The Canalith Repositioning Procedure for Benign Positional Vertigo: A Meta-Analysis

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.

Epley's Manoeuvre: A Single Line Treatment for Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo

Benign Paroxysmal Positional Vertigo (BPPV) is the commonest cause of peripheral vertigo. Displaced free floating otoconia in the semicircular canals are responsible for brief attacks of vertigo and nystagmus. Epley's manoeuvre relocates these particles into the utricle. Here we studied the efficacy of Epley's manoeuvre in posterior semicircular canal BPPV without labyrinthine sedatives. 120 patients presented with positional vertigo were included in the study based on positive Dix- hallpike test from August 2018 to July 2019. These patients were treated with only the Epley's manoeuvre and followed up for 6 months. Patients who were previously on labyrinthine sedatives were advised to stop them and treated with only the Epley's manoeuvre. In our study of 120 patients, mean age was 43.5 yrs. Females (52.5%) were commonly affected. Left side posterior semicircular involvement was more than the right side. Epley's manoeuvre had 90% efficacy at 1st week and 100% efficacy at 4th week. Duration of vertigo had significant association (p < 0.01) with the number of sessions required. There was significant improvement in the duration of vertigo attack (p < 0.0001) and frequency of attack (p < 0.0001) before and after the manoeuvre. Epley's manoeuvre lead to significant (p < 0.001) improvement in the quality of life of affected patients measured by DHI scoring. In our 6 months follow up, 10 recurrences occurred having significant (p < 0.01) association with the duration of vertigo attack. Only Epley's manoeuvre without any labyrinthine sedatives is an effective treatment for posterior semicircular canal BPPV patients. It also improves the quality of life of affected patients.

Optimal reassessment time for treatment response in posterior canal benign paroxysmal positional vertigo

OBJECTIVES/HYPOTHESIS

The present study aimed to evaluate the optimal reassessment time for treatment response in posterior canal benign paroxysmal positional vertigo (PC-BPPV) following the initial Epley maneuver.

STUDY DESIGN

Prospective, single-blinded, randomized study.

METHODS

One hundred eight patients with PC-BPPV agreed to participate. These patients received a single modified Epley maneuver (recommended by the 2008 American Academy of Otolaryngology-Head and Neck Surgery guidelines) daily until positional nystagmus disappeared during the Dix-Hallpike maneuver 24 hours after the treatment. Repeated Dix-Hallpike testing to reassess the treatment response was performed at 1 hour (post-1 hour), every 24 hours (post-24 hours) until the positional nystagmus resolved, 1 week (post-1 week), and 1 month (post-1 month) following the therapeutic maneuver. The difference in the resolution rates at post-1 hour and post-24 hours reassessment was analyzed, and the recurrence rates at post-1 week and post-1 month were evaluated.

RESULTS

The resolution rate was 67.6% at post-1 hour, which increased to 79.6% at post-24 hours reassessment. There was a statistically significant difference in the results of the Dix-Hallpike test between post-1 hour and post-24 hours follow-up. After complete resolution, nine out of 108 patients (8.3%) demonstrated recurrence within 1 month.

CONCLUSIONS

Reassessment after 24 hours following the initial Epley maneuver is more advantageous than a 1-hour follow-up in patients with PC-BPPV. This information may be helpful for clinicians in deciding the appropriate follow-up period after treatment for PC-BPPV.

LEVEL OF EVIDENCE

1b Laryngoscope, 130:496-499, 2020.

Implementation of evidence-based practice for benign paroxysmal positional vertigo: DIZZTINCT- A study protocol for an exploratory stepped-wedge randomized trial

Background

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder, and accounts for 8% of individuals with moderate or severe dizziness. BPPV patients experience substantial inconveniences and disabilities during symptomatic periods. BPPV therapeutic processes – the Dix-Hallpike Test (DHT) and the Canalith Repositioning Maneuver (CRM) – have an evidence base that is at the clinical practice guideline level. The most commonly used CRM is the modified Epley maneuver. The DHT is the gold standard test for BPPV and the CRM is supported by numerous randomized controlled trials and systematic reviews. Despite this, BPPV care processes are underutilized.

Methods/design

This is a stepped-wedge, randomized clinical trial of a multi-faceted educational and care-process-based intervention designed to improve the guideline-concordant care of patients with BPPV presenting to the emergency department (ED) with dizziness. The unit of randomization and target of intervention is the hospital. After an initial observation period, the six hospitals will undergo the intervention in five waves (two closely integrated hospitals will be paired). The order will be randomized. The primary endpoint is measured at the individual patient level, and is the presence of documentation of either the Dix-Hallpike Test or CRM. The secondary endpoints are referral to a health care provider qualified to treat dizziness for CRM and 90-day stroke rates following an ED dizziness visit. Formative evaluations are also performed to monitor and identify potential and actual influences on the progress and effectiveness of the implementation efforts.

