Delayed diagnosis and treatment of benign paroxysmal positional vertigo associated with current practice

A Study of Quality of Life Improvement in Videonystagmography Guided Epley's Manoeuvre in Posterior Canal Benign Paroxysmal Positional Vertigo

To assess Quality of life improvement in Videonystagmography guided Epley's Manoeuvre in posterior canal benign paroxysmal positional vertigo. The design of present study is cross-sectional analytical study. The study is conducted in the Department of Otorhinolaryngology, Sri Aurobindo Medical College and Post Graduate Institute, Indore in association with Sri Aurobindo Institute of speech and hearing, Indore. Current study done to assess the effectiveness of canalolith repositioning procedures (Epley's maneuver) with and without drug therapy in posterior canal benign paroxsymal positional vertigo and to assess the patients based on Dizziness Handicap Inventory. All Patients who come to ENT OPD at Sri Aurobindo Medical College and Post Graduate Institute, Indore in the specified duration and according to the inclusion criteria were chosen in the study. Majority of the patients were in the age group of 18-58 years with the median age of 32 and subjective symptomatic relief on Epley's manoeuvre and DHI on day 15, 46 out of 60 subjects reported symptomatic relief with a percentage of 76.6%. This group of 46 subjects with symptomatic relief was labeled as resolved group. The age range in resolved group was between 18 and 58 years. Remaining 14 subjects, labelled as relapsed group were prescribed beta-histine and repeat Epley's maneuver was performed to assess the effectiveness of adjunct therapy. We conclude that a single Videonystagmography guided Epley's maneuver is an excellent tool for effective rehabilitation of majority of posterior canal BPPV alone and combined with adjunct betahistine therapy can even cure refractory cases providing them with better quality of life.

Do single-session Epley maneuvers treat benign paroxysmal positional vertigo?

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular condition characterized by short-term vertigo attacks that significantly affect quality of life.

OBJECTIVES

Examine how well a single Epley maneuver worked in an outpatient setting for people with posterior canal benign paroxysmal positional vertigo (PC-BPPV) and whether they needed a second Dix-Hallpike maneuver.

DESIGN

Prospective.

SETTINGS

Otorhinolaryngology department of a tertiary care center.

PATIENTS AND METHODS

Sociodemographic data, body mass index (BMI), and systemic disease history of 75 patients diagnosed with PC-BPPV were recorded, and their relationship with success rates after the modified Epley maneuver was analyzed.

MAIN OUTCOME MEASURES

Detect cases that could not be repositioned with the diagnostic control Dix-Hallpike test performed 20 minutes after the modified Epley reposition maneuver in the same session in PC-BPPV patients.

SAMPLE SIZE

75.

RESULTS

Of the 75 patients, 31 were male (41.3%), 44 female (58.6%) with a mean (standard deviation) age of 58.6 (15.9) years age, 54.6% had one or more chronic diseases. BMI was 30 mg/kg2 and above in 31 patients (41.3%). The modified Epley maneuver was successful in 77.3%. No significant relationship was found between additional diseases or BMI in the patient group in whom the maneuver was unsuccessful.

CONCLUSION

The success rates of repositioning maneuvers in treating patients diagnosed with PC-BPPV are high. However, more than a single maneuver is required in some resistant patients. Second diagnostic and repositioning maneuvers performed in the same session will reduce multiple hospital admissions. While it is helpful to repeat the maneuver in the patient group where it was unsuccessful, other factors causing the failure should be investigated.

LIMITATIONS

Lack of follow-up results of patients after 7-10 days.

Prevalence of Horizontal Canal Variant in 3,975 Patients With Benign Paroxysmal Positional Vertigo: A Cross-sectional Study

Background and Objectives

Current understanding based on older studies is that pc-BPPV is far more common than hc-BPPV. Such studies are limited by small sample sizes, and often the supine roll test for hc-BPPV is not performed. To better estimate the prevalence of hc-BPPV, we studied a large cross-section of patients with VOG-diagnosed BPPV.

Methods

Using a cross-sectional study of patients with BPPV, we investigated patients referred to NeuroEquilibrium specialty clinics throughout India between January 1, 2021, and December 31, 2021. All patients were evaluated with video oculography (VOG) during positional tests, and all diagnoses were confirmed by a neurotologist and neurologist.

Results

Of 3,975 patients with VOG-confirmed and specialist-diagnosed BPPV (median age, 51 years; 56.6% women), pc-BPPV accounted for 1,901 (47.8%), hc-BPPV was seen in 1,842 (46.3%), and anterior canal BPPV was found in 28 (0.7%) patients.

Discussion

This study found that hc-BPPV is far more common than previously reported. It is important to perform the supine roll test in addition to the Dix-Hallpike in all patients suspected with BPPV. Better training to diagnose patients with BPPV and to accurately recognize the nystagmus pattern of hc-BPPV should be a priority.

Perceived illness consequences predict the long-term course of handicap in patients with vertigo and dizziness beyond vestibular abnormality

OBJECTIVE

Vertigo and dizziness (VD) affect one third of the population during their lifetime. VD patients are oftentimes severely handicapped. One current study showed that illness perceptions, emotional as well as behavioral responses to illness were associated with VD-related handicap at 3-months follow-up. However, no study has yet investigated this association for a period longer than six months. This study aimed to investigate long-term associations of cognitive, emotional, and behavioral factors with VD-related handicap.

METHODS

In a naturalistic longitudinal study design, n = 161 patients with VD were examined at baseline, at 6-months follow-up, and at 12-months follow-up. Participants underwent neurological and psychiatric examinations as well as comprehensive psychological assessments using self-report questionnaires.

