Of the 49 patients, 11 were men and 38 were women aged 60.4±13.0 years (mean ±SD), and 30 (61%) of them complained of residual dizziness after successful repositioning treatment. There were two types of residual dizziness: continuous lightheadedness and short-lasting unsteadiness occurring during head movement, standing, or walking. The dizziness lasted for 16.4±17.6 days (range=2-80 days, median=10 days). A longer duration of BPPV before treatment was significantly associated with residual dizziness (p=0.04).

Conclusions

Residual dizziness after successful repositioning was observed in two-thirds of the patients with BPPV and disappeared within 3 months without specific treatment in all cases. The results indicate that early successful repositioning can reduce the incidence of residual dizziness.     

Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is characterized by brief recurrent episodes of vertigo triggered by changes in head position. BPPV is the most common etiology of recurrent vertigo and is caused by abnormal stimulation of the cupula by free-floating otoliths (canalolithiasis) or otoliths that have adhered to the cupula (cupulolithiasis) within any of the three semicircular canals. Typical symptoms and signs of BPPV are evoked when the head is positioned so that the plane of the affected semicircular canal is spatially vertical and thus aligned with gravity. Paroxysm of vertigo and nystagmus develops after a brief latency during the Dix-Hallpike maneuver in posterior-canal BPPV, and during the supine roll test in horizontal-canal BPPV. Positioning the head in the opposite direction usually reverses the direction of the nystagmus. The duration, frequency, and symptom intensity of BPPV vary depending on the involved canals and the location of otolithic debris. Spontaneous recovery may be expected even with conservative treatments. However, canalithrepositioning maneuvers usually provide an immediate resolution of symptoms by clearing the canaliths from the semicircular canal into the vestibule.     

Natural course of the remission of vertigo in patients with benign paroxysmal positional vertigo

The authors assessed the natural course of benign paroxysmal positional vertigo (BPPV) in 108 patients who were not treated with canalith repositioning procedure. The average number of days from onset to remission of positional vertigo in patients with posterior canal BPPV (P-BPPV) (39 days) was longer than in those with horizontal canal BPPV (H-BPPV) (16 days). The ratio of patients with H-BPPV to those with BPPV was 33%.     

Apogeotropic central positional nystagmus as a sole sign of nodular infarction

Positional vertigo and nystagmus without associated neurological symptoms and signs are characteristic features of benign paroxysmal positional vertigo (BPPV). Although positional nystagmus may occur with caudal cerebellar infarction including the nodulus, positional nystagmus is usually associated with other neurological signs such as spontaneous or gaze-evoked nystagmus, perverted head-shaking nystagmus, cerebellar dysmetria, or severe gait ataxia with falling. We present a patient with nodular infarction who had positional vertigo with nystagmus as a sole manifestation. Video-oculography showed apogeotropic positional horizontal nystagmus during head turning while supine, which was consistent with apogeotropic BPPV involving the horizontal canal. MRI disclosed acute infarct in the nodulus. Nodulus infarction should be considered in a patient with positional nystagmus, especially when the presenting symptoms and signs are consistent with BPPV involving the horizontal canal.     

良性阵发性位置性眩晕的耳石复位治疗

目的探讨良性阵发性位置性眩晕(BPPV)耳石复位法的疗效。方法应用Epley手法、Barbecue翻滚法和Semont手法对12例BPPV患者进行治疗。结果12例患者经上述手法复位治疗48h后眩晕症状均完全消失,无明显不良反应,分别随访3～11个月无再发。结论耳石复位法治疗BPPV有效、简便、安全,可作为BPPV的首选治疗方法。     

Benign paroxysmal positional vertigo in spontaneous intracranial hypotension

Objectives: To assess the prevalence and related factors of benign paroxysmal positional vertigo (BPPV) in patients with spontaneous intracranial hypotension (SIH).

Methods: We retrospectively reviewed 156 consecutive inpatients with SIH, and collected the clinical and radiological data. These patients were divided into BPPV group and non-BPPV group according to the clinical manifestation and the results of Dix-Hallpike or supine roll tests during hospitalization period. We performed a univariate analysis and a further multiple logistic regression analysis to identify the related factors of the development of BPPV in SIH patients.

Results: BPPV was detected in 18 patients among the total 156 SIH patients (11.54%). The univariate analysis showed a low cerebrospinal fluid (CSF) pressure (P = 0.018), a small pontomesencephalic angle (P = 0.012) and a positive venous distension sign (VDS) (P = 0.045) were associated with the presence of BPPV. But the multivariate analysis only demonstrated a low CSF pressure was related to the presence of BPPV (OR = 1.022, 95% CI: 1.001–1.043, P = 0.044).

Conclusion: BPPV is common in SIH patients. SIH patients with low CSF pressure may be prone to develop BPPV.     