Discussion

If this study safely increases documentation of the DHT/CRM, this will be an important step in implementing the use of these evidenced-based processes of care. Positive results will support conducting larger-scale follow-up studies that assess patient outcomes. The data collection also enables evaluation of potential and actual influences on the progress and effectiveness of the implementation efforts.

Trial registration

ClinicalTrials.gov, ID: NCT02809599. The record was first available to the public on 22 June 2016 prior to the enrollment of the first patients in October 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3099-0) contains supplementary material, which is available to authorized users.

Two-Hour Follow-Up is Equivalent to One-Day Follow-Up of Posterior Canal Benign Paroxysmal Positional Vertigo

OBJECTIVES

To evaluate short-term outcome for posterior canal benign paroxysmal positional vertigo (p-BPPV) after modified Epley's maneuver (mEM).

MATERIALS AND METHODS

Patients who were diagnosed with p-BPPV between September 2017 and January 2018 in a tertiary care center were included. Patients were treated with mEM. Five follow-up points were set at one hour, two hours, one day, three days and one week. If Dix-Hallpike test (DH) was positive, mEM was performed and patient was scheduled for follow-up at the next follow-up point. If negative, the patient was accepted as completely resolved and scheduled for follow-up at one week. The proportion of completely resolved patients at each follow-up point, recurrence, lateral canal conversion rate and time were noted. A retrospective control group was created from patients treated for p-BPPV between April and August 2017. The outcome of the study and control groups were compared.

RESULTS

There were 93 patients in study group. 63 (67.7%), 8 (8.6%), 3 (3.2%), 0 (0%) and 9 (9.7%) patients completely resolved at one-hour, two-hour, one-day, three-days and one-week follow-ups. 1.96±1.60 (1-5) mEMs were performed. Control group included 61 patients. At one-week follow-up a total of 83 (89.2%) patients in study group and 48 (78.7%) in control group were completely resolved(p=0.1043). In study group 5 (5.37%) of patients had lateral canal conversion within one day. 2(2.15%) had recurrence one day later after two-hour follow-up. The number of patients completely resolved at two-hour follow-up and before (76.34%) compared to the patients completely resolved at one-day follow-up and before (79.56%) were not significantly different (p=0.7235).

CONCLUSION

Two-hour follow-up is equivalent to one-day follow-up of p-BPPV in terms of therapy outcome and adverse affects.

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.

Liberatory vertigo: a new prognostic factor for repositioning maneuvers

OBJECTIVE

This study suggests the new concept of liberatory vertigo to facilitate emergency department treatment of benign paroxysmal positional vertigo.

METHODS

The present prospective nonrandomized study enrolled 535 patients with typical forms of positional vertigo, who were treated following clinical practice guidelines. We observed the onset of liberatory vertigo during the maneuver as a prognostic factor, and we tested the correlation between that symptom and therapeutic effectiveness. A subjective evaluation of vertigo was made by way of a questionnaire. Data analysis was performed that made use of statistical software.

RESULTS

Complete recovery occurred in 287 patients (76.5%) with posterior semicircular canal positional vertigo and in 67 patients (80%) with horizontal semicircular canal positional vertigo; liberatory vertigo occurred in 195 (67.9%) and 59 (88%) of those cases, respectively. Differences in terms of recovery probability resulted regardless of the canal involved. Positive predictive value ranged from 93% to 97%.

CONCLUSIONS

In our sample, liberatory vertigo could predict the effectiveness of the maneuver regardless of the canal involved.

Classification, diagnostic criteria and management of benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vertigo and the posterior and/or lateral semicircular canals are usually affected. BPPV is characterized by brief attacks of rotatory vertigo associated with positional and/or positioning nystagmus, which are elicited by specific head positions or changes in head position relative to gravity. In patients with the posterior-canal-type of BPPV, torsional nystagmus is induced by the Dix-Hallpike maneuver. In patients with the lateral-canal-type of BPPV, horizontal geotropic or apogeotropic nystagmus is induced by the supine roll test. The pathophysiology of BPPV is canalolithiasis comprising free-floating otoconial debris within the endolymph of a semicircular canal, or cupulolithiasis comprising otoconial debris adherent to the cupula. The observation of positional and/or positioning nystagmus is essential for the diagnosis of BPPV. BPPV is treated with the canalith repositioning procedure (CRP). Through a series of head position changes, the CRP moves otoconial debris from the affected semicircular canal to the utricle. In this review, we provide the classification, diagnostic criteria, and examinations for the diagnosis, and specific and non-specific treatments of BPPV in accordance with the Japanese practical guidelines on BPPV published by the Japan Society for Equilibrium Research.

