The Dix-Hallpike test and the canalith repositioning maneuver

The Dix-Hallpike test and the canalith repositioning maneuver (CRM) are used to diagnose and treat benign positional vertigo (BPV). Dix-Hallpike is the standard procedure for diagnosis of BPV, but if the horizontal canal is not tested for BPV and the Dix-Hallpike is only carried out once, the condition may not be diagnosed and appropriately treated. We describe our method of testing for BPV and treating it with CRM. The Dix-Hallpike test involves rapidly moving the patient from a sitting position to "head hanging," where the patient's head is at least 10 degrees below horizontal. This is performed initially for the posterior semicircular canals. If these movements fail to elicit vertigo and nystagmus, tests of the horizontal semicircular canals are performed by laying the patient on each side. Importantly, if there is no vertigo or nystagmus elicited by testing the horizontal semi-circular canals, the posterior semicircular canals are tested again. It appears that being held in the head hanging positions and then left and right lateral positions will often allow the canaliths to collect such that the Dix-Hallpike test will become positive. Failure to repeat the tests of the posterior semicircular canals may result in a falsely negative test. Testing the horizontal canals and repeating the Dix-Hallpike test will reduce the likelihood of patients undergoing extra testing or other consequences of misdiagnosis. If, during any of this testing, a movement elicits vertigo or nystagmus, the appropriate CRM is then carried out.     

Reliability of the Muller maneuver and its association with sleep-disordered breathing

OBJECTIVES/HYPOTHESIS: Use of the Muller maneuver (MM) in the evaluation of patients with obstructive sleep apnea is controversial. One criticism of this test is that it is somewhat subjective. Our objective is to explore the reliability of this technique and its association with sleep-disordered breathing. STUDY DESIGN: Prospective study performed in an academic tertiary care center. METHODS: An analysis of MM scores from 180 consecutive patients obtained independently by two examiners was completed. These scores were compared with each other and with the apnea-hypopnea index (AHI) obtained from polysomnographic studies. RESULTS: Collapse of the soft palate (PAL), lateral pharyngeal wall (LPW), and base of the tongue (BOT) was rated on a five-point scale (0-4). The mean scores determined by the faculty examiner were 2.47, 2.06, and 1.58, respectively; the mean scores determined by the resident examiner were 2.34, 2.25, and 1.48, respectively. The scores of the two examiners correlated to within +/- 1 unit 83.9% of the time at the PAL, 91.1% at the LPW, and 85.0% at the BOT. The degree of correlation was not influenced by year of training of the resident. When the AHI was converted to a four-point scale based on severity, the score correlated within +/- 1 of the average MM score 72.1% of the time. CONCLUSIONS: Despite the subjective nature of the MM, the five-point scale can be used by independent examiners to achieve an evaluation of the upper airway that is reproducible. The preoperative severity of sleep-disordered breathing based on the AHI is moderately correlated with the MM score.     

The canalith repositioning maneuver in patients with benign positional vertigo

The canalith repositioning maneuver (CRM), as defined by Epley, can be an effective treatment for benign paroxysmal positional vertigo (BPPV). The staff at Başkent University’s Ear Nose and Throat Clinic performed CRM on 68 cases of canalithiasis in 64 BPPV patients from June 1996 to August 1997. Symptoms resolved after the first session in 49 patients (72%) and after the second session in 11 cases (16.2%). It was necessary to repeat the maneuver three times in two cases (2.9%) and four times in one patient (1.5%). Discounting three patients who were lost to follow-up, only two patients in our study did not respond to CRM treatment. There was no co-existing pathology found in all but two of the patients studied. Our experience indicates that unless there is no response to CRM or there is suspicion of an incorrect diagnosis, it is not necessary to perform diagnostic studies routinely for differentiating other neuro-otologic disorders prior to using CRM in BPPV patients diagnosed by the Dix-Hallpike test. Received: 10 November 1998 / Accepted: 4 March 1999     

The old-fashioned Politzer maneuver: a video clip demonstration

Politzer maneuver causes retrograde inflation of the middle ear by forcing air through the eustachian tube, and it has been proposed by many authors as the main nonsurgical treatment of middle ear effusion. To our knowledge, this is the first case in the literature in which air entering into a middle ear with effusion through a Politzer maneuver has been captured on video (www.laryngoscope.com).     

The Epley maneuver for the treatment of benign paroxysmal positional vertigo

In recent years, different forms of physical therapy have been proposed for the treatment of benign paroxysmal positional vertigo (BPPV). These mainly consist of maneuvers aiming to reposition and disperse free-floating endolymph particles in the posterior semicircular canal. We report our experience with one of these procedures, the Epley maneuver (EM), in treating 30 cases of BPPV. Twenty-six patients (87%) were cured, while four (13%) did not respond to treatment. These results are similar to those reported in the literature for the EM and the Sémont maneuver.     