RESULTS

During the study period VD-related handicap decreased significantly (Cohen's d = .35, p < .001). Cognitive, emotional, and behavioral factors remained without significant change during the study period. Vestibular testing as well as the type of diagnosis were not associated with changes in VD-related handicap. Changes in perceived illness consequences (ß = .265, p < .001), depression (ß = .257, p < .001), and anxiety (ß = .206, p = .008) significantly predicted the course of VD-related handicap over 12 months, while the presence vs. absence of vestibular abnormality did not.

CONCLUSION

Our results extend findings that cognitive and emotional factors including perceived illness consequences, depression, and anxiety are associated with the long-term course of VD-related handicap and may provide therapeutic targets to improve long-term outcomes in patients with VD.

Needs and supporting tools for primary care physicians to improve care of patients with vertigo and dizziness: a national survey

Background

The diagnostic workup and treatment decisions for vertigo or dizziness in primary care can be challenging due to the broad range of possible causes and limited time and expertise of physicians. This can lead to delays in treatment and unnecessary tests. We aimed to identify the unmet needs of primary care physicians (PCPs) and strategies to improve care for dizzy patients.

Materials and methods

An online survey was conducted among board-certified PCPs in Switzerland to explore needs in caring for dizzy patients and potential educational approaches.

Results

Based on responses from 152 participating PCPs, satisfaction and confidence were higher in diagnosing (82%) and treating (76%) acute dizziness compared to episodic/chronic cases (63 and 59%, respectively). Younger PCPs had lower diagnostic yield and confidence. Areas for improvement in specialist interactions included communication between physicians (23%/36%; always/often true), shorter waiting times for consultations (19%/40%), more detailed feedback (36%/35%), and consistent patient back referrals (31%/30%). PCPs expressed interest in hands-on courses, workshops, practical guidelines, web-based algorithms, and digital tools such as printed dizzy diaries and apps for follow-up.

Conclusion

Enhanced dialog between PCPs and specialists is crucial to address the most common unmet needs. Reducing waiting times for referrals and providing clear instructions to specialists for triage are essential. The findings from this survey will guide the development of tools to improve the diagnosis and treatment of dizzy patients. Younger PCPs, who face higher diagnostic uncertainty, should be prioritized for educational approaches such as hands-on courses, workshops, and practical recommendations.

Torsional nystagmus recognition based on deep learning for vertigo diagnosis

Introduction

Detection of torsional nystagmus can help identify the canal of origin in benign paroxysmal positional vertigo (BPPV). Most currently available pupil trackers do not detect torsional nystagmus. In view of this, a new deep learning network model was designed for the determination of torsional nystagmus.

Methods

The data set comes from the Eye, Ear, Nose and Throat (Eye&ENT) Hospital of Fudan University. In the process of data acquisition, the infrared videos were obtained from eye movement recorder. The dataset contains 24521 nystagmus videos. All torsion nystagmus videos were annotated by the ophthalmologist of the hospital. 80% of the data set was used to train the model, and 20% was used to test.

Results

Experiments indicate that the designed method can effectively identify torsional nystagmus. Compared with other methods, it has high recognition accuracy. It can realize the automatic recognition of torsional nystagmus and provides support for the posterior and anterior canal BPPV diagnosis.

Discussion

Our present work complements existing methods of 2D nystagmus analysis and could improve the diagnostic capabilities of VNG in multiple vestibular disorders. To automatically pick BPV requires detection of nystagmus in all 3 planes and identification of a paroxysm. This is the next research work to be carried out.

Evaluating patients with vertigo

ABSTRACT

Dizziness and vertigo are among the most common complaints in medicine. Patients often provide vague descriptions of symptoms, making clinicians' jobs challenging. However, a patient with vertigo also can be one of the most rewarding encounters of a clinician's day. In most cases, a focused history and bedside vestibular testing provide enough information to make a diagnosis and identify patients for appropriate referral. Canalith repositioning maneuvers often resolve symptoms, leaving patients and clinicians satisfied.

Cerebral Outflow Discrepancies in Recurrent Benign Paroxysmal Positional Vertigo: Focus on Ultrasonographic Examination

This prospective pilot study aimed to evaluate whether cerebral inflow and outflow abnormalities assessed by ultrasonographic examination could be associated with recurrent benign paroxysmal positional vertigo (BPPV). Twenty-four patients with recurrent BPPV, affected by at least two episodes, and diagnosed according to American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) criteria, evaluated at our University Hospital, between 1 February 2020 and 30 November 2021, have been included. At the ultrasonographic examination, 22 of 24 patients (92%) reported one or more alterations of the extracranial venous circulation, among those considered for the diagnosis of chronic cerebrospinal venous insufficiency (CCSVI), although none of the studied patients were found to have alterations in the arterial circulation. The present study confirms the presence of alterations of the extracranial venous circulation in recurrent BPPV; these anomalies (such as stenosis, blockages or regurgitation of flow, or abnormal valves, as per the CCSVI) could cause a disruption in the venous inner ear drainage, hampering the inner ear microcirculation and then possibly causing recurrent otolith detachment.

Outcome of canalith repositioning manoeuvre in benign paroxysmal positional vertigo in children and adolescents: A systematic review

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is a debilitating condition that has been significantly described in adults. Recent data points out that BPPV occurs in children as well. Canalith repositioning manoeuvre (CRM) has shown promising results amongst adult patients with BPPV.

OBJECTIVE

We reviewed the literature to determine the outcome of CRM in children and adolescents with BPPV.

METHODS

A literature search was conducted over 1 month (March 2022). The primary outcome was defined as the resolution of positional nystagmus and symptoms, and secondary outcomes were determined by the presence of recurrence and the number of attempts of CRM.

RESULTS

Ten articles were selected based on our objective and selection criteria. A total of 242 patients were included, with a mean of 10.9 years. BPPV was diagnosed based on history and positional nystagmus in all patients (100%). CRM was performed in 97.9% of patients, whereby 80.5% recovered following a single attempt of CRM. Recurrence of symptoms was identified in 10% of patients with no reported major complications.