Visual dependence and BPPV

The increased visual dependence noted in some vestibular patients may be secondary to their vertigo. We examine whether a single, brief vertigo attack, such as in benign paroxysmal positional vertigo (BPPV), modifies visual dependency. Visual dependency was measured before and after the Hallpike manoeuvre with (a) the Rod and Frame and the Rod and Disc techniques whilst seated and (b) the postural sway induced by visual roll-motion stimulation. Three subject groups were studied: 20 patients with BPPV (history and positive Hallpike manoeuvre; PosH group), 20 control patients (history of BPPV but negative Hallpike manoeuvre; NegH group) and 20 normal controls. Our findings show that while both patient groups showed enhanced visual dependency, the PosH and the normal control group decreased visual dependency on repetition of the visual tasks after the Hallpike manoeuvre. NegH patients differed from PosH patients in that their high visual dependency did not diminish on repetition of the visual stimuli; they scored higher on the situational characteristic questionnaire ('visual vertigo' symptoms) and showed higher incidence of migraine. We conclude that long term vestibular symptoms increase visual dependence but a single BPPV attack does not increase it further. Repetitive visual motion stimulation induces adaptation in visual dependence in peripheral vestibular disorders such as BPPV. A positional form of vestibular migraine may underlie the symptoms of some patients with a history of BPPV but negative Hallpike manoeuvre. The finding that they have non adaptable increased visual dependency may explain visuo-vestibular symptoms in this group and, perhaps more widely, in patients with migraine.     

良性阵发性位置性眩晕发病与复发相关危险因素分析

良性阵发性位置性眩晕（benign paroxysmal positional vertigo,BPPV）是所有眩晕疾病中最 常见的类型,主要表现为短暂的旋转样感觉,由头位改变（相对于重力作用方向）诱发。其病因尚不 明确,可能与头部外伤、各种内耳疾病等有关,耳石复位是有效的治疗方法,尽管BPPV患者无论治疗 与否疾病缓解率较高,但是仍有复发情况存在。本文结合近年国内外发表的文献对良性阵发性位置 性眩晕发病与复发相关的危险因素进行探讨。     

Neuro-otological features of benign paroxysmal vertigo and benign paroxysmal positioning vertigo in children: a follow-up study

BACKGROUND: Causes of benign episodic vertigo in paediatric age include benign paroxysmal vertigo of childhood (BPV) and benign paroxysmal positional vertigo (BPPV). OBJECTIVE: The aim is to review the clinical, audiological and vestibular findings in a cohort of children with BPV and in a group of children with BPPV and to highlight the differences useful to formulating a differential diagnosis. METHODS: Eighteen children, aged 4-9 years, consecutively examined for paroxysmal attacks of dizziness and/or vertigo attacks between January 2002 and December 2002 entered our study. The clinical characteristics of vertigo, presence of triggering factors, family history of migraine, presence of motion sickness, migraine and other accompanying symptoms were considered. Neurological, ophthalmologic, vestibular and auditory functions were assessed. RESULTS: Eight children suffered from BPPV and ten children from BPV. In the BPPV group, the vestibular examination was normal except for the Dix-Hallpike maneuver. Liberatory maneuvers were immediately effective in all patients and all remained symptom-free during the follow-up. In the BPV group, the vestibular examination was positive in 3 patients but none had positive Dix-Hallpike maneuver. All patients with BPV have a positive family history of migraine and seven had a history of motion sickness. In all, migraine was present one year before the vertigo symptoms, with a frequency of at least two migraine episodes a month. CONCLUSION: BPV differs from BPPV in terms of family history, clinical symptoms, otoneurological signs, therapy and clinical evolution. BPPV is characterized by specific otoneurological signs, and must be treated with liberatory maneuvers: neither medical therapy nor strict follow-up is needed.     

Health services utilization of patients with vertigo in primary care: a retrospective cohort study

Vertigo and dizziness count among the most frequent symptoms in outpatient practices. Although most vestibular disorders are manageable, they are often under- and misdiagnosed in primary care. This may result in prolonged absence from work, increased resource use and, potentially, in chronification. Reliable information on health services utilization of patients with vertigo in primary care is scarce. Retrospective cohort study in patients referred to a tertiary care balance clinic. Included patients had a confirmed diagnosis of benign paroxysmal positional vertigo (BPPV), Menière’s disease (MD), vestibular paroxysmia (VP), bilateral vestibulopathy (BVP), vestibular migraine (VM), or psychogenic vertigo (PSY). All previous diagnostic and therapeutic measures prior to the first visit to the clinic were recorded. 2,374 patients were included (19.7 % BPPV, 12.7 % MD, 5.8 % VP, 7.2 % BVP, 14.1 % VM, 40.6 % PSY), 61.3 % with more than two consultations. Most frequent diagnostic measures were magnetic resonance imaging (MRI, 76.2 %, 71 % in BPPV) and electrocardiography (53.5 %). Most frequent therapies were medication (61.0 %) and physical therapy (41.3 %). 37.3 % had received homoeopathic medication (39 % in BPPV), and 25.9 % were treated with betahistine (20 % in BPPV). Patients had undergone on average 3.2 (median 3.0, maximum 6) diagnostic measures, had received 1.8 (median 2.0, maximum 8) therapies and 1.8 (median 1.0, maximum 17) different drugs. Diagnostic subgroups differed significantly regarding number of diagnostic measures, therapies and drugs. The results emphasize the need for establishing systematic training to improve oto-neurological skills in primary care services not specialized on the treatment of dizzy patients.     

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common and most treatable cause of vertigo. In most cases, a simple maneuver that takes less than a few minutes to do resolves the problem. BPPV is caused by misplaced calcium carbonate crystals (otoconia) in the semicircular canal of the inner ear that have broken free from the utricle. When these crystals break free, they either remain loose in one of three different semicircular canals or attach to the hair cells within a canal. Several different types of treatment maneuvers have been described. The maneuver to use varies according to the semicircular canal involved and whether the crystals are loose or attached to the hair cells.