Treatment of benign paroxysmal positional vertigo. A clinical review

Benign paroxysmal positional vertigo(BPPV) is the most frequent episodic vestibular disorder. It is due to otolith rests that are free into the canals or attached to the cupulas. Well over 90% of patients can be successfully treated with manoeuvres that move the particles back to the utriculus. Among the great variety of procedures that have been described, the manoeuvres that are supported by evidenced-based studies or extensive series are commented in this review. Some topics regarding BPPV treatment, such as controlling the accuracy of the procedures or the utility of post-manoeuvre restrictions are also discussed.

Probable benign paroxysmal positional vertigo, spontaneously resolved:Incidence in medical practice, patients’ characteristics and the natural course

Background: Probable benign paroxysmal positional vertigo, spontaneously resolved (pBPPVsr), is a variant of benign paroxysmal positional vertigo (BPPV) in which there is no observable nystagmus and no vertigo with any positional maneuver. Objectives: To calculate the incidence pBPPVsr, compare the characteristics of the patients with pBPPVsr and BPPV not spontaneously resolved and describe the spontaneous resolution in the natural course of BPPV. Methods: Multicenter prospective descriptive study. During a one-year period, all patients with suspected BPPV that presented to the Neurotology Units of five participating centers were recruited. The incidence of pBPPVsr was calculated as a percentage of the total number of patients with BPPV. The prevalence of several variables was compared between pBPPVsr and BPPV not spontaneously resolved. The timing of spontaneous resolution was estimated using Kaplan-Meier curves. Results: 457 patients met the inclusion criteria. The incidence of pBPPVsr was 33.5%. It was significantly higher in males, in patients with normal bone mass and in patients who were not taking sulpiride. A rate of 18% of spontaneous resolution after the first month and 51% after the first year was found. This percentage did not change in a significant way after this moment. The curves for males, patients under 50 and patients with normal blood pressure decreased significantly faster. Conclusions: In our serie, BPPV spontaneously resolved in half of the patients with BPPV during the first year. This seemed to occur more commonly in males and could have been hindered by sulpiride intake, osteoporosis, advanced age and high blood pressure.

Causes and treatment of idiopathic benign paroxysmal positional vertigo based on endocrinological and other metabolic factors

The genesis of the Benign Paroxysmal Positional Vertigo(BPPV)seems to be related to some metabolic factors.These factors,such as vitamin D,glucocorticoids,and even thyroid and growth hormones,can affect bone metabolism and the mineralization of otoconia.It also seems to link to factors related to aging or nutritional habits.Besides,since the incidence of BPPV is quantitatively higher in women than in men,female sex steroids could be associated with this process.It could be useful to understand how these factors act in otoconial mineralization if we want to develop treatments aimed at preventing or delaying BPPV recurrences.In this review,we will analyze the role of these metabolic and hormonal factors in otoconial mineralization and in the treatment of BPPV.

A comparative study of two methods for treatment of benign paroxysmal positional vertigo in the emergency department

Introduction: Posterior canal benign paroxysmal positional vertigo (PC-BPPV) is considered the mostcommon cause of peripheral vertigo in the emergency department (ED). Although the canalith repositioning maneuver (CRM) is the standard of care, the most effective method to deliver it in the ED hasbeen poorly studied.Objective: To compare two protocols of the Epley maneuver for the treatment of PC-BPPV.Patients and methods: We prospectively recruited 101 patients with unilateral PC-BPPV on physical examination, randomizing them to either a single Epley maneuver (EM) (n ¼ 46) or multiple maneuvers(n ¼ 55) on the same visit. Measured outcomes included presence/absence of positional nystagmus,resolution of vertigo, and score on the dizziness handicap inventory (DHI) at follow-up evaluations. TheDHI was stratified into mild ( 30) and moderate-severe (>30).Results: Normalization of the Dix-Hallpike maneuver at day 5 was observed in 38% of the single EMgroup and 44.4% in the multiple EM group (p ¼ 0.62). The DHI showed reduction from 42.2 (SD 18.4) to31.9 (SD 23.7) in the single EM group and from 43.7 (SD 22.9) to 33.5 (SD 21.5) in the multiple EM group(p ¼ 0.06). A higher number of patients improved from moderate-severe to mild DHI (p ¼ 0.03) in thesingle EM group compared to the multi-EM group (p ¼ 0.23).Conclusion: There was no statistically significant difference between performing a single EM versusmultiple EMs for treatment of PC-BPPV in the emergency department. The single EM approach isassociated with shorter physical contact between patients and examiner, which is logically safer in apandemic context.