CONCLUSION

CRM has demonstrated promising results in children and adolescents. The quality of evidence is limited until a better-quality study involving randomised controlled studies with a larger sample size is completed.

A critical appraisal of clinical practice guidelines for the diagnosis and management of benign paroxysmal positional vertigo

BACKGROUND

Delays in the diagnosis and therapy of benign paroxysmal positional vertigo can greatly impact quality of life and increase healthcare costs for patients. This study aimed to appraise the quality of clinical practice guidelines for the diagnosis and management of benign paroxysmal positional vertigo.

METHODS

A comprehensive database search of clinical practice guidelines was completed up to 30 October 2021. Four independent reviewers used the Appraisal of Guidelines for Research and Evaluation II instrument in the quality appraisal.

RESULTS

The highest score was in 'clarity and presentation' (58.33 ± 22.7). The lowest score was in 'applicability' (13.96 ± 30.1). Overall, four clinical practice guidelines were 'low quality' and only one guideline was 'high quality'.

CONCLUSION

This review identified a significant lack of quality in clinical practice guideline development for benign paroxysmal positional vertigo, highlighting the need for a more rigorous approach for future guideline development.

The Prevalence of Symptom Reporting for Benign Paroxysmal Positional Vertigo in a Traumatic Brain Injury Population

OBJECTIVE

To assess the prevalence of benign paroxysmal positional vertigo (BPPV) in traumatic brain injury population.

STUDY DESIGN

In this cross-sectional design, each subject completed screening for BPPV, which included subjective questioning and positional testing. Subjects were asked if they experienced dizziness with bed mobility. All were tested with the Dix-Hallpike and the roll test to determine if nystagmus consistent with BPPV was present.

SETTING

Brain injury inpatient rehabilitation unit.

PARTICIPANTS

Subjects admitted to the rehabilitation unit during a 6-month time frame who had a traumatic mechanism of brain injury or experienced a fall resulting from a neurologic event.

INTERVENTIONS

Diagnostic interventions included the Dix-Hallpike and roll tests.

MAIN MEASURES

The primary outcomes of this study were the prevalence of BPPV and symptom reports.

RESULTS

Seventy-six subjects met the inclusion criteria. Three subjects were transferred to acute care before screening for BPPV could be completed. Of the 73 subjects who completed the screening process, 42 (58%) tested positive for BPPV, of which only 7 (10%) reported subjective symptoms of dizziness and/or vertigo. χ2 Analysis of the two screening methods demonstrated a statistically significant difference in the positivity rate between tests (χ21 = 5.715, p = 0.017, Cohen's W = 0.279). If subjects responded yes to both screening questions, they were significantly more likely to test positive for BPPV with a moderate effect size of 0.279.

CONCLUSION

There was a high prevalence of BPPV within an inpatient rehabilitation facility in subjects with traumatic brain injury, with a small percentage of patients reporting dizziness with subjective questioning.

A mechanical rotation chair provides superior diagnostics of benign paroxysmal positional vertigo

Background

Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disease. Both therapeutic and diagnostic benefits with mechanical rotation chairs (MRCs) for management of BPPV have been reported. No previous studies have compared diagnostics in MRCs to traditional diagnostics on an examination bed.

Objective

To investigate the agreement between BPPV diagnostics performed with an MRC and traditional diagnostics on an examination bed. Secondary objectives were to (1) examine if the two test modalities differ in diagnostic properties when diagnosing largely untreated patients referred from general practitioners (uncomplicated BPPV) compared to patients referred from private ENTs (complicated BPPV) and (2) examine whether impaired participant cooperation during Manual Diagnostics (MDs) alters agreement, sensitivity and specificity.

Method

Prospective randomized clinical trial in which patients with a case history of BPPV were recruited by referrals from general practitioners, otorhinolaryngologists and other hospital departments in the Northern Region of Denmark. Participants underwent diagnostic examinations twice: once by traditional MDs on an examination bed and once with an MRC. Initial examiner and order of test modality were randomized. Examiners were blinded to each other's findings.

Results

When testing the ability to diagnose BPPV, agreement between the two test modalities, was 0.83, Cohen's kappa 0.66. When comparing MD diagnostics to MRC diagnostics (set as gold standard diagnostics following test result interpretation), values for MDs were: sensitivity 71%, specificity 98%, Negative Predictive Value 73%, and Positive Predictive Value 97%. Agreement regarding BPPV subtype classification was found to be 0.71, and Cohen's kappa 0.58. Agreement when isolating the diagnosis to posterior canalolithiasis (p-CAN) was 0.89, Cohen's kappa 0.78.

Conclusion

Diagnostics, aided by an MRC, are more sensitive than traditional manual BPPV diagnostics. The overall agreement level between test modalities was found to be weak to moderate. When isolating diagnostics to p-CAN, the level of agreement increased to "moderate-strong." Results also showed higher agreement between test modalities and a significantly higher negative predictive value for MDs when examining patients referred directly from General Practitioners following no- or a single treatment attempt. The diagnostic properties of MDs improved in patients with a higher degree of cooperation.

Implementing specialised vestibular physiotherapy in an emergency department: a process evaluation

Background

Dizziness and vertigo-like symptoms, often caused by common peripheral vestibular disorders such as benign paroxysmal positional vertigo (BPPV), may significantly impact function and quality of life. These symptoms often result in emergency department (ED) presentations. Evidence-based clinical practice guidelines strongly recommend using physical assessment and treatment manoeuvres for the assessment, diagnosis and treatment of these symptoms. This study aimed to evaluate the process of implementing specialised vestibular physiotherapy (SPV) in an emergency department from the clinician’s perspective.

