Position in bed is associated with left or right location in benign paroxysmal positional vertigo of the posterior semicircular canal

Relationship between Location of Focal Traumatic Brain Injury and Canal Involved in Benign Paroxysmal Positional Vertigo

INTRODUCTION

 Benign paroxysmal positional vertigo (BPPV) has a prevalence of 58% in a traumatic brain injury (TBI) population. Research on idiopathic BPPV has demonstrated a higher prevalence of right-sided canal involvement. While many studies have investigated the epidemiology of canal involvement in BPPV in both idiopathic and traumatic BPPV (BPPV associated with a fall), there has been no assessment of trauma location as a predictor of the location of BPPV.

OBJECTIVES

 The aim of this study was to assess the relationship between the location of a focal TBI and canal involvement in BPPV.

METHODS

 Patients who were admitted to an inpatient rehabilitation unit with a diagnosis of TBI were screened for BPPV. The primary outcome of this study was the side of the TBI, the BPPV type (posterior, horizontal, or anterior canal), and the side of the BPPV (right, left, or bilateral).

RESULTS

 There were 42 people who had BPPV. Twenty-one had right-sided canal involvement, 14 had left-sided involvement, and 7 had bilateral involvement. Sixteen had right-side tissue involvement, 13 had left-side involvement, and 13 had bilateral involvement. There was no significant correlation between variables (χ2 = 1.70, p = 0.80).

CONCLUSION

 All patients with a TBI should have all canals assessed for BPPV as there is no relationship between the side of focal damage and canal involvement.

Comparison between Classical- and Rotational-Mechanical-Chair-Assisted Maneuvers in a Population of Patients with Benign Paroxysmal Positional Vertigo

Introduction: Benign paroxysmal positional vertigo (BPPV) stands as the most common cause of peripheral vertigo. Its treatment with repositioning maneuvers on an examination table is highly effective. However, patients with back or neck problems, paraplegia, or other conditions face challenges with these maneuvers, potentially experiencing longer healing times and creating additional difficulties for physicians diagnosing and treating BPPV in everyday practice. The emergence of mechanical rotational chairs (MRCs) offers a more convenient alternative for performing these maneuvers. Objectives: The primary objective was to compare the effectiveness of maneuvers on the examination table with those on MRCs in BPPV patients diagnosed in the emergency room and randomly classified into one of the treatment options. The secondary objectives included a comparison of patient quality of life during BPPV episodes and after their resolution and an analysis of recurrences and associated risk factors. Methods: This was a cohort study on sixty-three patients diagnosed with BPPV in the emergency department. Patients were classified into two cohorts depending on diagnostic and treatment maneuvers (MRC or conventional repositioning maneuvers (CRMs)) and received weekly follow-ups until positioning maneuvers became negative. Subsequent follow-ups were conducted at 1 month, 3 months, and 6 months after the resolution of vertigo. Patients were classified into two groups based on their assigned treatment method. Results: Thirty-one patients were treated with CRMs and 32 with TRV. Mean age was 62.29 ± 17.67 years and the most affected canal was the PSC (96.8%). The mean number of required maneuvers was two, while 55.56% only required one maneuver until resolution. Recurrence was present in 26.98% of the patients during the 6-month follow-up. Comparing both cohorts, there were no statistically significant differences between treatments (TRV vs. CRM) regarding the number of maneuvers, number of recurrences, and days until remission of BPPV. Dizziness Handicap Inventory and Visual Analogue Scale values decreased considerably after BPPV resolution, with no statistically significant differences between the groups. Age was identified as a covariable in the number of maneuvers and days until BPPV resolution, showing that an increase in age implies a greater need of maneuvers. Conclusions: There was no difference between the means of treatment for BPPV in our population ot There was no difference between the groups of treatments for BPPV in our population. The quality of life of patients improved six months after the resolution of BPPV, regardless of the treatment applied.

Different clinical course of BPPV according to the medical conditions

Dizziness is one of the most prevalent complaints in medicine, and benign paroxysmal positional vertigo (BPPV) accounts for one-third of all cases. The present study was aimed at identifying differences in the course and prognosis of BPPV depending on the patient's medical condition during hospitalization. Patients in group 1 were hospitalized due to trauma, those in group 2 for scheduled surgery, and those in group 3 for medical treatment. The intervals from admission to symptom onset, surgery to symptom onset, and symptom onset to ENT department referral were compared. The interval from admission to symptom onset was shortest in group 1 (3.1 ± 8.0 days) and differed significantly from that in group 3 (20.0 ± 35.0 days, p < 0.001). The interval from surgery to symptom onset for group 2 was 5.6 ± 5.8 days and was significantly shorter than that from admission to symptom onset for group 3 (p = 0.014). The interval from symptom onset to ENT referral in group 3 (2.0 ± 2.8 days) was significantly shorter than in groups 1 and 2 (4.1 ± 5.1 and 4.0 ± 3.6 days, p = 0.008 and p = 0.002, respectively). The findings imply that the course of BPPV differed according to the patients' medical condition.

Seasonality of benign paroxysmal positional vertigo : A retrospective study from Central Europe

BACKGROUND

Although benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo in clinical practice, factors influencing the pathophysiology remain not fully understood.

OBJECTIVE

Here we aim to investigate possible seasonal influences on the occurrence of BPPV in Vienna, a city located in a Central European country with pronounced seasonal fluctuations.