[Treatment of benign paroxysmal positional vertigo]

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder. BPPV is easily diagnosed by positioning tests and effectively treated by repositioning maneuvers. The authors focus on the treatment of BPPV, when different canals are affected, including canalo- and cupulolithiasias. Complications of BPPV and surgery of cases, resistant to conservative treatment, are also discussed.

Effectiveness of the Parnes particle repositioning manoeuvre for posterior canal benign paroxysmal positional vertigo

BACKGROUND

Benign paroxysmal positional vertigo is a common vestibular disorder that negatively affects an individual's health-related quality of life. This study aimed to examine the effectiveness of the Parnes particle repositioning manoeuvre as an intervention for individuals with posterior canal benign paroxysmal positional vertigo.

METHODS

The de-identified records of 155 individuals treated with the Parnes manoeuvre were examined. Descriptive statistics were calculated, including the frequency and valid per cent of participants whose nystagmus was resolved with the Parnes manoeuvre.

RESULTS

In all, nystagmus was resolved with the Parnes manoeuvre in 145 participants (93.5 per cent). The mean number of manoeuvres needed to resolve the nystagmus was 1.3.

CONCLUSION

The Parnes manoeuvre proved to be as effective as the Epley canalith repositioning manoeuvre, currently the most common intervention, in treating individuals with posterior canal benign paroxysmal positional vertigo.

Epley and Semont maneuvers for posterior canal benign paroxysmal positional vertigo: A network meta-analysis

OBJECTIVES/HYPOTHESIS

Using network meta-analysis, we aimed to compare the efficacy and safety of Epley and Semont maneuvers as treatment options for posterior canal benign paroxysmal positional vertigo.

STUDY DESIGN

Network meta-analysis.

METHODS

Randomized controlled studies with a Jadad score ≥ 3 that used an Epley or Semont maneuver in posterior canal benign paroxysmal positional vertigo patients were analyzed in this project. The following efficacy outcomes included 1-week recovery rate and end of study recovery rate. Recurrence rate was used to assess the safety of each treatment.

RESULTS

Of 589 articles, 12 studies that enrolled 999 posterior canal benign paroxysmal positional vertigo patients were selected. The pooled analysis revealed that the Epley maneuver was as efficacious as the Semont maneuver, in both the 1-week recovery rate and end of study recovery rate (odds ratio [OR] = 1.8, 95% confidence interval [CI] = 0.48-7.00; OR = 1.8, 95% CI = 0.47-7.20), and had a similar recurrence rate (OR = 1.00, 95% CI = 0.33-4.4). These two techniques were both better than sham-controlled treatment in the two efficacy indicators. No difference was observed in recurrence rate for treatments.

CONCLUSIONS

The Epley maneuver was similar to the Semont maneuver in both efficacy and safety for posterior canal benign paroxysmal positional vertigo in short-term effects, and both were superior to the sham-controlled treatment.

LEVEL OF EVIDENCE

NA.

Benign paroxysmal positional vertigo: opportunities squandered

Benign paroxysmal positional vertigo (BPPV) presentations are unique opportunities to simultaneously improve the effectiveness and efficiency of care. The test and treatment for BPPV--the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM), respectively--are supported by two evidence-based guidelines (American Academy of Otolaryngology--Head and Neck Surgery and American Academy of Neurology). With these processes, patients can be readily identified and treated at the bedside, quickly and without expensive tests. Patients randomized to the CRM have a cure rate of 80% at 24 h, compared to only 10% of controls. Despite this large effect size, less than 10% of affected patients receive the treatment, which shows that the management of BPPV in routine care is suboptimal. Future research is necessary to disseminate and implement the DHT and the CRM into routine practice.

A multicenter randomized double-blind study: comparison of the Epley, Semont, and sham maneuvers for the treatment of posterior canal benign paroxysmal positional vertigo

We evaluated the short-term efficacy of Epley, Semont, and sham maneuvers for resolving posterior canal benign paroxysmal positional vertigo (BPPV) in a prospective multicenter randomized double-blind controlled study. Subjects were randomly divided into three groups: Epley (36 patients), Semont (32 patients), and sham (Epley maneuver for the unaffected side, 31 patients). Out of 14 institutes which participated in this study, 5 institutes had previous experience of the Epley but not the Semont maneuver and the other 9 had previous experience of both maneuvers. Each maneuver was repeated twice if there was still positional vertigo or nystagmus on day 0, and the presence of nystagmus and vertigo on positional testing were evaluated immediately, 1 day, and 1 week after treatment. After the first maneuver, the Epley group showed a significantly higher resolution rate of positional nystagmus than the Semont or sham groups (63.9, 37.5, and 38.7%, respectively). After the second maneuver, the resolution rate (83.3%) of the Epley group was significantly higher than that (51.6%) of the sham group. At 1 day and 1 week after treatment, the resolution rate of the Epley group was significantly higher than those of the other groups. Similar results were seen for the resolution of positional vertigo. The Epley maneuver showed persistent resolution rates of positional vertigo and nystagmus without a fatigue phenomenon. The Epley maneuver was significantly more effective per maneuver than Semont or sham maneuvers for the short-term treatment of posterior canal BPPV. The Semont maneuver showed a higher success rate than the sham maneuver, but it was not significantly different.