Methods

This implementation study utilised a retrospective mixed-methods process evaluation to understand how SVP operated in an Australian emergency department. The i-PARiHS framework was embedded within the methodology and analytical approach of the study to ensure a comprehensive approach closely aligned to implementation science. Nine clinicians retrospectively completed the Organisational Readiness for Change Assessment (ORCA), Acceptability of Intervention Measure (AIM), Intervention Appropriateness Measure (IAM) and Feasibility of Intervention Measure (FIM). Seven clinicians also participated in a focus group or interview.

Results

A range of barriers and facilitators to the implementation process were identified by participants, some of which spanned multiple domains of the i-PARiHS framework. Relationships with service leaders, champions and medical staff were pivotal facilitators to implementation, along with a generally held perception that SVP was acceptable and feasible. The main barrier identified was a lack of capacity to deliver and facilitate this innovation within the physiotherapy workforce and the broader multidisciplinary recipients.

Conclusions

This study demonstrates that the process of implementing an SVP service in an ED context was generally well-received by clinicians but also involved some challenges and barriers. Services looking to implement SVP in the ED should aim to build stakeholder relationships; develop a shared vision with clear goals and intended outcomes; embed the innovation in organisation processes, procedures and policies; and increase workforce capacity to deliver and facilitate SVP to guide their approach to this innovation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-022-00313-2.

Assessment of Saudi Physicians and Physical Therapists' Adherence to the Updated Clinical Practice Guideline for Benign Paroxysmal Positional Vertigo: A Cross-Sectional Study

Introduction  Variations in clinical practice regarding the management of benign paroxysmal positional vertigo (BPPV) among clinicians have been noted in previous studies. Such variations might be related to the different adherence to clinical practice guidelines. Objective  To evaluate clinicians' adherence to BPPV guidelines and investigate the variations in the adherence between different specialties and qualifications. Methods  This is a cross-sectional study with a vignettes-based survey conducted between June and August, 2020. We included clinicians engaged in managing BPPV that had at least one year of clinical experience. We excluded students, and clinicians who were not involved in the management of individuals with BPPV. Participants were asked to make their management choices based on four hypothetical patient vignettes. The sample ranged from 77 participants for the first vignette to 45 participants for the last vignette. Results  We included 77 clinicians in the study, with the majority being Otolaryngologists (31.2%). The respondents' mean adherence to the guideline was of 63.3%. Result showed that Otolaryngologists' adherence was higher than that of clinicians from different specialties ( p  = 0.006, d  = 0.72). Furthermore, clinicians with a postgraduate degree were more likely to adhere than those with a bachelor's degree only ( p  = 0.014, d  = 0.58) and participants who were aware of the guideline were more likely to adhere to it ( p  < 0.001, d  = 1.05). Lastly, regression analysis exhibited that adherence was affected by postgraduate degree and guideline awareness. Conclusion  Otolaryngologists were more likely to adhere to the guideline than other specialties. Among all specialties, higher adherence was associated with guideline awareness and postgraduate degrees.

A Deep Learning Model for Three-Dimensional Nystagmus Detection and Its Preliminary Application

Symptoms of vertigo are frequently reported and are usually accompanied by eye-movements called nystagmus. In this article, we designed a three-dimensional nystagmus recognition model and a benign paroxysmal positional vertigo automatic diagnosis system based on deep neural network architectures (Chinese Clinical Trials Registry ChiCTR-IOR-17010506). An object detection model was constructed to track the movement of the pupil centre. Convolutional neural network-based models were trained to detect nystagmus patterns in three dimensions. Our nystagmus detection models obtained high areas under the curve; 0.982 in horizontal tests, 0.893 in vertical tests, and 0.957 in torsional tests. Moreover, our automatic benign paroxysmal positional vertigo diagnosis system achieved a sensitivity of 0.8848, specificity of 0.8841, accuracy of 0.8845, and an F1 score of 0.8914. Compared with previous studies, our system provides a clinical reference, facilitates nystagmus detection and diagnosis, and it can be applied in real-world medical practices.

Optimizing Testing for BPPV - The Loaded Dix-Hallpike

OBJECTIVES

Although the Dix-Hallpike testing is generally considered as the gold standard for the identification of the posterior canal benign paroxysmal positional vertigo (BPPV), we investigated a modification of the maneuver termed the "loaded Dix-Hallpike."

STUDY DESIGN

Prospective randomized controlled trial.

MATERIALS AND METHODS

Twenty-eight patients participated in this prospective study comparing the standard Dix-Hallpike (S-DH) to the loaded Dix-Hallpike (L-DH) test. Each patient underwent repeated testing with the S-DH and the L-DH. The patients were placed into two groups. Fourteen patients underwent 3 rounds of S-DH testing followed by 3 rounds of L-DH testing. The other fourteen patients underwent 3 rounds of L-DH testing followed by 3 rounds of S-DH testing. The duration of nystagmus and the latency prior to the onset of nystagmus were measured for each test. Additionally, the patients were asked to rate the severity of their symptoms following each test.

RESULTS

The duration of nystagmus of the L-DH was significantly longer than that of the S-DH (p<0.0001). The patients reported a higher severity score with L-DH as compared to with S-DH (p<0.001). The L-DH was found to be more sensitive than the S-DH (p=0.0131).

CONCLUSION

The L-DH produces significantly longer duration of nystagmus, stronger symptoms, and improved sensitivity when compared to the S-DH.

How rare is benign paroxysmal positional vertigo in children? A review of 20 cases and their epidemiology

OBJECTIVE

The clinical features and incidence of benign paroxysmal positional vertigo (BPPV) are not well known in pediatric populations. The aim of this study was to describe the clinical characteristics of pediatric BPPV and to estimate the frequency of pediatric BPPV in the general population.