METHODS

We retrospectively investigated data from 503 patients presenting with BPPV to the outpatient clinics of the Medical University of Vienna between 2007 and 2012. Analyses included age, gender, type of BPPV, seasonal assignment, as well as daylight hours and the temperature in Vienna at symptom onset.

RESULTS

Out of 503 patients (159 male, 344 female, ratio 1:2.2; mean age 60 ± 15.80 years), most patients presented with posterior (89.7%) and left-sided (43.1%) BPPV. There was a significant seasonal difference (χ2 p = 0.036) with the majority of symptoms occurring in winter seasons (n = 142), followed by springtime (n = 139). Symptom onset did not correlate with the average temperature (p = 0.24) but on the other hand very well with daylight hours (p < 0.05), which ranged from 8.4 h per day in December, to an average of 15.6 h in July.

CONCLUSION

Our results show a seasonal accumulation of BPPV during winter and springtime, which is in line with previous studies from other climatic zones, suggesting an association of this seasonality with varying vitamin D levels.

Nystagmus Parameters of Supine Roll Test Correlates With Prognosis After Repositioning Maneuver in Horizontal Semicircular Canal Benign Paroxysmal Positional Vertigo

Background: Positional nystagmus induced by supine roll test is characteristic for diagnosing horizontal semicircular canal benign paroxysmal positional vertigo (HC-BPPV). In this study, we aimed to explore the value of nystagmus parameters in by supine roll test (SRT) as prognostic factors in HC-BPPV.

Methods: We retrospectively analyzed the nystagmus parameters of 813 patients diagnosed with HC-BPPV by the SRT model in the SRM-IV system through video nystagmography. Then we used the computer-controlled canalith repositioning procedure (CCRP) mode for treatment. Based on the outcomes, patients were divided into either the cured group or the resistant group. The 1:1 propensity score matching (PSM) was applied to minimize potential selection bias. Then univariable and multivariable analyses were performed to identify the association of nystagmus parameters and the efficacy of CCRP.

Results: Among the 813 patients, 99 (12.2%) were classified in the resistant group. The right side of HC-BPPV patients was twice the number of the left side patients (537 vs. 276). PSM is used to pair resistant patients to the cured patients, in which 99 pairs were successfully matched. Results of univariate and multivariate analyses showed that patients in the resistant group have longer latency in the affected side [odds ratio (OR) = 1.231 (1.110–1.366); P < 0.001] and slower slow phase velocity (SPV) in the healthy side [OR = 0.957 (0.917–0.999); P = 0.045].

Conclusion: Nystagmus parameters may represent the characteristics of canalith. HC-BPPV patients with a longer latency in the affected side and slower SPV on the healthy side during SRT have a higher risk of HC-BPPV persisting after a single CCRP.

Variants of benign paroxysmal positional vertigo in relation to head position during sleep

BACKGROUND

Patients with posterior- and lateral-(canal)-benign paroxysmal positional vertigo (BPPV)-canalolithiasis sleep in the affected-ear-down head position. Posterior-BPPV-canalolithiasis typically affects the right than left ear; sleeping in the right-ear-down head position may be causal.

OBJECTIVE

To investigate the relationship between habitual head position during sleep and the onset of BPPV variants.

METHODS

Among 1,170 cases of BPPV variants with unknown etiology, the affected ears, habitual head positions during sleep based on interviews, and relationships among them were investigated.

RESULTS

Posterior-BPPV-canalolithiasis and lateral-BPPV-canalolithiasis-geotropic affected the right ear significantly more often. Significantly more patients with posterior-BPPV-canalolithiasis and lateral-BPPV-canalolithiasis-apogeotropic habitually slept in the right-ear-down head position. Patients with posterior- and lateral-BPPV-canalolithiasis and light cupula were more likely to sleep habitually in the affected-ear-down position than in the healthy-ear-down head position; no relationship was observed in patients with posterior- and lateral-BPPV-cupulolithiasis. In patients with posterior-BPPV-canalolithiasis and lateral-BPPV-canalolithiasis-geotropic, the proportion of right-affected ears in those sleeping habitually in the right-ear-down head position was significantly greater than that for the left-affected ear.

CONCLUSIONS

A habitual affected-ear-down head position during sleep may contribute to BPPV-canalolithiasis and light cupula onset, but not BPPV-cupulolithiasis onset. However, habitual sleeping in the right-ear-down head position cannot explain the predominance of right-affected ears.

Risk Factors for the Recurrence of Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-Analysis

OBJECTIVE

Benign paroxysmal positional vertigo (BPPV) has a high recurrence rate, but the risk factor-associated recurrence are elusive.

METHODS

Searches were performed in PubMed, Embase, Cochrane library, Web of science, Chinese National Knowledge Infrastructure, and Sino Med up to November 3, 2019. The effect size was analyzed by odds ratio and 95% CI. Data from eligible studies were meta-analyzed using Stata version 15.0.

RESULTS

Our search resulted in a total of 4076 hits. Twenty-four outcomes of sixty articles were included in the meta-analysis. Risk factors for the recurrence of BPPV included female gender, age (≥65years), hyperlipidemia, diabetes, hypertension, migraine, cervical spondylosis, osteopenia/osteoporosis, head trauma, otitis media, abnormal vestibular evoked myogenic potential, and long use of computers. No significant differences were found in side, type of the involved semicircular canals, smoking, alcohol consumption, stroke, ear surgery, duration of vertigo before treatment, the times of repositioning, Meniere disease, sleep disorders, hypercholesterolemia, and 25-hydroxy vitamin D.