A possible objective test to detect benign paroxysmal positional vertigo. The role of the caloric and video-head impulse tests in the diagnosis

Background:Benign paroxysmal positional vertigo(BPPV)is characterized by vertigo lasting from seconds to minutes,induced by head movements.Objectives:Our study aimed to investigate the clinical significance of the caloric vestibular and video head-impulse tests(vHIT)diagnosing the disorder.Methods:68 patients suffering from posterior canal BPPV(25 male,43 females,mean age±SD,54.5±13.2 years)and 56 patients with a normal functioning vestibular system as control were investigated.Bithermal caloric test and vHIT was performed during the same medical check-up.Canal paresis(CP%),gain(GA)and asymmetry(GA%)parameters were calculated.Results:The Dix-Hallpike manoeuvre was only positive in 4%of this population.The CP%parameter was only pathologic in two patients,and there was no significant difference between control and BPPV patients(p=0.76).The GA value was never under 0.8 in this population,but GA%was abnormal in 63.2%.A significant difference comparing the GA%values to the control group was seen(p=0.034).There was no correlation detected between the CP%and GA%values in BPPV.Regarding the GA%value,61%sensitivity and 76%specificity was seen.Conclusion:The Dix-Hallpike manoeuvre was not often positive in the non-acute phase of BPPV;therefore,objective testing is essential.The caloric test does not have clinical significance in BPPV,but vHIT can be helpful based on the GA%parameter。

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

Objective:To 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.Methods:SVV 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.Results:The 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).Conclusions:SVV 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.

Square wave manoeuvre for apogeotropic variant of horizontal canal benign paroxysmal positional vertigo in neck restricted patients

Objective:We aimed to describe the clinical features of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo(HC BPPV-AG)in a cluster of patients with restrictive neck movement disorders and a new therapeutic manoeuvre for its management.Methods:In a retrospective review of cases from an ambulatory tertiary referral center,patients with HC BPPV-AG in combination with neck movement restriction that prevented any classical manual repositioning procedure or who were refractory to canalith repositioning manoeuvres,were treated with a new manoeuvre comprised of sequential square-wave pattern of head and body supine rotations while nystagmus was being monitored,until either an apogeotropic to geotropic conversion or resolution of the nystagmus was observed.Results:Fifteen patients were studied.All but one[14/15 cases]showed a positive therapeutic response to the repositioning procedure in a single session.In two cases,a direct relief of vertigo and elimination of nystagmus was observed without an intermediate geotropic phase.Although in three patients the affected ear was not initially identified,it was ultimately identified and successfully treated by the square wave manoeuvre in all of them.Conclusions:The square-wave manoeuvre is an alternative for HC BPPV-AG treatment in either cases with neck restriction,where the affected side is not well identified at the bedside or when other manoeuvres fail to resolve the HC BPPV-AG.

CASE REPORT: TOTAL SUDDEN HEARING LOSS WITH BENIGN PAROXYSMAL POSITIONAL VERTIGO

Introduction Sudden sensorineural hearing loss(SSNHL)is defined as a hearing loss of at least 30 dB over three contiguous frequencies occurring in less than 3 days[1].Vertigo and profound hearing loss are considered poor prognostic factors in SSNHL[2-4].The most common diseases associated with vertigo in SSNHL include BPPV,vestibular neu-[3]

Climatic variations and benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo(BPPV) is probably the most common diagnosis at vertigo clinics.Seasonal cycles of several human illnesses could be attributed variously to changes in atmospheric or weather conditions.In this retrospective study,patients with BPPV from January 2010 to December 2012 were studied,and their charts were reviewed.Statistical analysis revealed a statistically significant difference in patients’ numbers among different months of the year.Also there is a significant statistical correlation between the numbers of patients with climatic variations especially the temperature.The present paper discusses the possible explanations for these results which confirms the seasonal variations in BPPV,together with a review of literature to view the possible associations with other disorders that causes such seasonality.

