Meta-analysis on the efficacy of Epley's manoeuvre in benign paroxysmal positional vertigo

When Particle Repositioning Maneuvers Just Will Not Stick: Clinical Considerations for Persistent Benign Paroxysmal Positional Vertigo

PURPOSE

Although benign paroxysmal positional vertigo (BPPV) is often considered benign and easily treatable, aberrant cases of persistent BPPV can be challenging to manage. Detailed differential diagnosis is essential as central-, vascular-, and cervical-related etiologies may mirror the presentation of persistent BPPV. In addition, an understanding of alternative noninvasive treatment options is important as persistent BPPV is often refractory to traditional particle repositioning maneuvers (PRMs). This article reviews clinical considerations for persistent BPPV.

METHOD

A case of a 68-year-old male diagnosed with posterior semicircular canal BPPV (PC-BPPV) and received various unsuccessful PRMs treatments is described. His clinical presentation is referenced alongside various possible etiologies to discern the most likely diagnosis. Nonsurgical treatment options for intractable PC-BPPV will also be reviewed.

CONCLUSIONS

BPPV recalcitrant to PRM treatment warrants investigation of other etiologies; however, key elements of the case history and objective examination are helpful for differential diagnosis. Brandt-Daroff exercises may facilitate habituation of symptoms secondary to persistent BPPV. More research is needed to understand the use of multiaxial repositioning chairs for the treatment of intractable BPPV.

Epley maneuver for benign paroxysmal positional vertigo: Evidence synthesis for guidelines for reasonable and appropriate care in the emergency department

BACKGROUND

Canalith repositioning maneuvers (such as the Epley maneuver) are recommended by specialty guidelines for management of benign paroxysmal positional vertigo (BPPV) yet are frequently underutilized in the emergency department (ED).

METHODS

We conducted a systematic review of systematic reviews to summarize the evidence of Epley maneuver for the treatment of posterior canal (pc) BPPV in any setting. We included systematic reviews of randomized controlled trials (RCTs) that compared Epley to control in adult patients with pc-BPPV. Titles, abstracts, and full texts were screened in duplicate. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. Odds ratios (OR) and 95% confidence intervals (CI) are reported. Meta-analysis of individual studies was conducted with random and fixed effects.

RESULTS

From 2,228 titles, 7 systematic reviews were selected for quality assessment. One review was of higher methodological quality, included only RCTs, and was the most current and comprehensive. Five of the 11 RCTs of the review, including 312 patients with pc-BPPV diagnosed by Dix-Hallpike, were relevant to our question. Meta-analysis of 4 RCTs (251 patients) showed the use of Epley (as compared to control) was associated with higher complete resolution of vertigo at 1 week (OR 7.19, CI 1.52 to 33.98, moderate certainty). Meta-analysis of 3 RCTs (195 patients) showed the use of Epley was associated with higher conversion to negative Dix-Hallpike at 1 week (OR 6.67, CI 1.52 to 33.98, moderate certainty). The number-needed-to-treat was 3. Meta-analysis of the outcomes at 1 month, and when observational studies were included, showed similar results. No serious adverse effects were reported.

CONCLUSIONS

Symptoms of pc-BPPV improve with the Epley maneuver. Emergency clinicians should become familiar with performing the Epley for BPPV. Further studies on ED implementation and clinician education of Epley are needed.

An Effective Home-Based Particle Repositioning Procedure for Posterior Canal Benign Paroxysmal Positional Vertigo (BPPV)

Patients with benign paroxysmal positional vertigo (BPPV) find it difficult to visit the hospital many times for a standard Epley's maneuver performed only by a specialist. The aim of this study was to compare the efficacy of a home-based particle repositioning procedure (HBPRP) with the standard Epley's maneuver in treating patients with posterior canal BPPV. A prospective non-blinded randomized controlled study was conducted. Patients were randomized into two groups, where one group received the standard treatment and other received a new HBPRP. The vertigo scale, duration of nystagmus during Dix-Hallpike test and frequency of vertigo, were documented on first, second and third visits, with complications noted during the second and third visits. These parameters were compared between both the groups following the treatment, during all visits. The patients were randomized into 2 arms with 15 each. Those belonging to group 1 received Epley's maneuver and group 2 received HBPRP. There was no significant difference in the baseline characteristics of patients in both groups. Both groups of patients had significant improvement of symptoms at the end of the study. A comparison of both groups at 2nd and 3rd visits showed no differences in frequency of vertigo, reduction in vertigo scale and duration of nystagmus following Dix-Hallpike test between both groups. HBPRP is a safe and effective procedure and can be taught as a home-based treatment for patients diagnosed with posterior canal BPPV.

A Holistic Approach to a Dizzy Patient: A Practical Update

Dizziness is one of the most common symptoms encountered by physicians daily. It is divided into four categories: vertigo, disequilibrium, presyncope, and psychogenic dizziness. It is essential to distinguish these four symptoms because the causes, prognosis, and treatment differ. Vertigo constitutes a disease of the central or peripheral nervous system. Central origin vertigo may be a life-threatening situation and must be detected as soon as possible because it includes diseases such as stroke, hemorrhage, tumors, and multiple sclerosis. Peripheral origin vertigo includes benign diseases, which may be fully treatable such as vestibular migraine, benign paroxysmal positional vertigo, vestibular neuritis, Ménière’s disease, and cervical vertigo. The HINTS (head impulse, nystagmus, test of skew) examination is essential to distinguish central from peripheral causes. A detailed history including the duration of vertigo (episodic or continuous), its trigger, and a clinical examination step by step following the appropriate protocol could help to make a definite and accurate diagnosis and treatment. Due to a lack of expertise in dizziness and inappropriate treatment, many patients are admitted to dizziness clinics with long-standing dizziness. A holistic treatment combining medications, vestibular rehabilitation, physiotherapy, and psychotherapy should be initiated to improve the quality of life of these patients. So, this review aims to recommend a clinical protocol for approaching a dizzy patient with vertigo and to present in detail the epidemiology, pathophysiology, symptoms, diagnosis, and contemporary treatments of all causes of vertigo.

Differential Diagnostic Reasoning Method for Benign Paroxysmal Positional Vertigo Based on Dynamic Uncertain Causality Graph

The accurate differentiation of the subtypes of benign paroxysmal positional vertigo (BPPV) can significantly improve the efficacy of repositioning maneuver in its treatment and thus reduce unnecessary clinical tests and inappropriate medications. In this study, attempts have been made towards developing approaches of causality modeling and diagnostic reasoning about the uncertainties that can arise from medical information. A dynamic uncertain causality graph-based differential diagnosis model for BPPV including 354 variables and 885 causality arcs is constructed. New algorithms are also proposed for differential diagnosis through logical and probabilistic inference, with an emphasis on solving the problems of intricate and confounding disease factors, incomplete clinical observations, and insufficient sample data. This study further uses vertigo cases to test the performance of the proposed method in clinical practice. The results point to high accuracy, a satisfactory discriminatory ability for BPPV, and favorable robustness regarding incomplete medical information. The underlying pathological mechanisms and causality semantics are verified using compact graphical representation and reasoning process, which enhance the interpretability of the diagnosis conclusions.