CONCLUSION

These findings strengthen clinical awareness of early warning to identify patients with potential relapse risk of BPPV and clinicians should counsel patients regarding the importance of follow-up after diagnosis of BPPV.

VEMP: An Objective Test for Diagnosing the Cases of BPPV

Vertigo is a medical condition where a person feels as if they or the objects around them are moving when they are not. Any disturbance in the functioning of vestibular organ may cause vertigo. This study aims to find the role of cervical Vestibular evoked myogenic potential in diagnosing BPPV. The study performed was a prospective study of 50 patients with the age distribution from 20 to 60 years of age, attending the OPD in ENT department of MY Hospital, Indore with complaints of Vertigo. c-VEMP test was performed. The results were evaluated to diagnose BPPV. Of all the patients with the complaints of vertigo maximum belonged to the 5th decade of life. Of all the patients, females were found to be affected more than males making the male female ratio to be 1:1.28. In our study Dix-Hallpike test was found to be positive in 38 (74%) patients. On performing cervical VEMP, 15 (30%) patients of 50 patients showed abnormal latencies and amplitudes suggesting abnormal saccular functioning on affected side. Of these 15 abnormal VEMPs, 13 patients were positive on performing Dix-Hallpike test i.e. were diagnosed to have BPPV. VEMP showed a positive correlation with Dix-Hallpike test in diagnosis of vertigo of postural origin and thus can be used as a diagnostic tool for BPPV as VEMP is found to have high specificity.

Benign paroxysmal positional vertigo as a complication of 90-day head-down bed rest

PURPOSE

This study aimed to report the occurrence of benign paroxysmal positional vertigo (BPPV) in a 90-day head-down bed rest experiment and evaluate the potential relationship between BPPV-related seizures and bone metabolic changes.

METHODS AND DESIGN

Five cases of lateral semicircular canal (LSC) BPPV were diagnosed during a 90-day head-down bed rest experiment. Five age-matched subjects who participated in this experiment and never felt dizziness or vertigo were assigned as controls. The differences between the BPPV and the controls in lumbar bone mineral density, 25-hydroxyvitamin D level, corrected serum calcium, potassium, sodium, phosphorus, iron, uric acid and N-terminal osteocalcin were analyzed to determine the cause of LSC-BPPV.

RESULTS

BPPV occurred from Day 17 to Day 42 during head-down bed rest. The occurrences of BPPV were related to low 25-hydroxyvitamin D level (BPPV:20.70 ± 1.95 ng/L vs. control: 30.59 ± 2.75 ng/L at Day 30 during HDBR, p < 0.05). The relatively longer duration in the prone posture at 6° head down in this experiment may have a potential role in the involvement of the LSC. The maneuver used in the experiment effectively alleviated the acute symptoms of LSC-BPPV.

CONCLUSION

The cases of LSC-BPPV in the early period of 90-day of head-down bed rest were related to the low 25-hydroxyvitamin D level and the 6° head-down posture. These results suggest that the potential role of unloading-induced bone loss on BPPV-related seizures deserves attention in future studies of long-term bed rest.

The eyes wake up: Screening for benign paroxysmal positional vertigo with polysomnography

OBJECTIVE

While positional nystagmus of benign paroxysmal positional vertigo (BPPV) has been shown to be detectable in electrooculography (EOG) tracings of polysomnography (PSG), the frequency of undiagnosed BPPV in patients referred for sleep-wake examination has never been investigated.

METHODS

Prospective evaluation of positional nystagmus in 129 patients, referred to a neurological sleep laboratory for sleep-wake examination with PSG. Both in the evening and morning, patients had diagnostic positioning maneuvers under ongoing EOG-PSG registration, followed by visual inspection of EOG for positional nystagmus.

RESULTS

In 19 patients (14.7%), we found patterns of positional nystagmus, typically appearing few seconds after changes in head position. In 9 of these patients (47%), the nystagmus was also provoked by the positioning maneuvers. Nystagmus only occurred during wakefulness, not during sleep. In a patient with severe cupulolithiasis, we observed disappearance of nystagmus while entering N1 sleep stage. Nocturnal positional nystagmus was independently associated with positive positioning maneuvers.

CONCLUSIONS

Inspection of EOG-PSG demonstrated that positional nystagmus is common, occurring only when wake, and independently associated with positive positioning maneuvers.

SIGNIFICANCE

By routinely searching for positional nystagmus in PSG, sleep physicians may substantially contribute to the identification of patients with so-far undiagnosed BPPV.

Review of the pathology underlying benign paroxysmal positional vertigo

The pathophysiological mechanism underlying benign paroxysmal positional vertigo (BPPV) is related to free-floating debris/otoliths in the semicircular canal (canalolithiasis) or debris/otoliths attached to the cupula (cupulolithiasis). These debris/otoliths are considered to originally accumulate after detachment from the neuroepithelium of the utricular macula secondary to a type of degeneration. An idiopathic form, which is assumed to occur spontaneously, is diagnosed when the causative pathology is obscure. However, an association between various other systemic or inner ear conditions and BPPV has been reported, indicating the existence of secondary BPPV. This study was performed to present the first review of the pathology underlying BPPV following a complete PubMed/Medline search. In total, 1932 articles published from 1975 to 2018 were reviewed. The articles were classified according to 17 potentially causative factors (aging; migraine; Meniere's disease; infection; trauma; idiopathic sudden sensorineural hearing loss; sleeping habits; osteoporosis and vitamin D insufficiency; hyperglycemia and diabetes mellitus; chronic head and neck pain; vestibule or semicircular canal pathology; pigmentation disorders; estrogen deficiency; neurological disorders; autoimmune, inflammatory, or rheumatologic disorders; familial or genetic predisposition; and allergy). A discussion of the underlying cause of BPPV for each factor is presented.

