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Varghese SS, Varghese A, Kumar N. Adoption of the international classification of vestibular disorders criteria in cases of Benign positional paroxysmal vertigo: a single-center experience. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08794-8. [PMID: 38977478 DOI: 10.1007/s00405-024-08794-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 06/17/2024] [Indexed: 07/10/2024]
Abstract
INTRODUCTION Benign positional paroxysmal vertigo (BPPV) stands as the commonest cause for vertigo. It accounts for 20% of all cases of vertigo, even with its high prevalence rate it often goes underdiagnosed and undertreated. Development of the consensus document by the Bárány society's International Classification of Vestibular Disorders (ICVD)significantly facilitates the diagnosis of BPPV and its variants. This study assesses the utilisation of ICVD criteria for managing BPPV. METHODOLOGY This is a cross-sectional descriptive study conducted at a tertiary care hospital in Northern India spanning from November 1, 2022, to November 30, 2023. A total of 110 participants diagnosed with BPPV were enrolled consecutively. All participants underwent Dix-Hallpike and supine log roll positional maneuvers. Diagnosis was made based on the history and type of nystagmus seen, and classified as per the ICVD criteria. RESULTS Posterior semicircular canalolithiasis (pc-BPPV) accounted for 25.45% of cases and horizontal canal canalolithiasis (hc-BPPV) accounted for 20.91% of cases. Probable BPPV, spontaneously resolved (pBPPVsr) was diagnosed in 16.36% of participants and possible BPPV(pBPPV) was diagnosed in 18.18% of participants. Multiple canal BPPV (mc-BPPV) accounted for 17.27% of cases. One participant was diagnosed with horizontal canal cupulolithiasis and anterior canal canalolithiasis respectively. No participant was diagnosed with posterior canal cupulolithiasis. CONCLUSION The most common type of BPPV was pc-BPPV followed by hc-BPPV. The affected canal in possible BPPV, can be identified, and appropriate repositioning maneuvers are effective in treating them as well as aids in confirming the diagnosis. The diagnostic clarity provided by ICVD, aids in effective management of BPPV. More studies with larger sample size are required to further validate its clinical utility.
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Affiliation(s)
- Sunil Sam Varghese
- Department of E.N.T, Chrisitan medical college, Brown Road, Ludhiana, 141008, Punjab, India.
| | - Ashish Varghese
- Department of E.N.T, Bangalore Baptist Hospital, Bellary Road, Hebbal, Bengaluru, Karnataka, India
| | - Navneet Kumar
- Department of E.N.T, Chrisitan medical college, Brown Road, Ludhiana, 141008, Punjab, India
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Kim HJ, Gil YE, Kim JS. Subjective BPPV revisited: identification of positional nystagmus with a new maneuver. J Neurol 2024; 271:4640-4643. [PMID: 38564054 DOI: 10.1007/s00415-024-12347-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/21/2024] [Accepted: 03/23/2024] [Indexed: 04/04/2024]
Affiliation(s)
- Hyun-Jae Kim
- Department of Neurology, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Young-Eun Gil
- Department of Neurology, College of Medicine, St. Vincent's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Ji-Soo Kim
- Department of Neurology, Dizziness Center, and Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea.
- Department of Neurology, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Saishoji Y, Yamamoto N, Fujiwara T, Mori H, Taito S. Epley manoeuvre's efficacy for benign paroxysmal positional vertigo (BPPV) in primary-care and subspecialty settings: a systematic review and meta-analysis. BMC PRIMARY CARE 2023; 24:262. [PMID: 38042776 PMCID: PMC10693044 DOI: 10.1186/s12875-023-02217-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/21/2023] [Indexed: 12/04/2023]
Abstract
BACKGROUND Although previous studies have reported general inexperience with the Epley manoeuvre (EM) among general physicians, no report has evaluated the effect of EM on benign paroxysmal positional vertigo (BPPV) in primary care by using point estimates or certainty of evidence. We conducted this systematic review and meta-analysis and clarified the efficacy of EM for BPPV, regardless of primary-care and subspecialty settings. METHODS Systematic review and meta-analysis of randomised sham-controlled trials of EM for the treatment of posterior canal BPPV in primary-care and subspecialty settings. A primary-care setting was defined as a practice setting by general practitioners, primary-care doctors, or family doctors. A systematic search was conducted in January 2022 across databases, including Cochrane Central Resister of Controlled Trial, MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. Primary outcomes were the disappearance of subjective symptoms (vertigo), negative findings (Dix-Hallpike test), and all adverse events. We evaluated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach. RESULTS Twenty-seven randomised controlled trials were identified. In primary-care settings, EM reduced the subjective symptoms [risk ratio (RR), 3.14; 95% confidence interval (CI), 1.96-5.02]; however, there was no applicable article for all adverse events. In the subspeciality setting, EM reduced the subjective symptoms (RR, 2.42; 95% CI, 1.64-3.56), resulting in an increase in negative findings (RR, 1.81; 95% CI, 1.40-2.34). The evidence exhibited uncertainty about the effect of EM on negative findings in primary-care settings and all adverse events in subspecialty settings. CONCLUSIONS Regardless of primary-care and subspecialty settings, EM for BPPV was effective. This study has shown the significance of performing EM for BPPV in primary-care settings. EM for BPPV in a primary-care setting may aid in preventing referrals to higher tertiary care facilities and hospitalisation for follow-up. TRIAL REGISTRATION The study was registered in protocols.io (PROTOCOL INTEGER ID: 51,464) on July 11, 2021.