Natural history of horizontal canal benign paroxysmal positional vertigo is truly short

The objective of the study is to characterize the natural course of positional vertigo and nystagmus in patients with horizontal canal benign paroxysmal positional vertigo (h-BPPV) and to analyze the difference in the natural course between the two variants of h-BPPV. We conducted a prospective study in 106 patients with geotropic type h-BPPV [h-BPPV (Geo)] (n = 43) and apogeotropic type h-BPPV [h-BPPV (Apo)] (n = 63) who agreed and signed the written informed consent of no treatment. All patients were asked to answer a detailed interview about the onset time of positional vertigo and to visit the hospital every 1-3 days. At every visit, they were interviewed about cessation time of positional vertigo and positional nystagmus was assessed. The mean period ± SD between the onset and remission of vertigo in the h-BPPV (Geo) was 6.7 ± 6.3 days, whereas that in the h-BPPV (Apo) was 3.7 ± 4.1 days. In addition, the mean period ± SD from the initial diagnosis to the disappearance of positional nystagmus in the h-BPPV (Geo) was 4.7 ± 3.9 days, whereas that in the h-BPPV (Apo) was 4.4 ± 5.0 days. Although the duration until natural remission of positional nystagmus did not differ between the two variants of h-BPPV, the remission of vertigo occurred faster in h-BPPV (Apo) than h-BPPV (Geo) (p < 0.05). The natural course of h-BPPV is much shorter than that indicated in previous reports. The positional vertigo disappeared faster in the h-BPPV (Apo) compared to the h-BPPV (Geo) unlike the positional nystagmus.

Efficacy of computer-controlled repositioning procedure for benign paroxysmal positional vertigo

OBJECTIVES/HYPOTHESIS

To evaluate the short-term efficacy of the computer-controlled canalith repositioning procedure (CRP) for treatment of posterior canal benign paroxysmal positional vertigo (BPPV) compared with the current standard CRP.

STUDY DESIGN

Prospective case series.

METHODS

One hundred thirty-two patients diagnosed as having idiopathic posterior canal BPPV, with an age range of 28 to 86 years (mean 56 years), 47 men and 85 women, were treated with computer-controlled CRP mimicking the Epley maneuver. Resolution of vertigo and nystagmus on the Dix-Hallpike test at 1-week follow-up after treatment was the main outcome measure to assess the efficacy of treatment.

RESULTS

At 1-week follow-up after treatment with computer-controlled CRP, 108 (81.8%) of 132 patients had complete resolution of vertigo and nystagmus, nine (6.8%) had resolution of vertigo but presence of nystagmus, and 15 (11.4%) had provoked vertigo and nystagmus on the Dix-Hallpike test. The 81.8% success rate was comparable to those who received current standard CRP treatment in randomized controlled trials at about 80%. No significant adverse effects or complications occurred in the patients treated with computer-controlled CRP, aside from two patients (1.5%) with conversion into lateral canal BPPV.

CONCLUSIONS

Computer-controlled CRP is effective for the treatment of posterior canal BPPV, with a success rate similar to those treated with the Epley maneuver, and is safe and easy to perform on patients.

Vestibular suppressants after canalith repositioning in benign paroxysmal positional vertigo

OBJECTIVES/HYPOTHESIS

To investigate the characteristics of residual symptoms and to evaluate the effects of adjuvant vestibular suppressants on residual symptoms after successful canalith repositioning procedures (CRPs).

STUDY DESIGN

Individual randomized controlled trial.

METHODS

One hundred fifty patients with idiopathic benign paroxysmal positional vertigo who achieved successful CRPs on initial visit participated in this study. Dizziness Handicap Inventory (DHI) questionnaires were completed before CRPs. All study populations were divided into three groups after successful CRPs on the initial visit day: the medication (V) group (treated with a vestibular suppressant [dimenhydrinate 50 mg per day]), the placebo (P) group, and the no medication (N) group. One week after successful CRPs, residual symptoms were checked and repeated DHI questionnaires were completed to compare residual symptoms.

RESULTS

Among the 138 patients who did not show positional nystagmus at follow-up, 67 (48.5%) complained of residual symptoms. The presence of residual symptoms was more prevalent in the P and N group compared with the V group (P = .035, P = .017, respectively). The most frequent residual symptom was lightheadedness (n = 42). Moreover, in the V group, lightheadedness was significantly reduced compared with the P group (P = .029). However, in the analysis of DHI, total and subscale scores did not differ across the three groups before or after successful CRP.

