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 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。

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.

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.

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.

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.

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.

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.

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]

“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.

Analysis of cost and effectiveness of treatment in benign paroxysmal positional vertigo

To the Editor: Benign paroxysmal positional vertigo (BPPV) is one of the most common causes of vertigo. Recently, the diagnosis and treatment of BPPV have become areas of increased interest. As such, the levels of clinical diagnosis and treatment have greatly improved. While studies have been conducted worldwide examining the pathogenesis and pathophysiology of BPPV, very few have focused on the cost of diagnosis and treatment of BPPV. Therefore, the current study was designed to analyze the effects and expenditure of the different treatment strategies for BPPV, according to the effective screening of BPPV patients, and vertigo classification.

Brandt-Daroff习服法联合倍他司汀治疗良性阵发性位置性眩晕复位后残余症状的疗效分析

目的观察Brandt-Daroff习服法,以及联合倍他司汀治疗良性阵发性位置性眩晕(BPPV)复位后残余症状的疗效。方法纳入2017年3月~2019年3月收治BPPV复位成功患者,将其中复位后仍存在残余头晕患者75例随机分3个组,对照组(倍他司汀治疗)、训练组(Brandt-Daroff习服法)和联合组(Brandt-Daroff习服法联合倍他司汀),每组25例。对所有患者治疗后残余症状持续时间,治疗前后的眩晕残障量表(dizziness handicap inventory,DHI)进行评分比较。结果治疗前各组患者的基线资料及DHI评分差异无统计学意义(P>0.05)。治疗后,联合组残余症状持续时间低于对照组和训练组(P<0.05),对照组和训练组之间差异无统计学意义(P>0.05);治疗7天后,联合组DHI评分低于训练组及对照组(P均<0.05),训练组和对照组比较差异无统计学意义(P>0.05);治疗28天后,联合组DHI评分均低于对照组和训练组(P均<0.001),训练组评分低于对照组,差异具有统计学意义(P<0.001)。结论Brandt-Daroff习服法联合倍他司汀能显著减轻BPPV成功耳石复位后残余的头晕症状,单用Brandt-Daroff习服法和常规内科药物倍他司汀有相似疗效。

Brandt-Daroff习服训练联合黛力新治疗良性阵发性位置性眩晕管石复位后残余头晕的疗效

目的:观察Brandt-daroff习服训练联合黛力新治疗良性阵发性位置性眩晕(BPPV)管石复位后残余头晕的疗效。方法:BPPV成功管石复位后发生残余头晕的患者96例随机分为4组:对照组(常规内科治疗),训练组(Brandt-Daroff习服训练),药物组(黛力新治疗),联合组(Brandt-Daroff习服训练联合黛力新治疗),每组24例。治疗前后采用医院焦虑抑郁量表(HADS)、眩晕残障量表(DHI)、前庭症状指数(VSI)对患者进行评分比较。结果:治疗前各组HADS、VSI、DHI评分差异无统计学意义(P>0.05)。治疗7、14 d后,3组HADS、VSI、DHI评分均低于对照组(均P<0.05)。治疗7、14 d后,联合组HADS、VSI、DHI评分均低于训练组及药物组(均P<0.05)。治疗7 d后,药物组HADS评分低于训练组(P<0.05);治疗14 d后,训练组DHI评分低于药物组(P<0.05)。结论:Brandt-Daroff习服训练、黛力新均能减轻BPPV成功管石复位后残余头晕症状,联合治疗较单一治疗更有效。

自拟拨云汤联合Brandt-Daroff习服疗法治疗良性阵发性位置性眩晕疗效评价

目的探讨自拟拨云汤联合Brandt-Daroff习服疗法治疗良性阵发性位置性眩晕(BPPV)的临床疗效。方法选取医院2017年9月至2019年9月收治的BPPV患者102例,按随机对照法分为观察组和对照组,各51例。两组均予Brandt-Daroff习服疗法治疗,观察组加用自拟拨云汤治疗。两组患者均连续治疗8周。结果观察组总有效率为90.20%,显著高于对照组的74.51%(P<0.05);观察组患者治疗第1,2,4,8周的眩晕症状评分简化量表(VSS-SF)、眩晕障碍量表(DHI)评分均显著低于对照组,Berg平衡量表(BBS)评分均显著高于对照组(P<0.05);观察组和对照组的不良反应发生率相当(13.73%比7.84%,P>0.05)。结论自拟拨云汤联合Brandt-Daroff习服疗法治疗BPPV疗效良好,能改善患者的眩晕障碍程度,降低日常跌倒风险,提高平衡状态和生活质量,且治疗安全性高。