Evaluation of a particle repositioning maneuver Web-based teaching module

OBJECTIVES/HYPOTHESIS: To compare the pass rate of residents performing the Particle Repositioning Maneuver (PRM) after one of three interventions: 1) small group PRM instruction (SG); 2) standard classroom instruction (CI); and 3) Web-based learning module (WM). We hypothesize that our Web-based learning module is more effective than CI and as effective as SG.Study Design: Prospective randomized control trial. METHODS: The study population includes all family medicine residents at the University of Western Ontario. On day 0, all subjects were tested. Residents were then randomized to one of three intervention groups: 1) SG, 2) CI, or 3) WM. On day 7, the residents were again tested. Observers were blinded to the intervention type. Testing (day 0 and day 7) was performed using the DizzyFIX (Clearwater Clinical Ltd., London, Ontario, Canada), a pass/fail test, and evaluation by a trained observer (correct or incorrect). RESULTS: There were no statistically significant differences in pass rates between the three groups before the interventions (DizzyFIX: P = .2096, observer: P = .3710). After the interventions, DizzyFIX testing pass rates were 50.0% SG, 60.0% CI and 100.0% WM (P = .3564). Observer testing pass rates were 85.7% SG, 28.6% CI, and 83.3% WM (P = .0431). CONCLUSIONS: This study demonstrated that our Web-based learning module for the PRM is comparable to small-group clinical instruction, and superior to standard classroom instruction for teaching the PRM when evaluated by a trained observer.     

Therapeutic efficacy of the Epley canalith repositioning maneuver

OBJECTIVES/HYPOTHESES: The hypotheses of the current study are as follows: 1) That if the Epley canalith repositioning maneuver is an effective treatment for benign positional vertigo (BPV), relief from the vertigo should occur virtually immediately after the performance of the maneuver; 2) that the Epley canalith repositioning maneuver does provide almost immediate relief in BPV and should be the established treatment of choice for this disorder in both primary and tertiary care settings; and 3) that residual symptoms of lightheadedness and imbalance do persist after the resolution of the vertigo. The distinction of these symptoms from the vertigo is required for the accurate evaluation of the efficacy of positional maneuvers. STUDY DESIGN: Prospective cohort study in a tertiary care balance center. METHODS: Eighty-six patients (95 cases) with a history and physical examination consistent with active BPV were entered in the study. Patients were treated with a modified Epley canalith repositioning maneuver. A modified 360 degrees roll was used to treat those patients with horizontal canal BPV. Patients were provided with a preprinted diary in which they were to circle the answer most relevant to their symptoms for 14 days after the maneuver. Patients were then re-evaluated in the office at 2 weeks after the maneuver. RESULTS: The mean duration of the BPV before treatment was 9 weeks. Seventy-four percent of cases that were treated with one or two canalith repositioning maneuvers had a resolution of vertigo as a direct result of the maneuver. A resolution attributable to the first intervention was obtained in 70% of cases within 48 hours of the maneuver. An additional 14% of cases that were treated had a resolution of vertigo; however, it is not possible to say that these patients definitely benefited from the canalith repositioning maneuver. Only 4% of cases (three patients) manifested BPV that persisted after four treatments. Residual symptoms of lightheadedness or imbalance, or both, were frequent (47% of cases) but rarely required formal intervention with vestibular rehabilitation physical therapy. CONCLUSIONS: The Epley canalith repositioning maneuver results in a resolution of vertigo in the majority of patients (70% of cases) immediately after one treatment. It is safe and requires no special equipment or investigations. It should be established as the treatment of choice for BPV in both primary and tertiary care settings.     

Effects of Semont maneuver on benign paroxysmal positional vertigo: a meta-analysis

Background: Benign paroxysmal positional vertigo (BPPV) is the most common type of peripheral vertigo. This study aimed to evaluate the effects of the Semont maneuver (SM) for BPPV treatment, compared with other methods.

Methods: Studies were selected in relevant databases under pre-defined criteria up to June 2015. The Cochrane evaluation system was used to assess the quality of the studies. Effect size was indicated as a risk-ratio (RR) with corresponding 95% confidential interval (CI). Statistical analysis was conducted under a randomized- or fixed-effects model. Sub-group analysis was performed.

Results: Ten studies were included in the meta-analysis. All of the studies presented a low attrition bias, but a high selection and reporting bias. SM had a much higher recovery rate (SM vs no treatment: RR?=?2.60, 95% CI?=?1.97–3.44, p?p?p?Conclusion: SM is as effective as EM and BDE for BPPV treatment.     