Use of the Bárány Society criteria to diagnose benign paroxysmal positional vertigo

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder affecting about 20% of dizzy patients. Early diagnosis and treatment can improve the quality of life for patients.

OBJECTIVE

We reviewed the classifications of different subtypes of benign paroxysmal positional vertigo and the problems we encountered using the diagnostic criteria of the Bárány Society.

METHODS

Both the Dix-Hallpike maneuver and supine roll test were performed on 568 patients, and diagnoses were made based on patient history and the type of provoked nystagmus (if any). Next, the numbers of patients with each subtype and other parameters, including age and sex, were analyzed.

RESULTS

Posterior semicircular canal BPPV (pc-BPPV) accounted for the largest proportion, followed by horizontal semicircular canal BPPV (hc-BPPV). Both anterior canal BPPV and multiple canal lithiasis BPPV were rare, and no patient was diagnosed with cupulolithiasis of the posterior canal.

CONCLUSIONS

pc-BPPV, hc-BPPV, and cupulolithiasis of the horizontal canal (hc-BPPV-cu) were the three major subtypes that could be definitively diagnosed, whereas the diagnoses of possible benign paroxysmal positional vertigo (pBPPV) and probable benign paroxysmal positional vertigo [spontaneously resolved] (pBPPVsr) require further investigation, with special attention being paid to appropriate differentiation and repositioning maneuvers.

Risk of benign paroxysmal positional vertigo in patients with depressive disorders: a nationwide population-based cohort study

OBJECTIVE

The association between depression and benign paroxysmal positional vertigo (BPPV) remains debated. This study aimed to investigate the risk of BPPV in patients with depressive disorders.

DESIGN

Longitudinal nationwide cohort study.

SETTING

National health insurance research database in Taiwan.

PARTICIPANTS

We enrolled 10 297 patients diagnosed with depressive disorders between 2000 and 2009 and compared them to 41 188 selected control patients who had never been diagnosed with depressive disorders (at a 1:4 ratio matched by age, sex and index date) in relation to the risk of developing BPPV.

METHODS

The follow-up period was defined as the time from the initial diagnosis of depressive disorders to the date of BPPV, censoring or 31 December 2009. Cox proportional hazard regression analysis was used to investigate the risk of BPPV by sex, age and comorbidities, with HRs and 95% CIs.

RESULTS

During the 9-year follow-up period, 44 (0.59 per 1000 person-years) patients with depressive disorders and 99 (0.33 per 1000 person-years) control patients were diagnosed with BPPV. The incidence rate ratio of BPPV among both cohorts calculating from events of BPPV per 1000 person-years of observation time was 1.79 (95% CI 1.23 to 2.58, p=0.002). Following adjustments for age, sex and comorbidities, patients with depressive disorders were 1.55 times more likely to develop BPPV (95% CI 1.08 to 2.23, p=0.019) as compared with control patients. In addition, hyperthyroidism (HR=3.75, 95% CI 1.67-8.42, p=0.001) and systemic lupus erythematosus (SLE) (HR=3.47, 95% CI 1.07 to 11.22, p=0.038) were potential risk factors for developing BPPV in patients with depressive disorders.

CONCLUSIONS

Patients with depressive disorders may have an increased risk of developing BPPV, especially those who have hyperthyroidism and SLE.

Efficacy of Repositioning Therapy in Patients With Benign Paroxysmal Positional Vertigo and Preexisting Central Neurologic Disorders

With the exception of migraines, benign paroxysmal positional vertigo (BPPV) in patients with preexisting central neurologic disorders (CND) is rarely discussed in the literature. Demographic features of this patient group and the efficacy of repositioning therapy are still unknown. We hypothesized that a CND may alter the function of the central vestibular pathway, thus changing the pattern of BPPV and outcomes of repositioning. In this study, we enrolled 93 consecutive idiopathic BPPV patients and categorized them into two groups according to the presence or absence of a CND. In our series, 31.2% of BPPV cases had a CND. The most common associated CNDs were cerebrovascular disease and migraines. The two groups showed similar age distributions, canal involvement, success rates of repositioning, and cycles of treatment used to achieve complete resolution. The major differences were the proportion of females (89.7%) and a right-side predominance (75.9%) in the CND group. There was a trend of more residual dizziness (RD) after successful repositioning in the CND group, but the difference was not significant. The reason for the female and right-side predominance in the CND group is unclear. We concluded that the efficacy of repositioning therapy was excellent (with a success rate of 80.6% with one cycle and 93.5% within two cycles of treatment) for BPPV with or without a preexisting CND. Clinicians are encouraged to diagnose and treat BPPV in patients with a preexisting CND as early as possible to improve patients' quality of life, avoid complications, and reduce medical costs.

Characteristics and Treatment Outcomes of Benign Paroxysmal Positional Vertigo in a Cohort of Veterans

BACKGROUND

The Mountain Home Veterans Affairs (VA) Medical Center has been diagnosing and treating veterans with benign paroxysmal positional vertigo (BPPV) for almost 2 decades. The clinic protocol includes a 2-week follow-up visit to determine the treatment outcome of the canalith repositioning treatment (CRT). To date, the characteristics of BPPV and treatment efficacy have not been reported in a cohort of veterans with BPPV.