CONCLUSIONS

Vestibular suppressants significantly reduced residual symptoms compared to both placebo and no medication after CRP. However, there was no significant reduction in DHI score compared with the control group, suggesting that the residual symptoms could not be evaluated by DHI score alone.

Rapid Systematic Review of the Epley Maneuver for Treating Posterior Canal Benign Paroxysmal Positional Vertigo

OBJECTIVE

The aim of this study was to compare watchful waiting to the Epley maneuver as a management option for patients with posterior canal benign paroxysmal positional vertigo (p-BPPV) regarding symptom relief.

DATA SOURCES

PubMed, Embase, and The Cochrane Library.

METHODS

A systematic search was conducted. Studies reporting original study data were included. Relevance and risk of bias (RoB) of the selected articles were assessed. Studies with low relevance, high RoB, or both were excluded. Absolute risk differences and their 95% confidence intervals (CIs) were extracted for the included studies.

RESULTS

A total of 1448 unique studies were retrieved. Eight of these satisfied the eligibility criteria. At 1-week follow-up, all included studies reported a clinically relevant effect in favor of the Epley maneuver regarding symptom relief (absolute risk differences ranging from 20% [95% CI, 5%-37%] to 59% [95% CI, 32%-76%]) or conversion to a negative Dix-Hallpike (absolute risk differences ranging from 17% [95% CI, -5%-37%] to 64% [95% CI, 29%-79%]). At 1-month follow-up, the results of the included studies diverged further. Absolute risk differences ranged from 6% (95% CI, -24%-35%) more symptom relief in favor of watchful waiting to 79% (95% CI, 56%-88%) in favor of the Epley maneuver.

CONCLUSION AND RECOMMENDATIONS

All data of the selected studies show a benefit in favor of the Epley maneuver at 1-week follow-up in the management of p-BPPV. The Epley maneuver should be considered in all patients with p-BPPV.

Evidence-based practice: management of vertigo

The article focuses on the evidence basis for the management of benign paroxysmal positional vertigo, the most common diagnosis of vertigo in both primary care and subspecialty settings. An overview is presented, along with evidence-based clinical assessment, diagnosis, and management. Summaries of differential diagnosis of vertigo and outcomes are presented.

Clinical evaluation of posterior canal benign paroxysmal positional vertigo

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is a mechanical peripheral vestibular disorder which may involve any of the three semicircular canals but principally the posterior. In as much as the literature has described theories to explain the mechanism of BPPV and also contains scholarly works that elucidate BPPV; its management remains an enigma to most clinicians. To this end, this work was aimed at outlining an evidence-based best practice for most common form of BPPV.

MATERIALS AND METHODS

A systematic review of the literature was conducted between 1948 and June 2011 in PubMed, Embase, Ovid, and Cochrane database through the online Library of the University of Cape Town. Seventy-nine worthy articles that addressed the study were selected on consensus of the two authors.

CONCLUSION

There is consensus for the use of canalith repositioning procedures as the best form of treatment for posterior canal canalolithiasis. However, successful treatment is dependent on accurate identification of the implicated canal and the form of lithiasis. Furthermore, clinicians should note that there is no place for pharmacological treatment of BPPV; unless it is to facilitate repositioning.

Anxiolytics reduce residual dizziness after successful canalith repositioning maneuvers in benign paroxysmal positional vertigo

CONCLUSIONS

This study suggests that adjuvant anti-anxiety medication may be helpful for patients with benign paroxysmal positional vertigo (BPPV) even after a successful canalith repositioning procedure (CRP).

OBJECTIVE

Although the CRP is an effective treatment for BPPV, many patients suffer from persistent dizziness despite successful CRPs. The aim of this study was to evaluate the effect of adjuvant anxiolytic medication on residual dizziness after successful CRP.

METHODS

Between January 2011 and March 2011, 73 patients were diagnosed with BPPV and they underwent successful treatment with CRPs. The patients were randomly assigned to either the medication group or the control group. The patients in the medication group were prescribed low dose etizolam for 2 weeks whereas the patients in the control group were not prescribed any medication. All patients were scheduled to return 2 weeks after evaluation of subjective visual vertical. Subjective symptoms before and after CRP were measured using the Dizziness Handicap Inventory (DHI) and the Activities-specific Balance Confidence (ABC) scale.

RESULTS

Both groups demonstrated a significant improvement in DHI scores. However, the medication group showed significantly greater decrease in the functional (p = 0.018) and emotional (p = 0.030) subscale scores, as well as in the total DHI (p = 0.038) score.

Effect of the canalith repositioning procedure on subjective visual horizontal in patients with posterior canal benign paroxysmal positional vertigo

CONCLUSION

Substantial numbers of patients with posterior canal benign paroxysmal positional vertigo (p-BPPV) have signs of utricular dysfunction at baseline. This improves after performing the canalith repositioning procedure.