Semont方法治疗40例后半规管良性发作性位置性眩晕

目的：探讨Semont方法对后半规管良性发作性位置性眩晕(PC-BPPV)的治疗效果。方法：对40例PC-BPPV患者按Semont方法进行治疗。结果：经1次Semont方法治疗后,32例症状消失,首次治疗成功率为80％,其中病程在1周内的19例患者有16例症状消失。3例经2次、2例经3次、1例经4次治疗后症状消失,总治疗成功率为95％,2例无效。随访至今,5例复发,复发率12．5％,复发者再行Semont方法治疗仍有效。结论：Semont方法治疗PC—BPPV安全有效。     

360°滚转复位法治疗良性阵发性位置性眩晕

目的明确在后半规管平面360°旋转患者对治疗典型的后半规管良性阵发性位置性眩晕是否有效。方法回顾分析了46例后半规管良性阵发性位置性眩晕患者,其中25例采用三维滚轮360°滚转复位法进行复位治疗,21例采用Epley手法复位治疗,对其疗效进行比较。结果采用三维滚轮360。滚转复位法治疗的患者中第一次治疗后有23例患者（92％）治愈,2例患者经过第二次治疗治愈;采用Epley手法复位的患者中第一次治疗后有19例患者（91.5％）治愈,2例患者经过第二次治疗治愈。应用X^2检验（α=0.05,X^2=0.1173,P=0.7319）二者的差异没有统计学意义。结论三维滚轮360°滚转复位法能有效的治疗后半规管良性阵发性位置性眩晕,其成功率及效果与Epley法一致,且操作简便、舒适度优于传统方法。     

手法复位治疗良性阵发性位置性眩晕

目的回顾性分析60例良性阵发性位置性眩晕（BPPV）诊断和治疗方法,为提高BPPV疗效提供参考依据。方法60例患者（男34例,女26例）通过常规神经耳科学检查、Dix—Hallpike和滚转试验确诊为BPPV。40例在发病10天内就诊,6N在发病1月内就诊,10例在5月内就诊,4例在6月以上就诊。采用Semont摆动手法、Epley颗粒复位法和Barbecue翻滚疗法治疗。对治疗1次无效者间隔7天重复治疗,重复3次无效者采用其它方法治疗。完成冶疗后2周复查评定疗效。结果后半规管BPPV54例,22例采用Semont手法复位治疗,14例痊愈,4例改善,4例无效。4例无效改用Epley颗粒复位法。Epley颗粒复位法治疗36例,28例痊愈,4例改善,4例无效。6例外半规管BPPV采用Barbecue翻滚疗法治疗4例痊愈,2例无效。40例10天内就诊者治愈32例,8例改善。6例发病1月内就诊者治愈2例,改善4例。10例5月内就诊者4例痊愈,4例改善,2例无效。4例6月以上就诊者治疗3次均无效。46例治疗1次有效,4例患者治疗2次有效,4例患者治疗3次有效。结论手法复位治疗BPPV有效率高,BPPV治疗效果与发病至就诊时间相关。     

水平背地性眼震良性阵发性位置性眩晕的诊断和手法复位

目的：验证一种新的用于治疗水平背地性眼震良性阵发性位置性眩晕（apogeotropicHSC—BPPV）的手法复位方法。方法：该研究采取改良的SupineRollTest（M-RollTest）方法共诊断出l78例水平半规管良性阵发性位置性眩晕（HSC-BPPV）患者,其中37例apogeotropicHSC—BPPV纳入该研究样本,占发病数的20．79％。采用管石重置手法先将37例apogeotropicHSC—BPPV患者水平背地性眼震转变为水平向地性眼震;此后,施行传统barbecue法进行手法复位。管石重置手法如下：①患者取仰卧头垫高30°体位静卧;②10min后头快速向患侧转90°;③2min后头向中线回旋45°;④保持体位2min后患者恢复仰卧头高30°体位;静卧10min后,采用M—RollTest检查验证患者是否出现双侧水平向地性眼震。如管石重置失败,重复以上手法多次,直至出现双侧水平向地性眼震为止。结果：36例双侧水平背地性眼震经水平背地性眼震管石重置手法全部转变为双侧不同强度的水平向地性眼震,其中,18例经1次,11例经2次,4例经3次,3例经4～6次。1例经1次管石重置手法后自觉症状减轻,再次行M—RollTest检查证明水平眼震消失,但Dix-hallpike手法复位检查出现同侧上跳性扭转性眼震,确诊为同侧后半规管良性阵发性位置性眩晕（PSC-BPPV）。该组管石重置成功率为为97．3％。36例HSC—BPPV患者经barbecue法手法复位全部一次性获得成功,1例PSC—BPPV患者经Eptey管石复位法一次性获得成功。结论：该研究设计的水平背地性管石重置手法是治疗apogeotropicHSC—BPPV的必要手段,简便易学、成功率高,患者舒适度好,相对依从性高。     