METHODS

We retrospectively reviewed the medical records of 20 children (6-14 years old) diagnosed with BPPV between 2007 and 2017. The age/sex distribution of BPPV for all ages at our hospital and in the Korean Health Insurance Review and Assessment Service-National Patient Sample (HIRA-NPS) database were compared. The annual incidence and proportion of children with BPPV were calculated.

RESULTS

BPPV occurred 1.86 times more frequently in girls than in boys. Nine children (45%) had associated comorbidities, such as inner ear disorders and recent head trauma. The posterior and lateral semicircular canals were most commonly involved (n = 9 for each), and recurrence was observed in two patients (10%). Children younger than 15 years accounted for approximately 1% of all BPPV cases. The annual incidence of BPPV was 171.5/100,000 for all ages and 9.5/100,000 in the pediatric population.

CONCLUSIONS

Our findings suggest that pediatric BPPV is a relatively uncommon cause of vertigo in children and that the rates of related illness and recurrence are high.

From illness perceptions to illness reality? Perceived consequences and emotional representations relate to handicap in patients with vertigo and dizziness

OBJECTIVE

Vertigo and dizziness (VD) are frequent symptoms that can occur due to various structural pathologies or due to functional impairment. Independent of their aetiology, the symptoms are often associated with physical and psychological burden which manifests in severe handicap in more than half of the patients. It is suggested that illness perceptions, the patients' cognitive and emotional concept of their disease, most likely impact the degree of handicap. For patients with VD, however, this relation of illness perceptions and handicap is so far not well understood. This study aimed to investigate the relation of illness perceptions and handicap for patients with VD.

METHODS

In a cross-sectional study design, n = 419 patients with VD were examined (53.7% female, age 53.5 ± 15.5 years). Participants underwent neurological and psychiatric examinations as well as a comprehensive assessment using self-report questionnaires.

RESULTS

Illness perceptions, specifically perceived consequences and emotional representations showed a moderate correlation with VD related handicap (r(419) = 0.62, p < .001). Our regression model including symptom severity, psychiatric comorbidity, and aspects of cognitive and emotional illness perceptions accounted for 52% of the variance in VD related handicap. In a moderation analysis, this relation did not differ significantly in patients with functional VD symptoms.

CONCLUSION

Findings of the present study provide evidence for the relevance of illness perceptions to handicap in patients with VD symptoms.

Comparative Study of Management of BPPV (Benign Paroxysmal Positional Vertigo) with only Drugs Versus Drugs Plus Epley Manoeuvre

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder, accounting for 20% of all vertigo cases. Idiopathic BPPV is most common between the ages of 50 and 70, although the condition is found in all age groups. The importance of early diagnosis and treatment can lead to a much improved quality of life for patients afflicted by this ailment. It is presently common for physicians to treat these patients mainly with benzodiazepines, antihistamines, and anticholinergic medications, especially if the history and physical is consistent with BPPV. This method of treatment has had questionable success. Several reviews of the management of vertigo have shown that no medication in current use has well established curative or prophylactic value or is suitable for long-term treatment. Epleys manoeuvre is also used in the treatment of BPPV. This manoeuvre relocates free floating particles from the affected semi-circular canals back into utricle, thus relieving the symptoms of vertigo. The purpose of this study is to compare the efficacy of Epleys manoeuvre with conventional drug therapy versus conventional therapy alone in patients who present with vertigo. The purpose of this study to evaluate and examine two methods of treatment.

Developing a Diagnostic Decision Support System for Benign Paroxysmal Positional Vertigo Using a Deep-Learning Model

Background: Diagnosis of benign paroxysmal positional vertigo (BPPV) depends on the accurate interpretation of nystagmus induced by positional tests. However, difficulties in interpreting eye-movement often can arise in primary care practice or emergency room. We hypothesized that the use of machine learning would be helpful for the interpretation. Methods: From our clinical data warehouse, 91,778 nystagmus videos from 3467 patients with dizziness were obtained, in which the three-dimensional movement of nystagmus was annotated by four otologic experts. From each labeled video, 30 features changed into 255 grid images fed into the input layer of the neural network for the training dataset. For the model validation, video dataset of 3566 horizontal, 2068 vertical, and 720 torsional movements from 1005 patients with BPPV were collected. Results: The model had a sensitivity and specificity of 0.910 ± 0.036 and 0.919 ± 0.032 for horizontal nystagmus; of 0.879 ± 0.029 and 0.894 ± 0.025 for vertical nystagmus; and of 0.783 ± 0.040 and 0.799 ± 0.038 for torsional nystagmus, respectively. The affected canal was predicted with a sensitivity of 0.806 ± 0.010 and a specificity of 0.971 ± 0.003. Conclusions: As our deep-learning model had high sensitivity and specificity for the classification of nystagmus and localization of affected canal in patients with BPPV, it may have wide clinical applicability.

A Chair-based Abbreviated Repositioning Maneuver (ChARM) for fast treatment of posterior BPPV

PURPOSE

To assess the effectiveness of a variation of the Epley maneuver, which we have titled "Chair-based Abbreviated Repositioning maneuver (ChARM)", in solving cases of benign positional paroxysmal vertigo (BPPV) of the posterior canal. ChARM addresses multiple issues of highly overloaded medical centers that delay its due and timely resolution. For example it does not necessitate an examination bed/table and requires only a backed chair, and less than 3 min to be performed. In combination with a recently published abbreviated diagnostic maneuver it can solve BPPV cases within few minutes of single medical visit.

METHODS

Patients being diagnosed with posterior BPPV by means of an abbreviated diagnostic maneuver were recruited. Immediately after diagnosis, a single attempt of ChARM was conducted. The patient was followed for 48 h and at 1 month after these procedures to assess the persistence of symptomatology.