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Affiliation(s)
- Yusuke Saishoji
- Department of General Internal Medicine, National Hospital Organization Nagasaki Medical Center, 2- 1001-1 Kubara, Omura, Nagasaki, 856-8562, Japan.
| | - Norio Yamamoto
- Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, Japan
- Department of Epidemiology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University, Okayama, 700-8558, Japan
| | - Takashi Fujiwara
- Department of Otolaryngology, Head and Neck Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Okayama, Japan
- Department of Management, Clinical Research Center, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, 710-8602, Okayama, Japan
| | - Hideki Mori
- Department of General Internal Medicine, National Hospital Organization Nagasaki Medical Center, 2- 1001-1 Kubara, Omura, Nagasaki, 856-8562, Japan
| | - Shunsuke Taito
- Systematic Review Workshop Peer Support Group (SRWS-PSG), Osaka, Japan
- Division of Rehabilitation, Department of Clinical Practice and Support, Hiroshima University Hospital, Kasumi 1-2-3, Minami-ku, Hiroshima, 734-8551, Japan
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Walker KN, Guy KM, Volsky PG. Delayed Diagnoses in Patients With Dizziness in the US Commonwealth of Virginia and the Tidewater Region. OTOLOGY & NEUROTOLOGY OPEN 2023; 3:e046. [PMID: 38516542 PMCID: PMC10950144 DOI: 10.1097/ono.0000000000000046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 11/08/2023] [Indexed: 03/23/2024]
Abstract
Objective In a region of approximately 1.7 million people (Tidewater, coastal Virginia), identify secondary diagnoses in persons with dizziness. Methods This cross-sectional study utilizing TriNetX included individuals in the region of interest diagnosed with dizziness between 2010 and 2020. Subsequent diagnoses of vestibular disease or medical conditions possibly associated with dizziness in the same subjects were catalogued. Results During the study period, 31,670 subjects were identified with diagnoses of dizziness as a symptom; 18,390 subjects were subsequently given a dizziness-related nonvestibular diagnosis, and 930 were given a subsequent vestibular disease diagnosis. The proportion of subjects diagnosed with vestibular disease (3%) after the dizziness diagnosis is far below expected norms (25%-34%) in the general population. There were greater proportions of delayed diagnoses of labyrinth dysfunction (odds ratio [OR], 4.8; P < 0.0001), superior semicircular canal dehiscence (OR, 3.1; P = 0.0023), otolith disease (OR, 3.1; P = 0.0023), among others, and a decreased proportion of delayed diagnosis of benign paroxysmal positional vertigo (OR, 0.56; P < 0.0001). Conclusions The discrepancy between expected and observed prevalence in our region indicates that vestibular disease is likely underdiagnosed.
