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.

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

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.

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.

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。

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.

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]

个体化护理在BPPV合并疾病患者治疗中的临床价值

目的 探讨良性阵发性位置性眩晕(benign paroxysmal positional vertigo, BPPV)合并疾病患者的护理对策。方法 选取2019年1~12月就诊的BPPV患者210例,无合并疾病BPPV患者37例为对照组,采用常规护理;BPPV合并疾病患者173例为试验组,采用个体化护理方案,比较2组患者的疗效、复发、生活质量改善情况。结果 试验组总有效率为97.1%,对照组总有效率为100%,差异无统计学意义(P>0.05);试验组复发率为11.5%,对照组复发率为10.8%,差异无统计学意义(P>0.05);2组患者治疗前、后DHI总分,差异有统计学意义(P<0.05)。结论 采用个性化护理方案可以为合并疾病BPPV患者治疗提供护理保障,护理操作流程具体、明确、步骤清晰,可提高患者生活质量,提升护理满意度。

复发BPPV成人患者自身因素与季节因素相关性探索

目的分析复发良性阵发性位置性眩晕(benign paroxysmal positional vertigo,BPPV)成人患者的自身因素与季节因素之间的关系,探讨反复发作BPPV的相关因素。方法采用回顾性队列研究方法,纳入2015年2月~2022年1月北京市普仁医院收治的815例复发BPPV成人患者,分析其发病年龄、性别、季节性特点,同时探讨血管性危险因素、补充钙剂和维生素D的影响。结果复发BPPV患者年龄22~88岁,中位年龄61(55,67)岁,男女性别比为1∶3.01,男女患者的年龄、各年龄组男女性别比、血管性危险因素患病率比较,差异无统计学意义(P>0.05),女性患者补充钙剂和维生素D的占比高于男性(P<0.001);复发BPPV发作无显著季节规律性,但呈现寒冷季节增多的趋势;血管性危险因素与年龄相关,与性别、季节无明显相关性;多次复发BPPV患者占20.86%(170/815),补充钙剂和维生素D是其独立影响因素。结论复发BPPV女性高发,老年多见,寒冷季发作次数较多,补充钙剂和维生素D可能减少复发频率。

BPPV复发患者与其骨密度及骨代谢指标的相关性分析

分析良性阵发性位置性眩晕(BPPV)复发患者与其骨密度(BMD)及骨代谢指标的相关性。选取莆田学院附属医院门诊90例BPPV患者为例,依据复发情况分为观察组(为复发者)与对照组(为非复发者)。结果显示:经耳石复位治疗后复发患者中,观察组BMD正常低于对照组,骨量减少组与骨质疏松组BMD低于对照组,且与对照组相比,观察组BMD的T值下降较为明显(P<0.05)。BPPV复发患者的骨代谢指标呈不同程度变化。BPPV复发患者与BMD、骨代谢指标的相关性呈正相关(r=0.905,P=0.000;r=0.954,P=0.000)。提示BPPV复发患者与BMD、骨代谢指标存在一定相关性。

不同责任半规管BPPV与主诉症状关系分析

目的分析确诊良性阵发性位置性眩晕(BPPV)患者的位置性眩晕主诉特征,以及主诉症状与BPPV责任半规管定位诊断的相关性。方法对2022年2-3月因位置性眩晕就诊于该院患者100例完成详细病史问卷调查,以视频眼震图位置试验进行BPPV客观定位诊断,分析确定诊断BPPV与病史主诉的关系。结果100例患者中以坐起-躺下、左右翻身为眩晕主要主诉者分别为39、56例,两者分辨不清5例;位置试验阳性75例,其中BPPV确定诊断63例,其他前庭周围性眩晕12例。分析63例确定诊断BPPV患者的主诉症状,以坐起-躺下眩晕确诊垂直、水平半规管BPPV的灵敏度和特异度分别为70.7%和94.4%、5.6%和29.3%,以左右翻身眩晕确诊水平、垂直半规管BPPV的灵敏度和特异度分别为94.4%和70.7%、29.3%和5.6%。进一步分析63例BPPV患者其位置性眩晕的首发体位,以坐起-躺下者确诊垂直、水平半规管BPPV的灵敏度和特异度为76.9%和55.6%、44.4%和23.1%,左右翻身者确诊水平、垂直半规管BPPV的灵敏度和特异度为55.6%和76.9%、23.1%和44.4%。对30例可明确表述眩晕诱发较重体位侧别的BPPV患者进行分析,右侧位为较重侧13例,左侧位为较重侧17例,余33例对诱发眩晕的左右侧分别描述不清。结论位置性眩晕患者的主诉症状中,“坐起-躺下”和“左右翻身”性眩晕主诉分别对垂直、水平半规管BPPV诊断的灵敏度和特异度高,符合Ewald′s定律;而首发体位及症状较重的体位侧别,对BPPV责任半规管侧别定位诊断的灵敏度和特异度均不高。位置性眩晕患者主诉症状对BPPV快速筛查具有一定的临床价值,确定定位诊断要依靠位置试验。