RESULTS

124 patients were treated with ChARM immediately after diagnosis during their very first medical visit. 92 patients (74.2%) solved their symptomatology completely after a single attempt of ChARM. The absence of symptoms persisted during the 30 days of follow-up.

DISCUSSION

ChARM showed high success rates in solving posterior BPPV. The entire diagnostic-treatment procedure takes less than 5 min to perform and may allow direct treatment of patients, thereby avoiding unnecessary referrals or full vestibular testing. These abbreviated tools may be particularly useful in primary care settings or heavily overloaded otolaryngology or neurology departments.

Diagnosis and treatment choices of suspected benign paroxysmal positional vertigo: current approach of general practitioners, neurologists, and ENT physicians

PURPOSE

Benign paroxysmal positional vertigo (BPPV) is a frequently underdiagnosed cause of vertigo, potentially due to the underuse of diagnostic and therapeutic canalith repositioning procedures (CRPs). We aimed to investigate self-reported use of the diagnostic and therapeutic approach to BPPV patients by Lithuanian neurologists, ear, nose, and throat (ENT) physicians, and general practitioners (GPs), and to explore potential reasons for the underuse of the maneuvers.

METHODS

Neurologists, ENT physicians, and GPs were invited to complete a written questionnaire focused on diagnostic and therapeutic practices related to BPPV. Between-group differences and associations between responses were analyzed statistically.

RESULTS

In total, 97 neurologists, 85 ENT physicians and 142 GPs (21.1%, 26.8%, and 5.7%, respectively, of all corresponding licensed Lithuanian physicians) completed the questionnaire. 24% of neurologists, 33% ENT physicians and 50% GPs do not perform diagnostic maneuvers for patients with suspected BPPV, and 28%, 61%, and 84%, respectively, do not perform CRPs. Years of clinical experience was a negative predictor of CRP performance [OR 0.97 (95% CI 0.95-0.99), p = 0.001]. Frequent reasons for not performing CRPs were time taken for the procedure, fear of provoking symptoms, and lack of knowledge. All physicians frequently ordered additional imaging or consultations for suspected BPPV and reported prescribing a range of medications.

CONCLUSIONS

A significant proportion of Lithuanian neurologists, ENT physicians, and GPs do not employ diagnostic maneuvers and CRPs for BPPV patients, contrary to established guidelines. Lack of expertise and time available is a common culprit that leads to unnecessary drug prescribing and investigation.

Effectiveness of the Epley manoeuvre in posterior canal benign paroxysmal positional vertigo: a randomised clinical trial in primary care

BACKGROUND

Evidence on the effectiveness of the Epley manoeuvre in primary care is scarce.

AIM

To evaluate effectiveness at 1 week, 1 month, and 1 year of a single Epley manoeuvre versus a sham manoeuvre in primary care.

DESIGN AND SETTING

Multicentre, double-blind randomised controlled trial in two primary care practices in Spain from November 2012 to January 2015.

METHOD

Patients were ≥18 years diagnosed with subjective or objective posterior benign paroxysmal positional vertigo (vertigo only, or vertigo and nystagmus after a Dix-Hallpike test [DHT]). The intervention group received the Epley manoeuvre, and the control group received a sham manoeuvre. Betahistine was prescribed following the same regimen in both groups. The main outcome measures were the DHT result classified as negative (neither vertigo nor nystagmus) or positive. Positive results were further divided into a positive result for both vertigo and nystagmus (positive DHT with nystagmus), and a positive result for vertigo only (positive DHT without nystagmus); self-reported resolution of vertigo; and self-reported severity of vertigo evaluated on a 10-point Likert scale (10 = worst imaginable vertigo).

RESULTS

In total, 134 patients were randomised to either the intervention group (n = 66) or the sham group (n = 68). The intervention group showed better results in the unadjusted analyses at 1 week, with a lower rate of positive DHT with nystagmus (P = 0.022). A positive baseline DHT with nystagmus was associated with a reduction in vertigo severity (marginal effect for 10-point Likert-like question -1.73, 95% confidence interval [CI] = -2.95 to -0.51) and better positive DHT rates in the intervention group (adjusted odds ratio 0.09, 95% CI = 0.01 to 0.92) in the multivariate analyses.

CONCLUSION

A single Epley manoeuvre performed in primary care is an effective treatment for reversing a positive DHT and reducing vertigo severity in patients with baseline nystagmus in the DHT.

A survey of current management of Benign Paroxysmal Positional Vertigo (BPPV) by physiotherapists' interested in vestibular rehabilitation in the UK

OBJECTIVES

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of dizziness. Extensive research has identified the best assessment and treatment manoeuvres for each subtype of BPPV. Education in vestibular rehabilitation (VR) is inconsistent. It is unclear if the evidence has been adopted by UK physiotherapists in clinical practice and no research has investigated this specifically.

DESIGN

An online survey with closed- and open-text answers.

PARTICIPANTS

A purposive sample of physiotherapists interested in VR. A response rate of 67% (100/150) was obtained, from which 20 responses were excluded.

RESULTS

Participants had good evidence-based awareness in assessment (79/80, 99%) and treatment (72/80, 90%) of posterior BPPV. Horizontal BPPV assessment awareness was lower than treatment (37/80, 46% vs 60/80, 75%). Differential diagnosis was poor in subjective (20/80, 25%) and objective stages of assessment (34/80, 43%). Thirty six percent (29/80) were able to list ≥3 test precautions with all three nystagmus characteristics described by 29% (23/80). Eighty one percent (65/80) encourage activity restrictions post-treatment. Only 28% (22/80) were aware of practice guidelines or Cochrane reviews in BPPV. External courses were rated the top method for learning how to manage BPPV. Lack of peer support (26/77, 34%) was the main challenge faced whilst learning. Recommendations for improving BPPV education included more external courses (23/87, 26%) and competency guidelines (13/87, 15%).