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Affiliation(s)
- Kendra N. Walker
- Department of Otolaryngology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Kevin M. Guy
- Department of Otolaryngology, Eastern Virginia Medical School, Norfolk, Virginia
| | - Peter G. Volsky
- Department of Otolaryngology, Eastern Virginia Medical School, Norfolk, Virginia
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Harrell RG, Hart R, Jen JC, Whitney SL. Surveying physical therapists' understanding of benign paroxysmal positional vertigo. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1228453. [PMID: 37662546 PMCID: PMC10469676 DOI: 10.3389/fresc.2023.1228453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/04/2023] [Indexed: 09/05/2023]
Abstract
Introduction Benign paroxysmal positional vertigo (BPPV) is a common condition with disabling symptoms that is diagnosed and effectively treated at the bedside. Our encounter with patients experiencing prolonged BPPV who may not have received appropriate physical therapy prompted us to explore barriers to the diagnosis and treatment for BPPV among physical therapists, which has not been extensively investigated. We hypothesize that a potential barrier may be a lack of understanding of subtle symptoms of BPPV that deviate from the classical presentation. The gold standard for diagnosing definite BPPV is subjective dizziness or vertigo with nystagmus in response to positional testing. There are variants of BPPV including subjective BPPV (subjective dizziness or vertigo without nystagmus) and vestibular agnosia (nystagmus without subjective dizziness or vertigo) that do not meet the diagnostic criteria for definite BPPV but are equally responsive to the same repositioning maneuvers. The purpose of this project was to survey physical therapists for their understanding of BPPV including subjective BPPV and vestibular agnosia. Methods A panel of experts created a 16-question survey, designed for physical therapists, with three categories: (1), inquiring if they treat persons with BPPV, (2) three clinical vignettes for definite BPPV, subjective BPPV, and BPPV with vestibular agnosia, and (3) demographic information. Data collection occurred at two large physical therapy meetings, one of which was a national professional meeting and the other was a professional continuing medical education course geared towards advancing vestibular rehabilitation skills. Results There were 426 people who completed the survey, 364 of whom treat BPPV in their practice. In the first clinical vignette created to assess the respondents' understanding of definite BPPV, 229 (62%) of respondents would always assess a patient for BPPV based on complaints of a "room spinning" vertigo from head movement. When asked if the complaint was lingering "lightheadedness or feelings of imbalance" from head movement, only 158 (43%) reported they would perform positional testing to reassess. In the BPPV variant vignettes, 187 (51%) identified the patient with subjective BPPV as having BPPV and 305 (85%) identified the patient with vestibular agnosia as having BPPV. Discussion The results of this survey demonstrate gaps in knowledge regarding BPPV across practice settings and experience, with opportunities to bridge these gaps to improve treatment for BPPV.
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Affiliation(s)
- Regan G. Harrell
- Department of Physical Therapy, The University of Pittsburgh, Pittsburgh, PA, United States
| | - Rebecca Hart
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Joanna C. Jen
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Susan L. Whitney
- Department of Physical Therapy, The University of Pittsburgh, Pittsburgh, PA, United States
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Sharif S, Khoujah D, Greer A, Naples JG, Upadhye S, Edlow JA. Vestibular suppressants for benign paroxysmal positional vertigo: A systematic review and meta-analysis of randomized controlled trials. Acad Emerg Med 2022; 30:541-551. [PMID: 36268806 DOI: 10.1111/acem.14608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/29/2022] [Accepted: 10/15/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Benign paroxysmal positional vertigo (BPPV) is a common cause of acute dizziness. Medication use for its treatment remains common despite guideline recommendations against their use. OBJECTIVES The objective was to evaluate the efficacy and safety of vestibular suppressants in patients with BPPV compared to placebo, no treatment, or canalith repositioning maneuvers (CRMs). METHODS We searched MEDLINE, Cochrane, EMBASE, and ClinicalTrials.gov from inception until March 25, 2022. for randomized controlled trials (RCTs) comparing antihistamines, phenothiazines, anticholinergics, and/or benzodiazepines to placebo, no treatment, or a CRM. RESULTS Five RCTs, enrolling 296 patients, were included in the quantitative analysis. We found that vestibular suppressants may have no effect on symptom resolution at the point of longest follow-up (14-31 days in four studies) when evaluated as a continuous outcome (standardized mean difference -0.03 points, 95% confidence interval [CI] -0.53 to 0.47). Conversely, CRMs may improve symptom resolution at the point of longest follow-up as a dichotomous outcome when compared to vestibular suppressants (relative risk [RR] 0.63, 95% CI 0.52 to 0.78). Vestibular suppressants had an uncertain effect on symptom resolution within 24 h (mean difference [MD] 5 points, 95% CI -16.92 to 26.94), repeat emergency department (ED)/clinic visits (RR 0.37, 95% CI 0.12 to 1.15), patient satisfaction (MD 0 points, 95% CI -1.02 to 1.02), and quality of life (MD -1.2 points, 95% CI -2.96 to 0.56). Vestibular suppressants had an uncertain effect on adverse events. CONCLUSIONS In patients with BPPV, vestibular suppressants may have no effect on symptom resolution at the point of longest follow-up; however, there is evidence toward the superiority of CRM over these medications. Vestibular suppressants have an uncertain effect on symptom resolution within 24 h, repeat ED/clinic visits, patient satisfaction, quality of life, and adverse events. These data suggest that a CRM, and not vestibular suppressants, should be the primary treatment for BPPV.
