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.     

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.     

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 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.     

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.     

Canal switch after canalith repositioning procedure for benign paroxysmal positional vertigo

Canal switch is a complication following canalith repositioning procedure (CRP) for posterior canal benign paroxysmal positional vertigo (BPPV). Instead of being returned to the utricle, the loose otoconia migrate into the superior or horizontal semicircular canal. Patients remain symptomatic, and treatment can be ineffective unless the switch is recognized and additional repositioning maneuvers directed toward the appropriate semicircular canal are performed. This report provides the first videographic documentation of canal switch involving conversion of unilateral posterior semicircular canal BPPV to geotropic horizontal canalithiasis. Laryngoscope, 2012.     

A randomized trial of the canalith repositioning procedure

OBJECTIVE: To compare the effectiveness and complications of our adaptation of the canalith repositioning procedure (CRP) with the expectation treatment for benign paroxysmal positional vertigo. STUDY DESIGN: A randomized, controlled trial in the setting of a neurotological clinic in Thailand. METHODS: Fifty-eight patients with posterior benign paroxysmal positional vertigo were randomly assigned to treatment and control groups using a block of four. The treatment group was treated with the modified CRP technique until the nystagmus disappeared. A mastoid oscillator was not used, nor were any instructions given for patients after the maneuver. Both groups recorded the daily grading of symptoms and the amount of anti-vertiginous drugs (cinnarizine) taken. Objective and subjective assessments were made weekly until the nystagmus disappeared or until 4 weeks had passed since treatment began. RESULTS: The rates of effectiveness of CRP treatment and the control treatment for benign paroxysmal positional vertigo were 75.9% and 48.2%, respectively. There was a significant difference in the treatment outcomes of the CRP and control groups (P =.03). The CRP group used significantly fewer drugs than the control group (P =.001). Complications in the CRP group, such as lateral canalithiasis and fainting, were observed in 13.8% of the patients. CONCLUSIONS: The CRP was more effective than the expectation treatment for benign paroxysmal positional vertigo insofar as it provided faster recovery and required less dependence on medication. Complications of CRP were limited to 13.8% of patients.     

The canalith repositioning procedure for benign positional vertigo: a meta-analysis

OBJECTIVE: To review the effectiveness of the canalith repositioning procedure (CRP) in the treatment of benign paroxysmal positional vertigo (BPPV) with a critical review of the literature and meta-analysis. STUDY DESIGN: Meta-analysis. METHODS: Studies eligible for inclusion were randomized, controlled trials of the CRP performed on clearly defined cases of BPPV. A total of nine studies meeting inclusion criteria were identified by two independent literature searches of Medline. Treatment and control groups were compared for symptom resolution and elimination of a positive Dix-Hallpike test. RESULTS: Patients treated with CRP were more likely to demonstrate symptom resolution (odds ratio [OR] 4.6; 95% confidence interval [CI] 2.8-7.6) and negative Dix-Hallpike (OR 5.2; 95% CI 3.0-8.8) at the time of first follow-up. The effect of CRP for symptom improvement was strongest within the first month after treatment (OR 4.1; 95% CI 3.1-5.2) with some decline thereafter (OR 2.8; 95% CI 1.7-3.9). Conversely, the ability of CRP to produce a negative Dix-Hallpike strengthened between the first month after treatment (OR 3.0; 95% CI 1.8-4.0) and later follow-up times (OR 5.0; 95% CI 3.9-6.1). CONCLUSIONS: The CRP is more effective than control in resolving vertigo and positive Dix-Hallpike associated with BPPV. This finding was consistent among a variety of studies using different study designs. Untreated patients may demonstrate symptom improvement with time; however, many will continue to have a positive Dix-Hallpike when examined. Resolution of vertigo in untreated patients is therefore most likely because of avoidance of provocative positions.     

Time Course of Recovery After Epley Maneuvers for Benign Paroxysmal Positional Vertigo

The canalith repositioning maneuver (CRP) of Epley is an effective treatment for benign paroxysmal positional vertigo (BPPV). While CRP has been advocated by some as a “single treatment” for BPPV, others have had less uniform results for this self-limited disorder. In order to better define the role of CRP in relieving vertigo, we studied the time course of recovery in 27 consecutive cases of BPPV. We recorded nystagmus after each head maneuver and at each evaluation until complete resolution took place, using absence of nystagmus as a strict criterion for cure. We found that while 93% of patients improved, many had persistent nystagmus at the first evaluation, and in only 63% was resolution clearly related to a CRP session. We believe that in certain cases, the effect of CRP may be due to adaptive conditioning, rather than particle redistribution.     

Benign paroxysmal positional vertigo: 10-year experience in treating 592 patients with canalith repositioning procedure

OBJECTIVE: To assess the long-term efficacy of canalith repositioning procedure (CRP) in the treatment of patients with benign paroxysmal positional vertigo (BPPV). BACKGROUND: Alternative theories for the pathophysiology of BPPV have been redefined in the past few years. CRP is considered to be the standard technique for its management. However, long-term follow-up results have been minimally reported in the literature. PATIENTS/METHODS: Five hundred ninety-two patients, 290 (49%) men and 302 (51%) women, were enrolled in this prospective study; their ages ranged from 18 to 84 (mean 59) years. At the time of their first examination, patients reported the duration of symptoms varied from 1 day to 18 months. Inclusion criteria were patient history compatible with BPPV and positive provocative maneuver (either Dix-Hallpike or Roll test). A variant of Epley and Barbeque maneuver was used. The Epley maneuver was used for posterior and anterior canal involvement, and "Barbeque roll" was used for horizontal canal involvement. Short-term follow-up was obtained 48 hours and 7 days after initial treatment, whereas long-term follow-up was obtained at repeated 6 month intervals. RESULTS: The posterior semicircular canal was involved in 521 (88%) patients treated, whereas the horizontal and anterior semicircular canals were involved in 59 (10%) and 12 (2%) patients, respectively. Symptoms subsided immediately in 497 (84%) patients. In 77 (13%) patients, the Dix-Hallpike maneuver remained positive after 48 hours, and CRP was performed again. Patients' mean follow-up was 46 months; 544 (92%) of 592 patients treated reported no symptoms of vertigo. CONCLUSION: Our data, based on long-term follow-up, suggest that CRP remains an efficient and long-lasting noninvasive treatment for BPPV.     