PURPOSE

To determine the prevalence and characteristics of veterans diagnosed with BPPV in a Veterans Affairs Medical Center Audiology Clinic and to examine treatment outcomes.

RESEARCH DESIGN

Retrospective chart review.

STUDY SAMPLE

A total of 102 veterans who tested positive for BPPV in the Vestibular Clinic at the Mountain Home VA Medical Center from March 2010 to August 2011.

RESULTS

In 102 veterans who were diagnosed with BPPV, the posterior semicircular canal was most often involved (75%), motion-provoked vertigo was the most common symptom (84%), and the majority (43%) were diagnosed with BPPV in their sixth decade. The prevalence of BPPV in the Audiology Vestibular Clinic was 15.6%. Forty-one percent of veterans reported a symptom onset within 12 months of treatment for BPPV; however, 36% reported their symptoms began > 36 months prior to treatment. CRT was effective (negative Dix-Hallpike/roll test) in most veterans (86%) following 1 treatment appointment (M = 1.6), but more than half reported incomplete symptom resolution (residual dizziness) at the follow-up appointment. Eighteen percent of veterans experienced a recurrence (M = 1.8 years; SD = 1.7 years).

CONCLUSIONS

The characteristics and treatment outcomes of BPPV in our veteran cohort was similar to what has been reported in the general population. Future work should focus on improving the timeliness of evaluation and treatment of BPPV and examining the time course and management of residual dizziness.

Efficacy of the Li maneuver in treating posterior canal benign paroxysmal positional vertigo

CONCLUSION

The Li maneuver is a safe, effective, and simple repositioning method for the treatment of BPPV. It is simple to master and exerts an exact effect. As a rapid repositioning method, the Li maneuver can result in reduced treatment times and increased treatment efficacy, and is, therefore, especially suitable for patients with limited cervical spine movement.

OBJECTIVE

To compare the short-term efficacies of the Li and Epley maneuvers in treating posterior canal benign paroxysmal positional vertigo (PC-BPPV).

METHODS

A total of 120 patients with PC-BPPV were randomly treated by either the Li or Epley maneuvers at our department between May 5, 2014 and July 30, 2015. Follow-up examinations were performed 3 days and 1 week after the first repositioning.

RESULTS

Of the 120 patients initially enrolled, 113 (72 females; 41 males; average age = 52 years; Li and Epley maneuver groups, 56 and 57 cases, respectively) satisfied the inclusion and exclusion criteria of this study. There were no statistically significant differences between the two groups of patients in terms of the success rates of treatment at either the 3-day or 1-week follow-ups (p = .756 and .520, respectively).

A Geriatric Perspective on Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo in older adults. Beyond the unpleasant sensation of vertigo, BPPV also negatively affects older adults' gait and balance and increases their risk of falling. As such it has a profound effect on function, independence, and quality of life. Otoconia are the inner ear structures that help detect horizontal and vertical movements. Aging contributes to the fragmentation of otoconia, whose displacement into the semicircular, most commonly posterior canals, can produce rotatory movement sensations with head movement. BPPV is more commonly idiopathic in older adults than in younger individuals, can present atypically, and has a more-protracted course and higher risk of recurrence. Medications such as meclizine that are commonly prescribed for BPPV can be associated with significant side effects. Dix-Hallpike and Head Roll tests can generally identify the involved canal. Symptoms resolve as otoconia fragments dissolve into the endolymph, but appropriate canalith repositioning (e.g., Epley maneuver) can expedite recovery and reduce the burden of this disorder. Observations suggesting an association between idiopathic BPPV and vitamin D deficiency and osteoporosis indicate that BPPV may share risk factors with other common geriatric conditions, which highlights the importance of moving beyond purely otological considerations and addressing the needs of older adults with vertigo through a systems-based multidisciplinary approach.

Benign paroxysmal positional vertigo during lateral window sinus lift procedure: a case report and review

PURPOSE

Benign paroxysmal positional vertigo (BPPV) is a possible and well-documented complication after the osteotome internal sinus lift technique. But we report a case of unexpected BPPV complication after direct sinus lift by lateral approach for implant placement that was not reported till date.

METHODS

A 30-year-old woman had undergone direct sinus lift procedure by lateral window technique to replace her missing right molar with dental implant. The patient suffered with intense vertigo with nausea, vomiting, and aggravated when she changed the position of her head towards right immediately after procedure and was diagnosed with BPPV after the referral.

CONCLUSION

We assume that prolonged hyperextended head position of iatrogenic origin can be the reason, in this case, for BPPV after direct lateral sinus lift procedure. There is also a possibility that the temporal relationship with the surgical area and surgical action by rotating tools during window preparation are also contributing factors.

Benign Paroxysmal Positional Vertigo: An Integrated Perspective

Benign paroxysmal positional vertigo (BPPV), the most common cause of dizziness, occurs in all age groups. It presents with vertigo on head movement, but in older patients presentation may be typical and thus accounting for a low recognition rate in the primary care setting. It may be recurrent in up to 50% of cases. BPPV is associated with displacement of fragments of utricular otoconia into the semicircular canals, most commonly the posterior semicircular canal. Otoconia are composed of otoconin and otolin forming the organic matrix on which calcium carbonate mineralizes. Otoconia may fragment with trauma, age, or changes in the physiology of endolymph (e.g., pH and calcium concentration). Presentation varied because otoconia fragments can be displaced into any of the semicircular canals on either (or both) side and may be free floating (canalolithiasis) or attached to the cupula (cupulolithiasis). Most cases of BPPV are idiopathic, but head trauma, otologic disorders, and systemic disease appear to be contributory in a subset. Positional maneuvers are used to diagnose and treat the majority of cases. In rare intractable cases surgical management may be considered. A strong association with osteoporosis suggests that idiopathic BPPV may have diagnostic and management implications beyond that of a purely otologic condition.