CONCLUSIONS

Good awareness of research evidence was observed in some aspects of BPPV management but many areas require development. Translation and implementation of evidence remains poor and suggests changes in education and knowledge dissemination are warranted.

Analysis of non-posterior canal benign paroxysmal positional vertigo in patients treated using the particle repositioning chair: A large, single-institution series

PURPOSE

Benign paroxysmal positional vertigo (BPPV) involving the horizontal and superior semicircular canals is difficult to study due to variability in diagnosis. We aim to compare disease, treatment, and outcome characteristics between patients with BPPV of non-posterior semicircular canals (NP-BPPV) and BPPV involving the posterior canal only (P-BPPV) using the particle repositioning chair as a diagnostic and therapeutic tool.

METHODS

Retrospective review of patients diagnosed with and treated for BPPV at a high volume otology institution using the particle repositioning chair.

RESULTS

A total of 610 patients with BPPV were identified, 19.0% of whom had NP-BPPV. Patients with NP-BPPV were more likely to have bilateral BPPV (52.6% vs. 27.6%, p < 0.0005) and Meniere's disease (12.1% vs. 5.9%, p = 0.02) and were more likely to have caloric weakness (40.3% vs. 24.3%, p = 0.01). Patients with NP-BPPV required more treatments for BPPV (average 3.4 vs. 2.4, p = 0.01) but did not have a significantly different rate of resolution, rate of recurrence, or time to resolution or recurrence than patients with posterior canal BPPV.

CONCLUSIONS

Comparison of NP-BPPV and P-BPPV is presented with reliable diagnosis by the particle repositioning chair. NP-BPPV affects 19% of patients with BPPV, and these patients are more likely to have bilateral BPPV and to require more treatment visits but have similar outcomes to those with P-BPPV. NP-BPPV is common and should be part of the differential diagnosis for patients presenting with positional vertigo.

Disconnect between available literature and clinical practice: Exploring gaps in the management of t-BPPV in the emergency department

Background: Healthcare costs associated with the diagnosis of benign paroxysmal positional vertigo (BPPV) alone approach $2 billion per year in the United States. Post-traumatic BPPV (t-BPPV) is well recognized, and can be managed with simple bedside physical maneuvers. Despite the availability of literature and clear guidelines supporting this approach, physical maneuvers are underutilized. The aim of this study was to explore the reasons for this practice disagreement. Methods: A cross-sectional survey of emergency physicians (EP) and non-emergency physicians (Non-EPs) managing head injury patients was conducted. The survey questions were aimed to explore the attitude of these frontline healthcare providers towards the diagnosis and management of t-BPPV in head injury patients. Results: A total of 102 physicians completed the survey. Of them, male physicians constituted 87.2%, and the majority were working as emergency physicians (80.4%). Although nearly three-fourths (72.5%; n = 74) of the participants admitted that it is important to explore the possibility of t-BPPV in patients with head injury, only one-fifth of the participating physicians (20.6%; 21 of 102) confirmed that they would investigate for t-BPPV. A lack of knowledge about t-BPPV in more than half of the study participants (55.9%; n = 57) was the main reason for them not probing the possibility of t-BPPV. Conclusion: To close the gap between available evidence-based guidelines and actual clinical practice, there is a need for raising awareness about this condition. Addressing the training needs of frontline healthcare providers to use physical maneuvers such as Dix–Hallpike (DHM) and canalith repositioning (CRP) maneuvers in the management of t-BPPV is an important step that needs to be taken.

The evaluation of anxiety and panic agarophobia scores in patients with benign paroxysmal positional vertigo on initial presentation and at the follow-up visit

CONCLUSION

Patients with BPPV experienced short but intense anxiety and/or panic disorder, especially at the initial visit, but most patients recovered without medication with successful treatment.

OBJECTIVE

Recent studies have shown that people with dizziness report some psychological problems such as panic and agoraphobia and anxiety. The aim of this study was to evaluate anxiety and panic agorophobia levels in patients with benign paroxysmal positional vertigo on initial presentation and at the follow-up visit and compare the scores with the control group.

METHODS

All the 32 patients in the study had a diagnosis of BPPV confirmed by their history, typical subjective symptom reports, and characteristic positional nystagmus during the Dix-Hallpike test and/or Roll test. The patients were instructed to complete the standard forms of Beck anxiety inventory and panic agoraphobia scale questionnaire before and at 7 and 14 days after the canalith repositioning treatment.

RESULTS

The validity scores of panic agoraphobia were statistically significantly higher in patients with BPPV than in the control group in each period (p < .001) and the validity scores of the Beck anxiety inventory were statistically significantly higher in patients with BPPV than in the control group at the first and second evaluation (p < .001).

Clinical characteristics and treatment outcomes for benign paroxysmal positional vertigo comorbid with hypertension

CONCLUSIONS

Patients with BPPV comorbid with hypertension (h-BPPV) tend to receive a delayed diagnosis of BPPV. Comorbidity with hypertension did not influence the efficacy of the repositioning maneuver; however, comorbidity with hypertension was associated with an increased recurrence rate of BPPV.

OBJECTIVES

To determine the clinical characteristics and outcomes of h-BPPV, as well as the clinical differences between h-BPPV and idiopathic BPPV (i-BPPV).

METHODS

The authors reviewed the medical records of 41 consecutive patients with h-BPPV (the h-BPPV group) from March to December 2014 and 47 patients with i-BPPV (the i-BPPV group) during the same period.