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。

手法复位与机械复位治疗不同年龄段BPPV患者疗效差异的随机对照研究

目的探讨手法复位与机械复位治疗不同年龄段良性阵发性位置性眩晕(benign paroxysmal positional vertigo,BPPV)患者的疗效差异。方法收集2022年6月至2023年9月期间,在天长天康医院神经内科眩晕中心就诊的BPPV患者260例。使用随机数字表法将患者分为机械复位组(机械组)和手法复位组(手法组),每组130例。根据WHO年龄分层标准,将两组患者进一步划分为中青年组(<60岁)和老年组(≥60岁),比较两组间的疗效,主要疗效观察指标为两组患者治愈所需要的治疗次数和治疗3 d、7 d、14 d内的治愈率,次要疗效指标为治疗90 d、180 d内的复发率。结果剔除无法完成复位治疗的患者后,机械组108例、手法组120例纳入分析。机械组108例中中青年患者50例(46.3%),老年患者58例(53.7%);手法组120例患者中中青年患者57例(47.5%),老年患者63例(52.5%)。机械组患者治疗次数显著低于手法组患者(P<0.05),且机械组老年患者治疗次数显著少于手法组老年患者[(2.93±1.42)次比(4.13±2.18)次,t=-3.529,P<0.001]。在治疗3 d、7 d和14 d内,机械组治愈率均高于手法组(P<0.05),且在治疗3 d内,机械组老年患者的治愈率显著高于手法组老年患者(48.27%比28.57%,χ^(2)=4.976,P=0.026),在治疗14 d内,机械组老年患者的治愈率高于手法组老年患者(100%比90.47%,χ^(2)=5.812,P=0.028)。两组治疗90 d内的复发率差异无统计学意义(P>0.05),治疗180 d内机械组复发率低于手法组(17.59%比30.00%,χ^(2)=4.781,P<0.05),且机械组老年患者复发率低于手法组老年患者(18.96%比38.09%,χ^(2)=5.375,P=0.027)。结论机械复位治疗BPPV相比手法复位具有更高的治愈率和更低的复发率,尤其是在老年患者中更加明显。