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Affiliation(s)
- Sameer Sharif
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Danya Khoujah
- Department of Emergency Medicine, University of Maryland Upper Chesapeake Medical Center, Bel Air, Maryland, USA.,Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Alisha Greer
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, Division of Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - James G Naples
- Division of Otolaryngology-Head & Neck Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Suneel Upadhye
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.,Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
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Edlow JA, Kerber K. Benign Paroxysmal Positional Vertigo: A Practical Approach for Emergency Physicians. Acad Emerg Med 2022; 30:579-588. [PMID: 35833326 DOI: 10.1111/acem.14558] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 11/28/2022]
Abstract
Benign paroxysmal positional vertigo (BPPV) is a very common condition in the population and an important cause of acute vertigo or dizziness in patients presenting to an emergency department (ED). Despite this, abundant evidence shows that current ED management of patients with BPPV is suboptimal. Common ED management processes include brain imaging and treatment with vestibular suppressant medications such as meclizine, neither of which is recommended by current guidelines. The most efficient management of BPPV is to perform a bedside test (Dix-Hallpike test) and then to treat the patients with a bedside positional (the Epley) maneuver. In this practical review we emphasize the efficient management for the most common form of BPPV-posterior canal BPPV. Using this management will reduce resource utilization (laboratory testing, brain imaging, specialist consultation), reduce ED length of stay, and reduce use of ineffective mediations that have side effects but little therapeutic effect. Application of these practices would improve important patient-centered outcomes such as symptom reduction, radiation exposure, side effects from medications, and less need for urgent follow-up with another health care provider. The article also discusses the approach to patients in whom the Dix-Hallpike and/or Epley maneuvers do not seem to work. This includes a discussion the second most common variant of BPPV (horizontal canal BPPV) and criteria for safe discharge of patients. Another important advantage of learning BPPV best practices is that it is enormously satisfying for the clinician, not unlike treating a child with a nursemaid's elbow.
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center.,Professor of Emergency Medicine, Harvard Medical School
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Prevalence of and Theoretical Explanation for Type 2 Benign Paroxysmal Positional Vertigo. J Neurol Phys Ther 2022; 46:88-95. [PMID: 35081081 DOI: 10.1097/npt.0000000000000383] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE A variant of benign paroxysmal positional vertigo (BPPV) involves the subjective report of vertigo without the coinciding nystagmus. This presentation includes truncal retropulsion when sitting up from the ipsilesional provocative test (ie, Dix-Hallpike), which we term type 2 BPPV. The primary objective of this study is to prospectively determine the prevalence and describe the clinical course of type 2 BPPV. We offer a theoretical explanation for the absence of nystagmus. METHODS Prospective, observational study carried out in 2 tertiary hospitals. One hundred eighty patients (134 women, 46 men) met the inclusion criteria and were included between January 10, 2018, and October 30, 2019. Efficacy of physical therapy maneuvers was determined at 1-week follow-up. Three-dimensional reconstructions of the planes of the semicircular canal cupula from histological preparations are offered as evidence for the theoretical explanation. RESULTS One-third of the patients met the criteria for type 2 BPPV; the remainder had typical posterior or horizontal semicircular canal involvement. Symptoms from type 2 BPPV were longer in duration yet responded favorably to physical therapy maneuvers. Upon repeat testing, 19 patients treated for posterior canalithiasis developed a slight, persistent positional downbeat nystagmus in the Dix-Hallpike position that we propose as evidence the otoconia entered the short arm of the posterior semicircular canal. DISCUSSION AND CONCLUSIONS Our data and 3-dimensional rendering suggest the report of vertigo, yet absent nystagmus in type 2 BPPV is from otoconia aligning with the gravitoinertial vector during provocative testing that precludes cupular stimulation. Type 2 BPPV appears to be a common and treatable form of vertigo.Video Abstract available for more insights from the authors (see Video, Supplemental Digital Content 1 available at: http://links.lww.com/JNPT/A372).
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