OBJECTIVE

To evaluate the changes of subjective visual horizontal (SVH) in patients with p-BPPV before and after treatment with the canalith repositioning procedure.

METHODS

Twenty-six patients with p-BPPV were treated with the canalith repositioning procedure, Epley's maneuver, according to the affected side. Baseline SVH measurements were taken before performing the Dix-Hallpike maneuver and Epley's maneuver, for comparison with measurements taken just after Epley's maneuver, and 2 weeks after Epley's maneuver.

RESULTS

Among 26 patients with p-BPPV, 11 (42%) showed abnormal deviation of SVH at baseline. Just after performing Epley's maneuver, the number of patients who showed an abnormal deviation of SVH decreased significantly to 15% (4 of 26 patients; p < 0.05). Two weeks after performing Epley's maneuver, only two patients (8%) showed an abnormal deviation of SVH (p < 0.001).

Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo.

PURPOSE

The purpose of this systematic review was to determine whether patients diagnosed with posterior canal (PC) BPPV, based on positional testing, and treated with a particle repositioning maneuver will show the resolution of benign paroxysmal positional nystagmus (BPPN) on the Dix-Hallpike Test performed 24 hours or more after treatment.

DATA SOURCES

Data were obtained from an electronic search of the MEDLINE, EMBASE, and CINAHL databases from 1966 through September 2009.

STUDY SELECTION

The study topics were randomized controlled trials (RCTs), quasi-RCTs, the diagnosis of PC BPPV, treatment with the particle repositioning maneuver, and outcome measured with a positional test 24 hours or more after treatment.

DATA EXTRACTION

Data extracted were study descriptors and the information used to code for effect size.

DATA SYNTHESIS

In 2 double-blind RCTs, the odds in favor of the resolution of BPPN were 22 times (95% confidence interval=3.41-141.73) and 37 times (95% confidence interval=8.75-159.22) higher in people receiving the canalith repositioning procedure (CRP) than in people receiving a sham treatment. This finding was supported by the results reported in 8 nonmasked quasi-RCTs. Studies with limited methodological quality suggested that a liberatory maneuver (LM) was more effective than a control intervention; there was no significant difference in the effectiveness of the LM and the effectiveness of the CRP; the self-administered CRP was more effective than the self-administered LM; and the CRP administered together with the self-administered CRP was more effective than the CRP administered alone. The Brandt-Daroff exercises were the least effective self-administered treatments.

LIMITATIONS

The limitations included the methodological quality of the studies, the lack of quality-of-life measures, and confounding factors in reporting vertigo.

CONCLUSIONS

Randomized controlled trials provided strong evidence that the CRP resolves PC BPPN, and quasi-RCTs suggested that the CRP or the LM performed by a clinician or with proper instruction at home by the patient resolves PC BPPN. There were no data on the effects of the maneuvers on outcomes relevant to patients.

Avaliação da manobra de reposicionamento de Epley em indivíduos com vertigem posicional paroxística benigna

OBJETIVO: avaliar os parâmetros estabilométricos após a manobra de reposicionamento de Epley em indivíduos com Vertigem Posicional Paroxística Benigna (VPPB) previamente confirmada através da manobra de Dix-Hallpike. MÉTODOS: estudo experimental que incluiu pacientes que apresentaram VPPB com nistagmo de posicionamento à prova de Dix-Hallpike, avaliados no ano de 2008, no Ambulatório Multidisciplinar de Vertigem, e que foram submetidos à manobra de reposicionamento de Epley e avaliados quanto ao equilíbrio postural pelo exame de Estabilometria, antes e após a citada manobra. RESULTADOS: os 13 indivíduos do gênero feminino com idade variando de 15 a 78 anos com VPPB, previamente confirmados e selecionados para a pesquisa, apresentaram melhora estatisticamente significante em parâmetros estabilométricos verificados da primeira para a segunda avaliação, confirmando melhora do equilíbrio postural, após a manobra de Epley. CONCLUSÃO: nesta pesquisa a manobra de reposicionamento de Epley mostrou-se como um procedimento de intervenção importante para a melhora das respostas do equilíbrio postural em indivíduos com VPPB avaliados pela estabilometria.

The evidence base for the evaluation and management of dizziness

OBJECTIVES

Dizziness presentations pose many clinical challenges. The objective of this study is to broadly summarize the evidence base that supports clinical decisions in dizziness presentations.

METHODS

MEDLINE (1966 to September 2007), Web of Science and The Cochrane Library were searched for articles with clinical relevance on topics concerning dizziness. Additional sources were also searched for clinical practice guidelines. The following information was abstracted from each article: year of publication, journal type, type of article and the topics of the article.