Association between osteoporosis and benign paroxysmal positional vertigo: a systematic review

BACKGROUND

Increasing recent evidence has implicated osteoporosis as a risk factor for benign paroxysmal positional vertigo (BPPV). We conducted a systematic review to examine the association between osteoporosis and BPPV.

METHODS

Four electronic databases (PubMed, EMBASE, Cochrane Library, and the China Network Knowledge Infrastructure) were searched to identify all papers, published in either English or Chinese, examining the association between osteoporosis (osteopenia) and BPPV.

RESULTS

Seven studies were eligible for analysis, though these studies included some weaknesses. Most of the studies demonstrated a correlation between osteoporosis (osteopenia) and the occurrence and recurrence of BPPV, especially in older women. Patients with osteoporosis may require more canalith-repositioning procedures.

CONCLUSIONS

This systematic review provides insight into currently available evidence and elucidates the possible existence of an association between BPPV and osteoporosis (osteopenia). However, the evidence supporting that conclusion is not strong, and further studies are needed to clarify the association between these conditions.

Impact of postmaneuver sleep position on recurrence of benign paroxysmal positional vertigo

Background

The necessity of postural restriction to patients suffering from benign paroxysmal positional vertigo is controversial.

Objective

To investigate the impact of the sleep position after the repositioning maneuver on BPPV recurrence.

Methods

150 unilateral BPPV patients who were treated by repositioning maneuver were distributed into two groups. The patients in group A were instructed to sleep in a semi-sitting position at an angle of approximately 30 degrees and refrain from sleeping on their BPPV affected side for one week. The patients in group B were told to sleep in any preferred position. The comparison of recurrence rates according to different actual sleep positions in one week and one month was performed.

Results

There was a statistically significant correlation between the sleeping side and the side affected by BPPV. Without instructions on postural restriction, most patients (82.9%, 73/88) avoided sleeping on their affected side. The patients sleeping on their affected side had a higher recurrence rate (35.3%) than ones sleeping in other positions in the first week after the repositioning maneuver (p<0.05, Chi-square test and Fisher's exact test). The patients sleeping randomly in following 3 weeks had a lower recurrence rate than ones sleeping in other position (p<0.05, Fisher's exact test).

Conclusions

BPPV patients had a poor compliance to postural instructions. The habitual sleep side was associated with the side affected by BPPV. The patients sleeping on their affected side had a higher recurrence rate than those sleeping in other positions in first week after the repositioning maneuver.

Benign paroxysmal positional vertigo in the elderly

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is the most frequent peripheral vertigo in the elderly. It is a well-characterized entity and generally easy to treat.

OBJECTIVE

To evaluate the main symptoms, time to consult for the problem, vertigo characteristics, treatment and follow-up in patients over 70 with BPPV.

METHODS

This was a retrospective cohort study. Four hundred and four patients were diagnosed to have BPPV (between January 2006 and December 2012); 211 of them were ≥70 years old (mean 77.7 years) and 193 <70 years old (mean 53.82 years).

RESULTS

Patients over 70 with BPPV took longer to consult for the problem (Spearman rho, p = 0.01). The frequency of a clinical presentation consisting of unsteadiness or imbalance without vertigo sensation is higher among elderly patients (χ(2), p = 10(-6)). The effectiveness of the repositioning maneuver is lower than in patients under 70 (χ(2), p = 0.002), and the recurrences are more frequent (χ(2), p = 0.04).

CONCLUSION

BPPV is a frequent entity in the elderly, and it is necessary to take it into account when older patients complain about imbalance. An appropriate treatment with repositioning maneuvers and prolonged follow-up are required in order to detect recurrences.

Effects of sleep position on time course in remission of positional vertigo in patients with benign paroxysmal positional vertigo

CONCLUSION

The findings suggest that it is easy for otoconial debris dislodged from the utricle to fall into the posterior semicircular canal (PSCC) or the horizontal semicircular canal (HSCC) of the undermost ear during sleep, but not to exit from the uppermost ear in patients with benign paroxysmal positional vertigo (BPPV).

OBJECTIVE

The aims of the present study were two-fold. (1) To examine the association between the preferred side of head-lying during sleep and the side of the affected ear in patients with both posterior canal BPPV (P-BPPV) and horizontal canal BPPV (H-BPPV). (2) To see whether that position affects the time course in remission of their positional vertigo.

METHODS

One hundred and sixteen patients with P-BPPV and 40 patients with H-BPPV who showed a habitual preference for right or left side sleeping position were included in this study.

RESULTS

The side of the affected ear was significantly associated with the head-lying side during sleep in patients with P-BPPV and was closely but not significantly associated with it in patients with H-BPPV. However, the head-lying side during sleep did not affect the remission rate of their positional vertigo.

Physical inactivity as a contributing factor for onset of idiopathic benign paroxysmal positional vertigo

CONCLUSION

Despite limitations arising from a questionnaire-performed study, it seems that nonspecific physical activity can protect against benign paroxysmal positional vertigo (BPPV), possibly by relocating loosened otoconia from the semicircular canals.