BENIGN PAROXYSMAL POSITIONAL VERTIGO

One of the most common causes of vertigo is Benign Paroxysmal Positional Vertigo(BPPV),a sensation of spinning that is caused by a sudden change in head position.This type of vertigo was first described by Robert Barany in the early 1920s[1].He suggested that BPPV was caused by abnormal otoliths,also called statoconium or otoconius,a structure in the saccule or utricle in

Benign paroxysmal positional vertigo with congenital nystagmus: A case report

BACKGROUND Benign paroxysmal positional vertigo(BPPV)is a form of temporary vertigo induced by moving the head to a specific position.It is a self-limited,peripheral,vestibular disease and can be divided into primary and secondary forms.Congenital nystagmus(CN),an involuntary,rhythmic,binocular-symmetry,conjugated eye movement,is found at birth or within 3 mo of birth.According to the pathogenesis,CN can be divided into sensory-defect nystagmus and motordefect nystagmus.The coexistence of BPPV and CN is rarely seen in the clinic.CASE SUMMARY A 62-year-old woman presented to our clinic complaining of a 15-d history of recurrent positional vertigo.The vertigo lasting less than 1 min occurred when she turned over,sometimes accompanied by nausea and vomiting.Both the patient and her father had CN.Her spontaneous nystagmus was horizontal to right;however,the gaze test revealed variable horizontal nystagmus with the same degree when the eyes moved.The patient’s Dix-Hallpike test was normal,except for persistent nystagmus,and the roll test showed severe variable horizontal nystagmus,which lasted for about 20 s in the same direction as her head movement to the right and left,although the right-side nystagmus was stronger than the left-side.Since these symptoms were accompanied by nausea,she was diagnosed with BPPV with CN and treated by manual reduction.CONCLUSION Though rare,if BPPV with CN is correctly identified and diagnosed,reduction treatment is comparably effective to other vertigo types.

倍他司汀联合Epley耳石复位法对BPPV患者血清VDBP、otolin-1水平的影响

目的 分析倍他司汀联合Epley耳石复位法对良性阵发性位置性眩晕(Benign paroxysmal positional vertigo;BPPV)的应用价值。方法 选择2021年3月—2023年3月本院收治的196例BPPV患者作为研究对象,随机分为对照组和研究组两组,每组各98例。对照组采用Epley耳石复位方法,研究组倍他司汀联合Epley耳石复位治疗。比较两组血清维生素D结合蛋白(vitamin D-binding protein;VDBP)、耳石蛋白(Otolith protein;otolin-1)水平、前庭功能及平衡情况、负性情绪评分及睡眠质量、眩晕障碍、临床疗效。结果 治疗后,研究组VDBP、otolin-1水平、BBS评分高于对照组,前庭症状指数(vestibular symptom index, VSI)、汉密尔顿焦虑量表(Hamilton Anxiety Scale, HAMA)、汉密顿抑郁量表(Hamilton Depression Scale, HAMD)、匹兹堡睡眠质量指数(Pittsburgh sleep quality index, PSQI)各评分及眩晕障碍低于对照组(P<0.05);研究组临床总有效率高于对照组(P<0.05);研究组总复发率低于对照组总复发率(P<0.05)。结论 对BPPV患者应用倍他司汀联合Epley耳石复位法治疗,可有效改善眩晕、眼震等临床症状,降低复发率,具有较理想的近远期疗效,值得临床予以重视和应用。

Otolin-1水平与良性阵发性位置性眩晕残余症状的相关性

目的探讨血清中耳石蛋白Otolin-1表达水平与良性阵发性位置性眩晕(benign paroxysmal positional vertigo,BPPV)复位成功后残余症状(residual dizziness,RD)的相关性。方法回顾性选取2017年5月-2018年5月在宁波市第二医院确诊的新发的特发性BPPV患者69例作为研究对象。BPPV患者耳石复位治疗成功后,根据随访中是否有RD,分为RD组28例和无RD组41例。收集BPPV患者的人口学数据、合并症等临床资料,同时抽取外周静脉血,测定血清Otolin-1及其他实验室相关指标。结果69例BPPV患者,其中40.6%(28/69)患者在治愈后有RD。血清Otolin-1水平在RD组和无RD组分别为357.4(313.6,411.4)pg/mL和312(265.3,345.7)pg/mL,两组比较差异有统计学意义(Z=-3.348,P=0.001)。受试者工作特征曲线显示,血清Otolin-1的截断值为330.81 pg/mL时,预测发生RD的曲线下面积为0.739(95%CI:0.622~0.865)。依据Otolin-1截断值,将BPPV患者分为Otolin-1值升高组和正常组。Logistic回归分析显示:Otolin-1升高组发生RD的风险是正常组的10.06倍(95%CI:2.33,43.42,P=0.002)。结论血清中Otolin-1水平在有RD的BPPV患者明显升高,推测血清中Otolin-1水平可作为预测BPPV治愈后发生RD的血清学标记物。