绝经BPPV患者血清25(OH)D_(3)、血钙与骨代谢变化及意义

目的探讨绝经女性良性阵发性位置性眩晕(benign paroxysmal positional vertigo,BPPV)患者血清25-羟维生素D_(3)[25-hydroxyvitamin D_(3),25(OH)D_(3)]、血钙水平与骨代谢指标的变化及临床意义。方法选取2020年8月至2021年8月杭州市第九人民医院103例绝经BPPV患者纳入BPPV组,根据1年复发情况,再将其分为复发组(n=18)与无复发组(n=85);另选取同期50名健康体检的绝经女性纳入对照组。收集其临床资料及血清25(OH)D_(3)、血钙、骨代谢指标[Ⅰ型前胶原氨基端前肽(procollagen typeⅠN-terminal propeptide,PINP)、骨钙素N端中分子片段(N-terminal midfragment of osteocalcin,N-MID)、Ⅰ型胶原羟基端肽β降解产物(β-isomerised C-terminal telopeptide of collagen typeⅠ,β-CTX)和骨性碱性磷酸酶(bone alkaline phosphatase,BALP)],构建Logistic回归模型分析绝经女性发生BPPV的危险因素,并采用受试者操作特征曲线分析相关指标对BPPV复发的预测价值。结果BPPV组患者的血清25(OH)D_(3)水平显著低于对照组(P<0.05),长期饮食不规律占比、PINP、N-MID、BALP水平均显著高于对照组(P<0.05);多因素Logistic回归分析结果显示,低25(OH)D_(3)、高PINP、高N-MID、高BALP均是绝经女性发生BPPV的危险因素(P<0.05);复发组患者的25(OH)D_(3)水平显著低于无复发组(P<0.05),PINP、N-MID、BALP水平均显著高于无复发组(P<0.05);25(OH)D_(3)、PINP、N-MID、BALP及四项联合预测BPPV复发的曲线下面积(area under the curve,AUC)分别为0.833、0.654、0.697、0.782、0.910,四项联合预测的AUC最大,敏感度和特异性分别为98.97%、70.62%。结论绝经女性BPPV患者血钙水平无明显改变,血清25(OH)D_(3)水平降低,PINP、N-MID与BALP水平升高均是发生BPPV的危险因素,且可用于BPPV复发的预测。

视频头脉冲试验与BPPV复位治疗后残余症状关系

目的回顾性分析视频头脉冲试验(Video head impulse test,vHIT)与良性阵发性位置性眩晕(Benign paroxysmal positional vertigo,BPPV)复位治疗后残余症状持续时间关系。方法回顾辽宁中医药大学附属医院就诊诊断为BPPV并经复位治疗后治愈患者共152例,按vHIT回报正常与否分为正常组(n=49)与异常组(n=103),对比两组间复位治疗次数、残余症状持续时间。其次将所有病例按不同责任半规管及不同类型进行分析与比较。再对所有病例年龄、复位治疗次数、残余症状持续时间之间相关性进行两两分析。另外对同时具有冷热试验结果的27例进行分析。结果正常组与异常组间复位治疗次数差异无统计学意义(P=0.370)。正常组残余症状持续时间(15.37±21.74d)小于异常组(19.57±16.70d),组间差异有统计学意义(P=0.008)。不同类型及不同责任半规管BPPV中,后管复位次数最少(P=0.021),水平管嵴顶结石症残余症状持续时间最短(P<0.001)。全部样本中年龄与复位治疗次数之间不相关(P=0.198),年龄与残余症状持续时间呈正相关(P=0.037,r=0.169),复位次数与残余症状持续时间呈正相关(P<0.001,r=0.317)。冷热试验结果与复位治疗次数、残余症状持续时间不相关(P=0.334)。结论BPPV残余症状持续时间长者可能伴有其他未诊断的前庭周围系统疾病,复位治疗次数主要与椭圆囊囊斑功能良好与否相关,vHIT检查结果对于判断残余症状预后有一定临床参考意义。

合并残余症状的BPPV向PPPD转化的相关因素分析

目的分析良性阵发性位置性眩晕(benign paroxysmal positional vertigo,BPPV)患者复位治疗后残余症状(residual dizziness,RD)持续时间的影响因素及其向持续性姿势感知性头晕(persistent postural-perceptual dizziness,PPPD)转化的相关因素。方法选取2021年1月-2022年1月陕西省人民医院眩晕门诊确诊为BPPV且复位成功的患者575例,存在RD的患者有273例。根据RD持续时间将患者分为RD≤1周组116例、1周<RD<3月组104例和RD≥3月组53例。根据是否转化为PPPD将RD≥3月组患者分为PPPD阴性32例和PPPD阳性21例,分析BPPV复位后RD转化为PPPD的相关危险因素。结果BPPV的RD发生率47.5%,其中42.5%的患者RD在1周内消失,但仍有19.4%的患者RD持续超过3月并转化为PPPD;焦虑抑郁状态是BPPV转化为PPPD的独立危险因素(OR=8.148;P=0.011);血压异常是合并RD的BPPV转化为PPPD的相关因素(P<0.05)。结论焦虑抑郁状态是合并RD的BPPV向PPPD转化的独立危险因素,合并血压异常是BPPV转化为PPPD的相关危险因素。