RESULTS

There were no significant differences in age, sex ratio, or the affected side between the h-BPPV and i-BPPV groups. The proportion of patients reporting an initial episode of positional vertigo was significantly lower in the h-BPPV group (51.22% vs 74.47%; p = .024). Patients in the h-BPPV group reported a longer median episode duration than did those in the i-BPPV group (60 days vs 15 days; p = .017). The results of treatment using repositioning maneuvers were similar between the two groups. At follow-up, 13 patients in the h-BPPV group were diagnosed with recurrent BPPV compared with six in the i-BPPV group (p = .031).

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)

Objective

This update of a 2008 guideline from the American Academy of Otolaryngology—Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV.

Purpose

The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV.

Action Statements

The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow-up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.

An Abbreviated Diagnostic Maneuver for Posterior Benign Positional Paroxysmal Vertigo

Introduction

Benign paroxysmal positional vertigo (BPPV) secondary to canalolithiasis of the posterior semicircular canal is perhaps the most frequent cause of vertigo and dizziness. One of its properties is a high response rate to canalith repositioning maneuvers. However, delays in the diagnosis and treatment of this entity can range from days to years, depending on the setting. Here, we present an abbreviated variation of the Dix–Hallpike maneuver, which can be used to diagnose this disease. It is similar to the standard maneuver but can be performed without an examination bed/table and requires only a backed chair (a difference that we feel is very important in settings where a clinical bed/table is not readily available).

Methods

A diagnostic assessment study was conducted in 163 patients who presented with vertigo or dizziness.

Results

The abbreviated test had fairly good sensitivity (80%) and high specificity (95%) for diagnosing posterior BPPV.

Discussion

This new diagnostic maneuver may serve as a screening procedure for quickly identifying this pathology. This will allow patients to be more directly treated, without requiring unnecessary referrals or full vestibular testing, and will be especially useful in primary care settings or heavily overloaded otolaryngology or neurology departments.

Assessment for benign paroxysmal positional vertigo in medical patients admitted with falls in a district general hospital

Having benign paroxysmal positional vertigo (BPPV) puts patients at a significantly higher risk of falling. It is poorly recognised and diagnosis is frequently delayed. BPPV has been studied in outpatient settings, but there have been no studies looking at the prevalence in patients admitted with falls. This study aims to establish how common BPPV is in these patients.For a 4-month period, patients admitted on an unselected medical take were screened for an admission precipitated by a fall. Patients who consented were assessed for BPPV using the Dix-Hallpike manoeuvre. Patients who tested positive were treated using the Epley manoeuvre. The assessments were carried out by specialist physiotherapists who were experienced at assessing and diagnosing patients with peripheral vestibular disorders. Out of the 111 patients initially identified, 37 (33%) were considered to be appropriate and consented to be part of the study. Of these, 20 patients (54%) had a positive Dix-Hallpike manoeuvre.Of the patients included in the study, over half tested positive for BPPV. This merits further study. Potentially, there is a proportion of patients admitted with falls who have an easily treatable contributing factor that is not being identified with standard practice.

Efficacy of Computer-Controlled and Modified Roll Maneuver for Treatment of Geotropic Lateral Canal Benign Paroxysmal Positional Vertigo

OBJECTIVE

To evaluate the short-term efficacy of computer-controlled and modified roll maneuver (CMRM) versus conventional roll maneuver (RM) for treatment of geotropic lateral canal benign paroxysmal positional vertigo (BPPV).

STUDY DESIGN

Prospective case-controlled study.

SETTING

Academic hospital.

PATIENTS

One hundred consecutive patients diagnosed as having unilateral idiopathic geotropic lateral canal BPPV with a duration of symptoms of less than 2 weeks.

INTERVENTIONS

Fifty-two patients (aged 32-80 yr; mean, 55.9 yr; 18 men and 34 women) were treated with CMRM that was composed of three sequential 360-degree rotations and 48 patients (aged 30-71 yr; mean, 52.4 yr; 20 men and 28 women) treated with RM that consisted of one 360-degree rotation.

MAIN OUTCOME MEASURES

Resolution of vertigo on the supine roll test at 48 hours after initial maneuver and the number of maneuvers required for final resolution of vertigo were main outcome measures to assess the efficacy of treatment.

RESULTS

On the supine roll test at 48-hour follow-up after initial maneuver, 44 (84.6%) of 52 CMRM-treated patients and 23 (54.2%) of 48 RM-treated patients had resolution of vertigo (p < 0.01). All patients obtained final resolution of vertigo with a maximum of five maneuvers in each group, but the CMRM group had less mean number of maneuvers required for final resolution of vertigo compared with the RM group (1.23 ± 0.39 versus 1.63 ± 0.68, p < 0.05). No significant adverse effects and complications occurred aside from two patients with conversion into posterior canal BPPV in each treatment.

CONCLUSION

The CMRM consisting of three sequential 360-degree rotations for geotropic lateral canal BPPV has a higher initial success rate compared with the conventional RM consisting of one 360-degree rotation.

Comparative study of the efficacy of the canalith repositioning procedure versus the vertigo treatment and rehabilitation chair

CONCLUSION

Vertigo treatment and rehabilitation chair (TRV) may be suggested as the first choice for patients with posterior canal benign paroxysmal positional vertigo (p-BPPV).

OBJECTIVE

To investigate the short- and long-term treatment efficacy of the canalith repositioning procedure (CRP) versus TRV for patients with p-BPPV.

METHODS

A total of 165 patients with unilateral p-BPPV were assigned to either the CRP group or the TRV group. Patients were assessed at 1 week, 4 weeks, 3 months, and 6 months after their first treatment. The numbers of treatment sessions required for successful repositioning in both groups at 4 weeks, 3 months, and 6 months were recorded.

RESULTS

Treatment efficacy of patients in the TRV group was significantly better than that of patients in the CRP group 1 week after the first treatment. The number of treatment sessions needed for successful repositioning was significantly lower in the TRV group than in the CRP group at 4 weeks and 3 months after the first treatment.