“Sitting-up vertigo as an expression of posterior semicircular canal heavy cupula and posterior semicircular canal short arm canalolithiasis”

Background:Vestibular symptoms on sitting-up are frequent on patients seen by vestibular specialists.Recently,a benign paroxysmal positional vertigo(BPPV)variant which elicits vestibular symptoms with oculomotor evidence of posterior semicircular canal(P-SCC)cupula stimulation on sitting-up was described and named sitting-up vertigo BPPV.A periampullar restricted P-SCC canalolithiasis was proposed as a causal mechanism.Objective:To describe new mechanisms of action for the sitting-up vertigo BPPV variant.Methods:Eighteen patients with sitting-up vertigo BPPV were examined with a pre-established set of positional maneuvers and follow-up until they resolved their symptoms and clinical findings.Results:All patients showed up-beating torsional nystagmus(UBTN)and vestibular symptoms on coming up from either Dix-Hallpike(DHM)or straight head-hanging maneuver.Sixteen out of 18 patients presented a sustained UBTN with an ipsitorsional component to the tested side on half-Hallpike maneuver(HH).A slower persistent contratorsional down-beating nystagmus was found in eleven out18 patients tested on nose down position(ND).Conclusions:Persistent direction changing positional nystagmus on HH and ND positions indicative of PSCC heavy cupula was found in 11 patients.A sustained UBTN on HH with the absence of findings on ND,which is suggestive of the presence of P-SCC short arm canalolithiasis,was found on 5 patients.All patients were treated with canalith repositioning maneuvers without success,but they resolved their findings by means of Brandt-Daroff exercises.We propose P-SCC heavy cupula and P-SCC short arm canalolithiasis as two new putative mechanisms for the sitting-up vertigo BPPV variant.

Comparisons of Supine Roll Test and Alternative Positional Tests in HC-BPPV Lateralization

Objective The purpose of the study was to evaluate the efficiency of the supine roll test(SRT)and alternative positional tests(APTs)including the bow and lean test(BLT),pseudo-spontaneous nystagmus(PSN),and lying down nystagmus(LDN)to identify the affected side in horizontal canal benign paroxysmal positional vertigo(HC-BPPV).Methods In our prospective study,we performed a testing profile(PSN,BLT,LDN,SRT)on 59 HC-BPPV patients using videonystagmography.We compared the accuracy and sensitivity of these tests in HC-BPPV lateralization.Data from 30 healthy patients were collected as the control group.Results When performing positional tests,the elicited nystagmus coinciding with Ewald’s second law was defined as a“positive response”.In 44 patients with geotropic nystagmus,the rates of positive response in LDN,PSN,and BLT were 22/44(50%),19/44(43%),and 18/44(41%),respectively,while in 15 patients with apogeotropic nystagmus,the positive response rates of these three tests were 10/15(66.7%),9/15(60%),and 4/15(27.00%),respectively.The sensitivity of LDN(54.38%)was higher than that of PSN(47.37%)and BLT(38.60%)but lower than that of SRT(89.47%).Notably,the accuracy rate of PSN(71.8%)was higher than that of the other APTs.In 6 patients with symmetrical nysgtamus during the roll test,5 patients showed a positive response in both LDN and BLT(83.34%),whereas 4 patients showed a positive response in PSN(66.67%).Conclusion All positional tests are helpful for determining the affected side of HC-BPPV,but SRT carries the highest accuracy of lateralization followed by PSN.

儿童良性阵发性位置性眩晕的临床分析

目的探讨儿童良性阵发性位置性眩晕(benign paroxysmal positional vertigo,BPPV)的临床特征,并观察其复位效果。方法将就诊于郑州大学第一附属医院耳科门诊2018年1月—2022年6月确诊为BPPV且年龄<18岁的17例患儿为儿童组,同期就诊确诊为BPPV行复位治疗的成年患者5275例为成人组,比较两组临床发病特点,分析其发病率、复位治疗效果等临床特征。结果儿童患者BPPV发病率为3.4%低于成人患者发病率39.8%,差异有统计学意义(P<0.01)。儿童组继发性BPPV比例为70.6%,高于成人组的32.6%,差异有统计学意义(P<0.01)。儿童组BPPV治愈率为94.1%,成人组的治愈率为92.0%,两组治愈率比较,差异无统计学意义(χ^(2)=0.102,P=0.750)。结论儿童BPPV发病率虽低于成年人,但并不少见,且复位治疗效果与成人无差异,一旦确诊建议尽可能行复位治疗。儿童BPPV以继发性多见,对于主诉不清或者已诊断为其他眩晕疾病的患儿,可加强变位试验的应用,谨防漏诊,延误患儿康复。