RESULTS

Of nearly 3000 articles identified, 1244 articles met the inclusion criteria. The most common article type was a case report or case series, followed by expert opinion or review articles, studies of medical tests and clinical trials. Meta-analyses and systematic reviews were found on benign paroxysmal positional vertigo and Meniere's disease, but only a few other topics. No clinical practice guidelines were found that focus specifically on dizziness.

CONCLUSIONS

The evidence base for the evaluation and management of dizziness seems to be weak. Future work to establish or summarize evidence in clinically meaningful ways could contribute to efforts to optimize patient care and health care utilization for one of the most common presenting symptoms.

Analysis of Residual Symptoms after Treatment in Benign Paroxysmal Positional Vertigo Using Questionnaire

OBJECTIVES: Canalith repositioning procedure (CRP) provides rapid and long-lasting relief of symptoms in most patients with benign paroxysmal positional vertigo. However, some patients express nonspecific symptoms such as anxiety or discomfort after treatment, even after the disappearance of nystagmus and vertigo. The purpose of this study was to assess the residual symptoms after CRP in patients with benign paroxysmal positional vertigo using the Dizziness Handicap Inventory (DHI) in a questionnaire format.

STUDY DESIGN AND SETTING: Controlled, prospective study.

SUBJECTS AND METHODS: CRP was performed in 135 patients until nystagmus and vertigo disappeared. Patients were asked to complete the questionnaire before and 5 to 7 days after treatment. A control group of 135 normal volunteers was selected and cross-matched according to the age and sex of the patient group. The data were compared for the pre-CRP, post-CRP, and control groups.

RESULTS: There was a significant improvement in the DHI scores when comparing the pre- and post-CRP groups ( P = 0.000), although six items showed incomplete improvement. Subsequent comparison of DHI scores between the control group and the post-CRP group still showed a difference in some items so that the improvement was incomplete.

CONCLUSION: Even after successful CRPs, Dizziness Handicap Inventory scores indicated that residual subjective symptoms may remain. Thus, additional follow-up and management are important for these patients.

Reliability of a rating scale used to distinguish direction of eye movement using infrared/video ENG recordings during repositioning maneuvers

The purpose of this study was to determine the validity of the nystagmus rating scale (NRS) and to assess inter- and intra-rater reliability of audiologists and experts using the scale. Face and content validity was established by eliciting feedback from two neurotologists and one neurologist. A training tape was developed to describe the rating scale and provide practice with patterns of nystagmus in benign paroxysmal positional vertigo (BPPV). Eye movements of 34 patients, ages 33 to 82 years, were videotaped using infrared/video ENG during repositioning maneuvers. Six randomly paired audiologists and six experts viewed the videotape recordings and completed the NRS for each pattern. Cohen's kappa coefficients were calculated to determine inter-rater reliability. The kappa values were 0.31 with 41% agreement for audiologists, and 0.48 with 59% agreement for experts. Intra-rater reliability for a subgroup of audiologists was 0.55 with 64% agreement, and for experts was 0.75 with 81% agreement. In summary, even in this experienced population, additional training in viewing nystagmus patterns is needed to improve reliability among clinicians during diagnosis and treatment.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo

Objectives:

This guideline provides evidence-based recommendations on managing benign paroxysmal positional vertigo (BPPV), which is the most common vestibular disorder in adults, with a lifetime prevalence of 2.4 percent. The guideline targets patients aged 18 years or older with a potential diagnosis of BPPV, evaluated in any setting in which an adult with BPPV would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with BPPV.

Purpose:

The primary purposes of this guideline are to improve 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 tests such as radiographic imaging and vestibular testing, and to promote the use of effective repositioning maneuvers for treatment. In creating this guideline, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of audiology, chiropractic medicine, emergency medicine, family medicine, geriatric medicine, internal medicine, neurology, nursing, otolaryngology–head and neck surgery, physical therapy, and physical medicine and rehabilitation.

Results

The panel made strong recommendations that 1) clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with nystagmus is provoked by the Dix-Hallpike maneuver. The panel made recommendations against 1) radiographic imaging, vestibular testing, or both in patients diagnosed with BPPV, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to BPPV that warrant testing; and 2) routinely treating BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines. The panel made recommendations that 1) if the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, clinicians should perform a supine roll test to assess for lateral semicircular canal BPPV; 2) clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo; 3) clinicians should question patients with BPPV for factors that modify management including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling; 4) clinicians should treat patients with posterior canal BPPV with a particle repositioning maneuver (PRM); 5) clinicians should reassess patients within 1 month after an initial period of observation or treatment to confirm symptom resolution; 6) clinicians should evaluate patients with BPPV who are initial treatment failures for persistent BPPV or underlying peripheral vestibular or CNS disorders; and 7) clinicians should counsel patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The panel offered as options that 1) clinicians may offer vestibular rehabilitation, either self-administered or with a clinician, for the initial treatment of BPPV and 2) clinicians may offer observation as initial management for patients with BPPV and with assurance of follow-up. The panel made no recommendation concerning audiometric testing in patients diagnosed with BPPV.