OBJECTIVES

Mechanical factors might play a role in the onset of the idiopathic form of BPPV. We performed a structured questionnaire study of physical activity in patients with BPPV and controls.

METHODS

Sixty-three consecutive patients with idiopathic BPPV participated in the study. Their mean age was 59.2 ± 14.5 years; 14 were men and 49 were women. Sixty-four age- and sex-matched generally healthy individuals served as controls. Levels of physical activity were assessed by the PASE questionnaire, which consists of 12 items quantifying physical activity during leisure, household, and occupational activities over a 7-day period.

RESULTS

The total physical score activity was significantly lower in BPPV patients than in controls. Differences were found mainly in household and leisure activity, while occupational activity was similar in both groups, regardless of gender. Patients older than 60 years had significantly lower PASE scores than controls, whereas patients aged 60 years or younger reported similar physical activity to controls. No differences were found between physical activity scores in different types of BPPV or in patients with a first versus recurrent attack of vertigo.

Acute vestibulopathy

The presentation of acute vertigo may represent both a common benign disorder or a life threatening but rare one. Familiarity with the common peripheral vestibular disorders will allow the clinician to rapidly "rule-in" a benign disorder and recognize when further testing is required. Key features of vertigo required to make an accurate diagnosis are duration, chronicity, associated symptoms, and triggers. Bedside tests that are critical to the diagnosis of acute vertigo include the Dix-Hallpike maneuver and canalith repositioning manuever, occlusive ophthalmoscopy, and the head impulse test. The goal of this review is to provide the clinician with the clinical and pathophysiologic background of the most common disorders that present with vertigo to develop a logical differential diagnosis and management plan.

Sleep position and laterality of benign paroxysmal positional vertigo

OBJECTIVE

The aim of this study was to investigate the frequency of posterior semicircular canal benign paroxysmal positional vertigo in each ear, and to assess the association between the ear affected by benign paroxysmal positional vertigo and the head-lying side during sleep onset. Based on a previous study which used objective methods to prove the preference of the elderly for the right head-lying side during sleep, we hypothesised that a predominance of the same head-lying side in benign paroxysmal positional vertigo patients may affect the pathophysiology of otoconia displacement.

STUDY DESIGN

We conducted a prospective study of out-patients with posterior semicircular canal benign paroxysmal positional vertigo, confirmed by a positive Dix-Hallpike test.

METHODS

One hundred and forty-two patients with posterior semicircular canal benign paroxysmal positional vertigo were interviewed about their past medical history, focusing on factors predisposing to benign paroxysmal positional vertigo. All patients included in the study were able to define a predominant, favourite head-lying side, right or left, during sleep onset.

RESULTS

The Dix-Hallpike test was found to be positive on the right side in 82 patients and positive on the left side in 54; six patients were found to be positive bilaterally. During sleep onset, 97 patients habitually laid their head on the right side and the remaining 45 laid their head on the left. The association between the affected ear and the head-lying side during sleep onset was statistically significant (p < 0.001).

CONCLUSIONS

Our study found a predominance of right-sided benign paroxysmal positional vertigo, a subjective preference amongst patients for a right head-lying position during sleep onset, and an association between the ear affected by benign paroxysmal positional vertigo and the preferred head-lying side during sleep onset. The clinical and therapeutical implications of this observation are discussed.

Dynamics of canal response to head-shaking test in benign paroxysmal positional vertigo

CONCLUSIONS

Time constant and maximum slow phase velocity (SPV) of head-shaking nystagmus (HSN) demonstrated a differential canal response to head shaking in 24% of patients with posterior canal benign paroxysmal positional vertigo (BPPV). We suggest that vestibular lithiasis has a limited contribution to the mechanism that generates HSN.

OBJECTIVE

To determine the canal response to head shaking in BPPV.

PATIENTS AND METHODS

This was a case-control study including 104 individuals with BPPV. The diagnosis was based on the presence of vertigo and nystagmus during the positional test. Subjects were examined by the horizontal and vertical head-shaking test. Eye movements were recorded on a video camera to analyze the nystagmus. The head was shaken passively in the horizontal and sagittal planes, respectively, for horizontal and vertical HSN at a frequency of 2 Hz. HSN was considered when six consecutive beats of nystagmus with an SPV of at least 2 degrees/s were detected. Main outcome measures were the presence of horizontal and vertical HSN, maximum SPV of HSN, time constant of HSN, and canal paresis.

RESULTS

Maximum SPV of vertical HSN was higher in BPPV patients with posterior canal BPPV (n = 10) than in controls (p = 0.04). Moreover, the time constant of vertical HSN was significantly lower for posterior canal BPPV when compared with controls (p < 0.02).

[Oculographic findings in 145 patients with benign paroxysmal positional vertigo]

OBJECTIVE

Benign paroxysmal positional vertigo (BPPV) can be produced by specific manoeuvres and be studied by electrooculography (EOG). It allows an exhaustive study of features in the positional nystagmus. Although most of the patients with BPPV express typical nystagmus, there exists a group of them that exhibit a non typical form. In this work, a comparative study was carried out between two groups of patients.

MATERIAL AND METHODS

We have studied retrospectively 145 patients with BPPV and Dix-Hallpicke (D-H) positive manoeuvre registered by EOG techniques. All patients were explored in a complete EOG tests. Two groups were identified: typical response/atypical response according to the features of nystagmus response. Possible alterations in other EOG tests in each group were investigated and differences between both types of response were analyzed.