良性阵发性位置性眩晕患者维生素D状态及影响因素研究

目的 了解北京地区良性阵发性位置性眩晕(BPPV)患者维生素D水平状况,探讨性别、年龄、季节对维生素D水平的影响。方法 将2018年10月—2021年9月就诊于首都医科大学附属北京朝阳医院耳鼻咽喉头颈外科的208例BPPV患者作为研究对象进行回顾性研究。结果 所有BPPV患者血清25-羟维生素D[25(OH)D]水平为15.31(10.68, 21.03)ng/mL。比较不同性别、年龄和各个季节血清25(OH)D水平,男性高于女性,61~70岁年龄组高于其他年龄组;夏季血清25(OH)D水平最高,夏秋季明显高于冬春季。所有纳入研究的BPPV患者维生素D缺乏146例(70.19%);维生素D不足41例(19.71%);维生素D充足21例(10.10%)。回归分析显示性别、年龄和季节均能影响维生素D水平。结论 北京地区BPPV患者维生素D缺乏较为普遍,性别、年龄和季节对维生素D水平有影响。

良性阵发性位置性眩晕患者七年大数据回顾分析

目的良性阵发性位置性眩晕(BPPV)是最常见的外周性前庭疾病,但目前我国尚缺乏对BPPV大样本数据的回顾性分析,本研究旨在为BPPV患者家庭疾病预警和防范提供相应的理论依据。方法回顾性选取2014年6月—2021年6月中国人民解放军总医院眩晕诊疗中心数据库中眩晕患者45807例的临床资料,其中符合BPPV诊断患者5883例,根据其类型分类,统计患者年龄、性别、就诊时间、首诊BPPV类型、复诊BPPV类型等信息。使用Python 3.7进行数据可视化。结果BPPV患者中,女性3909例,男性1974例,50~59岁人群BPPV患者最多,且各BPPV类型中,女性患者比例均高于男性患者。所有眩晕患者位置性试验(+)阳性率为12.8%。不同类型BPPV比例中后管BPPV比例为64.5%,水平管BPPV比例为30.9%。有1092例BPPV复诊记录,首次诊断BPPV至复诊阴性有411例,234例患者BPPV类型在2~6次的就诊过程中有改变,BPPV类型转换比较常见的是左右耳PC-BPPV之间变化(71例)。结论本研究大数据显示,BPPV患者主要分布在50岁左右人群,女性患者约为男性的2倍。LC-BPPV患者比例远高于前期研究数据,约占所有BPPV患者的30.9%。在长期随访中,除大部分患者的BPPV类型没有发生变化外,主要的耳石变化存在后管侧别之间、后管与水平管之间进行转换的趋势。

良性阵发性位置性眩晕再发危险因素研究进展

良性阵发性位置性眩晕(benign paroxysmal positional vertigo,BPPV)是临床常见的外周性前庭疾病,其复发率高,随访10年患者复发率可达50%,反复发作的BPPV会对患者正常生活产生较大影响。研究其复发因素对降低复发、改善患者生活质量具有较大意义。我们将对目前关于BPPV复发影响因素的研究进行综述。

桂枝加葛根汤联合当归芍药散治疗良性位置性眩晕的效果

目的 探讨桂枝加葛根汤联合当归芍药散治疗良性位置性眩晕(benign paroxysmal positional vertigo,BPPV)的效果。方法 选取2021年2月-2023年8月收治的80例老年后半规管BPPV痰瘀互阻证患者,按照掷硬币法分为2组,对照组(n=40)采取常规西药治疗,观察组(n=40)另用桂枝加葛根汤联合当归芍药散治疗,比较2组疗效。结果 治疗7 d、14 d后,观察组中医证候积分较对照组低(P<0.05)。14 d治疗后,观察组眩晕评分、血液流变学指标、血清同型半胱氨酸(homocysteine,Hcy)水平均优于对照组(P<0.05)。治疗后,观察组脑血流动力学较对照组优(P<0.05)。2组在治疗期间均未出现头痛、乏力不良反应。结论 对老年后半规管BPPV痰瘀互阻证患者采取桂枝加葛根汤联合当归芍药散治疗,可明显减轻患者眩晕症状和中医证候积分,改善其血液流变学和脑血流动力学,值得推广。