Effects of postural restriction after modified Epley maneuver on recurrence of benign paroxysmal positional vertigo

Objective

In the present study, we calculated the success rate of the modified Epley maneuver and determined the effectiveness of post-maneuver positional restriction in terms of the prevention of early and late recurrence.

Methods

The present study was conducted on 78 patients who had unilateral benign paroxysmal positional vertigo (BPPV) of the posterior semicircular canal (SCC) and who were treated in the Otorhinolaryngology Department of Susehri State Hospital. The Dix–Hallpike test was performed on all patients. After the involved canal was identified using this test, we guided patients through the modified Epley repositioning maneuver. A maximum of two maneuvers were performed in the same session. The patients were randomly divided into two groups. One group was not advised any positional restriction, while the second group was advised positional restriction for 10 days after the procedure. Recurrences during 1–90 days after the treatment were noted as early recurrences, while those that occurred after 90 days were noted as late recurrences.

Results

In the restriction group (n = 39), repositioning was successful after a single maneuver in 32 (82.05%) patients and after two maneuvers in 5 (12.8%) patients. Repositioning failed in two (5.1%) patients. In the non-restriction group (n = 39), repositioning was successful after a single maneuver in 31 (79.4%) patients and after two maneuvers in 6 (15.3%) patients. Repositioning failed in two (5.1%) patients. Thus, the success rate was 94.8% in each group. Early recurrence occurred in 3 (8.1%) of 37 patients in the restriction group and 2 (5.4%) of 37 patients in the non-restriction group (p > 0.05). Late recurrence occurred in 5 (13.5%) of 37 patients in both the restriction and non-restriction groups (p > 0.05).

Conclusion

Postural restriction after a canalith repositioning procedure does not improve procedural success or decrease early and late recurrence rates. However, the number of patients was too small to detect a difference between both treatment groups.     

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.     

Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV

Objective

To check the value of home particle repositioning maneuver in the prevention of the recurrence of posterior canal benign paroxysmal positional vertigo (pc-BPPV).

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。     

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.     

耳石复位法治疗良性阵发性位置性眩晕32例

目的 探讨耳石复位法治疗良性阵发性位置性眩晕（BPPV）的的效果。方法 应用Epley管石复位法、Semont管石解脱法及Barbecue翻滚法对良性阵发性位置性眩晕32例予以治疗。结果 32例中经耳石复位法治愈27例(84.4%)，有效 3例(9.4%)，复位失败2例(6.3%)，后经前庭功能训练治愈。结论 耳石复位法是BPPV的首选治疗方法，对于复位失败的患者前庭功能训练可获得较好的疗效。     

165例良性阵发性位置性眩晕患者管石复位治疗疗效观察

目的评估BPPV患者管石复位治疗短期和长期疗效。方法回顾分析了后半规管和上半规管BPPV患者165例，男53例、女112例，年龄范围18岁至84岁（平均53岁），分为2组，手法复位治疗（治疗组）125例，非手法复位（对照组）40例。结果治疗组中，后半规管BPPV患者81例，上半规管BPPV患者31例，双侧后半规管BPPV13例。65岁以上老年BPPV患者41例。治疗结果分析．治疗组首次治愈83人（66．4％），其中后半规管BPPV60人（74．1％），上半规管BPPV14人（45．2％），双侧后半规管BPPV9人（69．2％），老年BPPV32人（78．0％）。对照组16人（40％）在一周后症状消失。在4个月至41个月的随访中，治疗组和对照组治愈率分别为92％和82．5％。有30人（24％）在随访中复发。有2例病史超过40个月的患者，手法复位治疗无效而进行后半规管阻塞术。结论手法复位治疗BPPV患者是一种非常有效的方法，它能有效的缩短病程，减轻患者痛苦，其方法简单、易行且费用低，可以在临床广泛使用。     

Role of subjective visual vertical in patients with posterior canal benign paroxysmal positional vertigo as a prognostic marker after canalith repositioning maneuver

ObjectiveTo study the potential role of subjective visual vertical (SVV) as a prognostic marker for canalith repositioning maneuver (CRM) in patients with posterior canal benign paroxysmal positional vertigo (PC-BPPV) for the Indian population.MethodsSVV was examined in 30 patients with PC-BPPV before and after canalith repositioning maneuver and after complete resolution of PC-BPPV. Study parameters included the mean of 10 angular tilt readings and direction of deviation, which were compared before and after CRM and following complete resolution of PC-BPPV.ResultsThe angle of SVV tilt was greater and deviated towards the affected ear before CRM in all patients, which decreased significantly shortly after CRM and continued to decrease after complete resolution of PC-BPPV (p < 0.0001).ConclusionsSVV can be used to test utricular dysfunction in PC-BPPV. The angle of tilt improves in response to CRM, which may be used as a prognostic marker in patients with PC-BPPV receiving CRM.