RESULTS

83.5% of cases showed typical nystagmus and atypical in the rest. Other EOG alterations observed in these patients, were (group typical response/atypical response): caloric hypofunction (17.3%/23%), positional nystagmus (12.4%/62.5%), alterations in visual-oculomotor function tests (10%/50%).

CONCLUSIONS

Frequent alterations were observed in the classic manoeuvres and also in the rest of EOG tests. Probably atypical response in the first is due to or can explain the existence of the second.

Usefulness of the dizziness handicap inventory in the screening for benign paroxysmal positional vertigo

OBJECTIVE

The purpose of the study was to determine whether a newly developed subscale of the Dizziness Handicap Inventory (DHI) could assist in the screening of benign paroxysmal positional vertigo (BPPV).

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary balance referral center.

PATIENTS

Charts of 383 patients (mean age, 61 yr) with a variety of vestibular diagnoses (peripheral and central) were reviewed.

INTERVENTIONS

Patients completed the DHI before the onset of physical therapy intervention.

MAIN OUTCOME MEASURES

A newly developed BPPV subscale developed from current DHI items was computed to determine whether the score could assist the practitioner in identifying individuals with BPPV.

RESULTS

Individuals with BPPV had significantly higher mean scores on the newly developed BPPV subscale of the DHI (p < 0.01). The five-item BPPV score was a significant predictor of the likelihood of having BPPV (chi2 = 8.35; p < 0.01). On the two-item BPPV scale, individuals who had a score of 8 of 8 were 4.3 times more likely to have BPPV compared with individuals who had a score of 0.

CONCLUSION

Items on the DHI appear to be helpful in determining the likelihood of an individual having the diagnosis of BPPV.

Multiple positional nystagmus suggests multiple canal involvement in benign paroxysmal vertigo

CONCLUSION

Video-oculography demonstrates a higher occurrence of atypical positional nystagmus in patients with benign paroxysmal positional vertigo (BPPV). This includes anterior and horizontal canal variants and multiple positional nystagmus, suggesting combined lesions affecting several canals.

OBJECTIVE

To analyse the video-oculographic findings of positional tests in patients with BPPV.

MATERIAL AND METHODS

Seventy individuals with symptoms of BPPV and positional nystagmus were included in this study. The diagnosis was based on a history of brief episodes of vertigo and the presence of positional nystagmus as confirmed by video-oculographic examination during the Dix-Hallpike test, the McClure test or the head-hanging manoeuvre. Patients were treated by means of different particle repositioning manoeuvres according to the affected canal (Epley's manoeuvre for the posterior or anterior canals and Lempert's manoeuvre for the lateral canal) and the effectiveness was evaluated at 7 and 30 days.

RESULTS

Twenty-nine individuals (41.43%) presented an affected unilateral posterior canal. Fifteen patients (21.43%) presented a pure horizontal direction-changing positional nystagmus consistent with a diagnosis of horizontal canal BPPV. Twelve individuals (17.14%) presented a unilateral down-beating nystagmus, suggesting possible anterior canal BPPV. In addition, 14 patients (20%) showed multiple positional nystagmus during the examination corresponding to simultaneous multi-canal BPPV, 5 had bilateral posterior canal BPPV and 2 presented a positional down-beating nystagmus in both left and right Dix-Hallpike manoeuvres and the head-hanging manoeuvre, which is highly suggestive of anterior canal BPPV. However, seven individuals showed positional horizontal and vertical side-changing nystagmus that could not be explained by single-canal BPPV. These patients with multiple positional nystagmus showed changing patterns of positional nystagmus at follow-up.

Health-Related Quality of Life in Patients over Sixty Years Old with Benign Paroxysmal Positional Vertigo

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is a common cause of dizziness within the geriatric population causing disability. The diagnosis is established by the position-induced rotatory nystagmus, related to the involved ear, demonstrated by the Dix-Hallpike test (DHT). Although the Epley's modified manoeuvre, or particle respositioning manoeuvre (PRM), is an effective treatment for this disorder, its impact on health outcome in patients over 60 years old is unknown.

OBJECTIVE

To assess BPPV health-related quality of life in elderly individuals using the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and the Dizziness Handicap Inventory Short Form (DHI-S).

METHODS

A prospective study including new cases of BPPV in patients older than 60 years was carried out. The diagnosis was based on the history of recurrent sudden crises of vertigo and a typical positional-induced nystagmus during the DHT. All patients were treated by a single PRM and relapses were investigated a the 30th post-treatment day.

RESULTS

DHT was found negative in 82% (23/28) individuals at 30 days. The eight scales of the SF-36 have a good internal consistency reliability in patients with BPPV (Cronbach's alpha > 0.7). The average standardized score for each SF-36 scale was compared with the reference population normative data, showing differences with norms for role physical, body pain, social function, role emotional and mental health. After PRM, patients restored scores to norms, showing a significant increase in role physical (p < 0.05), body pain (p < 0.04), vitality (p < 0.02), social function (p < 0.003) and mental health scores (p < 0.005). DHI-S total score significantly decreased from 17.19 +/- 9.06 (mean +/- SD) at the first day to 9.70 +/- 10.13 at 30 days (p < 0.001).

CONCLUSIONS

BPPV has a significant impact on health-related quality of life in elderly patients on their emotional and physical states compared to those unaffected. The PRM can restore health-related quality of life in elderly patients with BPPV.