Contralateral incipient posterior canal benign positional paroxysmal vertigo: complication after Epley maneuver

Background: Particle repositioning procedures give consistent results for the treatment of benign positional paroxysmal vertigo (BPPV). However, little consideration has been given to the possibilities of bilateral disease. Objective/Hypothesis: To report contralateral symptoms and signs suggestive of revealed or incipient BPPV as a complication of Epley maneuver. Study Design: A prospective cohort of 198 cases over a period of 11 years. Results: Ten (5.0%) developed contralateral symptoms and signs suggestive of revealed or incipient posterior canal BPPV within 2 weeks of treatment. Conclusion: This novel observation has not been previously described and may influence the strategy for future management of patients with BPPV. Particle repositioning maneuvers for the previously asymptomatic contralateral ear may need to be considered in a subset of patients with posterior canal BPPV who suffer contralateral symptoms after undergoing treatment for the original ear.     

Theoretical observation on diagnosis maneuver for benign paroxysmal positional vertigo

Conclusion: To make a comprehensive analysis with a variety of diagnostic maneuvers is conducive to the correct diagnosis and classification of BPPV.

Objective: Based on the standard spatial coordinate-based semicircular canal model for theoretical observation on diagnostic maneuvers for benign paroxysmal positional vertigo (BPPV) to analyze the meaning and key point of each step of the maneuver.

Materials and methods: This study started by building a standard model of semicircular canal with space orientation by segmentation of the inner ear done with the 3D Slicer software based on MRI scans, then gives a demonstration and observation of BPPV diagnostic maneuvers by using the model.

Results: The supine roll maneuver is mainly for diagnosis of lateral semicircular canal BPPV. The Modified Dix-Hallpike maneuver is more specific for the diagnosis of posterior semicircular canal BPPV. The side-lying bow maneuver designed here is theoretically suitable for diagnosis of anterior semicircular canal BPPV.     

Vibration with the canalith repositioning maneuver: a prospective randomized study to determine efficacy

OBJECTIVES/HYPOTHESIS: The objective was to determine whether the inclusion of vibration and additional treatment cycles has an effect on short- and long-term success rates in the treatment of benign paroxysmal positional vertigo with the canalith repositioning maneuver. STUDY DESIGN: Prospective randomized study of patients treated at a tertiary vestibular rehabilitation center. METHODS: Variables identified for statistical analysis included patient age, gender, vibration used, and canalith repositioning cycles. Analysis using Student t test, chi2 test, Kaplan-Meier curves with log rank test, and Cox proportional hazards regression was performed. RESULTS: One hundred two patients with benign paroxysmal positional vertigo treated over a 1-year period (August 2001-August 2002) were randomly assigned to receive the canalith repositioning maneuver with or without vibration. Average duration of follow-up was 9.44 months. The single treatment success rate was 93.1%. To relieve symptoms, 29.4% of patients required more than one canalith repositioning cycle. The relapse rate was 30.5%. Thirty-nine patients were assigned to the canalith repositioning group with vibration, and 63 to the canalith repositioning group without vibration. There was no statistical difference in age, gender, initial success rates, or relapse rates between the canalith repositioning groups with and without vibration. On average, patients required 1.38 canalith repositioning cycles for successful treatment. Vibration did not affect the number of canalith repositioning cycles required to convert the Dix-Hallpike test result to normal. The need for additional canalith repositioning cycles had no statistical effect on initial treatment success or relapse rates. CONCLUSION: Vibration provided no additional benefit in initial treatment success or in reducing long-term relapse rates when included in the canalith repositioning maneuver. Many patients with benign paroxysmal positional vertigo require more than one canalith repositioning cycle at the time of initial treatment to relieve symptoms, but this does not indicate a higher likelihood for recurrence. No variable predicted a higher rate of recurrence.     

改良Valsalva法(玩具式自家鼓气吹鸣器)治疗分泌性中耳炎临床观察

目的评估使用玩具式自家鼓气吹鸣器治疗分泌性中耳炎的疗效.方法24名分泌性中耳炎患儿采用改良Valsalva法行咽鼓管吹张,每日3次以上,持续2周后复查,行耳科检查及听力学评估,包括耳镜检查、声导抗及纯音测听,无效者继续3月;另23名同样患儿作为对照组.结果治疗组患儿68%骨气导差减至小于15 dB,对照组为26%,治疗组患儿有62%其声导抗鼓室峰压值恢复正常(大于-100dapa),对照组有29%,统计学分析两组差异有显著性.结论玩具式自家吹鸣器进行改良Valsalva吹张治疗分泌性中耳炎是有效的,儿童使用时有浓厚兴趣,可作为一种治疗分泌性中耳炎的辅助器械.