Repositioning intervals in the modified Epley's maneuver and their effect on benign paroxysmal positional vertigo treatment outcome

Difference in the immediate effect on positional nystagmus for head positions with interval time during Epley maneuver: a randomized trial

OBJECTIVES

The Epley maneuver (EM) shows immediate effect, wherein disappearance of positional nystagmus occurs soon after the EM. Our previous study showed that setting interval times during the EM reduced the immediate effect. The purpose of this study is to identify the head position for which interval time reduces the immediate effect.

METHODS

Fifty-one patients with posterior canal type of benign paroxysmal positional vertigo (BPPV) were randomly assigned to the following three groups: 10 min interval time set at the first head position of the EM in group A, at the third head position in group B, and at the fourth head position in group C. The primary outcome measure (POＭ) was the ratio of maximum slow-phase eye velocity of positional nystagmus soon after the EM, compared with that measured before the EM. A large ratio value indicates a poor immediate effect of the EM.

RESULTS

The POＭ in group A (0.07) was smallest (B: 0.36, C: 0.49) (p < 0.001).

DISCUSSION

The interval times at the third and fourth head positions reduced the immediate effect of the EM. Our previous study showed that the effect of BPPV fatigue is continued by maintaining the first head position of the EM. BPPV fatigue constitutes fatigability of positional nystagmus with repeated performance of the Dix-Hallpike test. Our findings may be interpreted in accordance with the theory that the immediate effect of the EM is BPPV fatigue itself, because we observed that the effect of BPPV fatigue is strongest in group A.

Predictive values of serum estradiol, calcium, and 25-hydroxyvitamin D levels for recurrence of benign paroxysmal positional vertigo in postmenopausal women

Objectives

This study aims to explore the predictive values of serum estradiol, calcium and 25-hydroxyvitamin D [25(OH)D] levels for benign paroxysmal positional vertigo (BPPV) recurrence in postmenopausal women.

Patients and methods

A total of 156 postmenopausal women (mean age: 59.5±7.4 years; range, 46 to 75 years) diagnosed with primary BPPV between January 2015 and August 2018 were included. After follow-up for one year, they were divided into non-recurrence (n=126) and recurrence groups (n=30). Fifty healthy females (mean age: 60.3±7.4 years; range, 48 to 75 years) with natural menopause for over one year were enrolled as the control group. Serum estradiol, calcium and 25(OH)D levels were compared, and their correlations in the recurrence group were analyzed by Pearson method. The predictive values of these levels for recurrence were evaluated using the receiver operating characteristic curve. Predisposing factors were determined by univariate and multivariate logistic regression analyses.

Results

Serum estradiol, calcium, and 25(OH)D levels of the control group were significantly higher than the non-recurrence and recurrence groups (p<0.05). The levels of recurrence group exceeded those of non-recurrence group (p<0.05). In recurrence group, estradiol level was positively correlated with those of calcium and 25(OH)D (r=0.7501, 0.7871, p<0.001), and calcium level was positively correlated with that of 25(OH)D (r=0.7904, p<0.001). The three levels had diagnostic values for recurrence. The maximum Youden’s index of their combination was 0.476, and the corresponding prognostic index was 13.04, suggesting a higher recurrence probability. Number of repositioning, Self-Rating Depression Scale score, levels of estradiol, calcium and 25(OH)D were predisposing factors for recurrence.

Conclusion

Serum estradiol, calcium, and 25(OH)D levels are significantly positively correlated in postmenopausal women with BPPV recurrence and their combination can be used to predict recurrence.

Vertigo returning to the sitting position after the Semont manoeuvre. Is it a prognostic symptom?

SUMMARY

Benign paroxysmal positional vertigo (BPPV) is a frequent benign vestibular condition usually managed with particle repositioning manoeuvres, such as Semont manoeuvre (SM). Since few authors have described prognostic aspects of liberatory manoeuvres, the purpose of the present study was to investigate the possibility of considering vertigo in the final sitting position of the SM as a prognostic symptom in the outcome of posterior BPPV. One hundred and thirteen patients with diagnosis of unilateral posterior BPPV were taking into account in our retrospective cohort study: 41 men and 72 women, aged 22 to 85 years. All were submitted to one repositioning SM and afterwards controlled 3 to 5 days later by means of an additional Dix-Hallpike manoeuvre. The main outcomes investigated were the occurrence of Ny and vertigo in the different phases of the SM, as well as their characteristics in relation to outcome of the disease. Among all patients, 75 (66%) presented both orthotropic Ny and vertigo in the second SM position and 72% obtained a complete resolution of the disease after the liberatory manoeuvre. Contrarily, 17 subjects (15%) manifested vertigo in the final sitting position of the SM and among these, only 7 (41%) completely recovered from BPPV. According to our data, in case of sudden vertigo returning to the final sitting position of the SM, the failure rate of the liberatory manoeuvre was higher, even though not statistically significant: therefore, it can be considered as a negative prognostic factor of posterior BPPV after SM.

Estradiol deficiency is a risk factor for idiopathic benign paroxysmal positional vertigo in postmenopausal female patients

OBJECTIVES/HYPOTHESIS

Although it is generally considered that benign paroxysmal positional vertigo (BPPV) is associated with changes in female sex hormone levels, no direct data have been reported until now. The purpose of this article was to provide direct data showing the distinct relationship between female sex hormone fluctuations and BPPV in postmenopausal female patients.

STUDY DESIGN

Prospective analysis in humans and basic research in animals.

METHODS

Blood samples were analyzed to determine the levels of estradiol, progesterone, follicle-stimulating hormone, and luteinizing hormone in 50- to 80-year-old postmenopausal female patients newly diagnosed with idiopathic BPPV based on history compatible with BPPV and positive provocative maneuvers. Animal models of bilateral ovariectomy and female sex hormone replacement therapy were used to further confirm the relationship between BPPV and female sex hormone levels by determining the expression levels of otoconin 90, the protein suggested as essential in the dislocation of otoconia.

RESULTS

Statistically significant differences between the estradiol level of BPPV patients and the control group were found (P < .001). Moreover, in bilateral ovariectomy in rats, 17β-estradiol replacement reversed the decrease of otoconin 90 levels.

CONCLUSIONS

Our results suggest that estradiol deficiency may be an important risk factor for idiopathic benign paroxysmal positional vertigo in postmenopausal female patients.

LEVEL OF EVIDENCE

NA. Laryngoscope, 128:948-953, 2018.