手法复位结合Brandt-Daroff锻炼治疗水平半规管良性阵发性位置性眩晕的疗效

目的探讨手法复位结合Brandt-Daroff锻炼对水平半规管良性阵发性位置性眩晕(BPPV)的治疗效果。方法50例水平半规管良性阵发性位置性眩晕患者,随机分为观察组和对照组,各25例。对照组接受正规手法复位治疗,观察组在对照组基础上采用Brandt-Daroff锻炼治疗。比较两组患者的临床疗效,前庭症状指数(VSI)及眩晕障碍量表(DHI)评分,眩晕障碍分级,治疗满意度。结果观察组患者的临床总有效率92.00%显著高于对照组的60.00%,差异具有统计学意义(P<0.05)。治疗后,观察组患者的VSI评分(12.42±1.48)分、DHI评分(24.43±3.00)分均低于对照组的(23.93±2.72)、(42.52±5.00)分,差异具有统计学意义(P<0.05)。观察组患者的眩晕障碍分级优于对照组,差异具有统计学意义(P<0.05)。观察组患者的治疗满意度96.00%高于对照组60.00%,差异具有统计学意义(P<0.05)。结论水平半规管良性阵发性位置性眩晕患者成功手法复位后给予Brandt-Daroff锻炼治疗,可有助于促进前庭中枢的代偿,改善眩晕症状,提高患者的生活质量,其效果明显,而且安全可靠,可广泛应用。

Brandt-Daroff训练对BPPV残余头晕的疗效

目的探究良性位置性眩晕治愈后残余头晕采取Brandt-Daroff耳石习服训练效果。方法随机抽取我院2018年1月—2019年11月门诊良性位置性眩晕治疗后残余头晕患者总计84例,按照就诊先后顺序分为两组,各42例,对照组接受敏使朗口服治疗,观察组在对照组基础上开展Brandt-Daroff耳石习服训练,比较两组治疗情况。结果治疗前,两组DHI、VSI评分差异无统计学意义(P>0.05),治疗后7 d、14 d,观察组DHI、VSI评分低于对照组,差异具有统计学意义(P<0.05),观察组治疗总有效率为92.86%,高于对照组78.57%,差异具有统计学意义(P<0.05)。结论良性位置性眩晕治愈后残余头晕患者,接受Brandt-Daroff耳石习服训练,可改善头晕及行走不稳感,进一步提高治疗疗效,改善预后。

Unilateral mimicking bilateral BPPV- a forgotten entity? Characteristics of a largecohort of patients, comparison with posterior canal BPPV and clinical implications

Objective: Unilateral mimicking bilateral benign paroxysmal positional vertigo (umb-BPPV) was attributed to inappropriate head positioning during testing of the posterior canal. Despite its inclusion in theDiagnostic criteria for the classification of vestibular disorders of the Barany Society, the clinical characteristics and treatment responsiveness of this BPPV subtype have not been intensively studied.Methods: Records of patients with BPPV seen at a single outpatient dizziness clinic during the years 2000e2020 were reviewed. Eighty seven patients with umb-BPPV and 86 random patients with posteriorcanal BPPV (p-BPPV) were retrieved. Their demographics and BPPV characteristics were analyzed.Results: Patients' and BPPV characteristics were similar in umb- and p-BPPV except for the prevalence ofmales in the umb-BPPV group. No differences were found between treatment responsiveness and recurrences in both groups. The recurrence rate of umb-BPPV was not influenced by age, gender, BPPV side,duration of symptoms or treatment responsiveness during the first attack.Conclusions: In accordance with our hypothesis about mixed canalo- and cupulolithiasis as the underlying mechanism of umb-BPPV, patients did not differ in characteristics and treatment responsivenessfrom p-BPPV patients. Recognition of umb-BPPV is important since inappropriate treatment can cause anunnecessary delay in therapy success.