Disclaimer:

This clinical practice guideline is not intended as a sole source of guidance in managing benign paroxysmal positional vertigo. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgement or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem. ® 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

Evaluation of meta-analyses in the otolaryngological literature

OBJECTIVE: To evaluate the quality of meta-analyses written on otolaryngological topics and define areas that can be improved upon in future studies.

DATA SOURCES: MEDLINE (PubMed) and EMBASE databases were searched. The Cochrane database of systematic reviews was excluded, because these meta-analyses have already been critically evaluated and found to be of high quality.

REVIEW METHODS: A systematic review of otolaryngological meta-analyses published between 1997 and 2006 (10 years) was performed in duplicate and independently by two authors. The search included 16 common otolaryngological terms. Inclusion criteria were meta-analytic methodology, otolaryngological topic, and at least one author from a department of otolaryngology. Fifty-one articles fulfilled eligibility criteria. In duplicate and independently, two reviewers assessed the quality of eligible metaanalyses using a validated 10-item index called the Overview Quality Assessment Questionnaire. Using the methods of Spearman, correlation coefficients are reported for associations examined between covariates and the Overall Score Quality.

RESULTS: The majority of studies had methodologic flaws (mean score 3.9, scale of 1-7). Variables predicting higher-quality meta-analyses were publication in journals with higher impact factors ( P = 0.0007) and authors who previously published metaanalyses ( P = 0.0001). Using and reporting about a validity assessment tool needs to be improved upon in future studies.

CONCLUSION: The quality of meta-analyses on otolaryngological topics is moderate. Future meta-analyses can be improved upon by following evidence-based guidelines for the reporting of metaanalyses, which include the use of a validity assessment tool, and consulting with an author familiar with meta-analysis methodology.

Balance improvement in patients with benign paroxysmal positional vertigo

Objective: To investigate the effect of an additional vestibular stimulated exercise programme on balance for patients with benign paroxysmal positional vertigo.

Design: Randomized controlled trial.

Setting: Medical centre.

Subjects: Twenty-six subjects with benign paroxysmal positional vertigo involving the unilateral posterior semicircular canal.

Interventions: Subjects were randomized into experimental or control groups. Thirteen subjects in the experimental group received the canalith repositioning manoeuvre and vestibular stimulated exercise training three times a week for four weeks. Thirteen subjects in the control group received only the canalith repositioning manoeuvre.

Main measures: Static balance tests, tandem walk test, Dynamic Gait Index and subjective rating of the intensity of vertigo were measured at baseline, two-week and four-week assessments.

Results: Compared with the control group, subjects in the experimental group demonstrated a statistically significant improvement in single leg stance with eyes closed at the two-week assessment (P<0.05). Furthermore, stance on foam surface with eyes closed, single-leg stance with eyes closed, and Dynamic Gait Index at the four-week assessment were also significantly improved (P<0.05).

Conclusion: The present study demonstrated that additional exercise training, which emphasizes vestibular stimulation, can improve balance ability and functional gait performance among patients with benign paroxysmal positional vertigo who had already undergone the canalith repositioning manoeuvre.

Neuro-ophthalmology

Neuro-ophthalmologic disorders arise from all areas of the neuro-ophthalmologic tract. They may be expressed simply as loss of vision or double vision, or as complex syndromes or systemic illnesses, depending on the location and type of lesion. Problems may occur anywhere along the visual pathway, including the brainstem, cavernous sinus, subarachnoid space, and orbital apex, and may affect adjacent structures also. A firm understanding of the neuroanatomy and neurophysiology of the eye is essential to correct diagnosis.

Epley's maneuver in benign paroxysmal positional vertigo associated with Meniere's disease

The effects of Epley’s maneuver in benign paroxysmal positional vertigo (BPPV) associated with Menière’s disease are controversial.

Aims

To evaluate the progression of positional vertigo and nystagmus after one or more of Epley’s maneuvers in BPPV associated with Menière’s disease, and the recurrence of BPPV.

Method

a retrospective study of 62 patients with BPPV associated with Menière’s disease, that underwent Epley’s maneuver, and that were monitored during 12 months after elimination of positional nystagmus.

Results

One Epley’s maneuver was required to eliminate positional nystagmus in 80.7% of the patients, two in 16.1%, and three in 3.2%; after elimination of nystagmus, positional vertigo was suppressed in 71.0% of the patients, improved in 27.4% and remained unaltered in 1.6%. Four weeks after elimination of positional nystagmus, all patients were asymptomatic. Recurrence of BPPV was seen in 19.4% of the cases, with elimination of the positional vertigo and nystagmus by means of the specific maneuver for the involved canal.

Conclusions

In BPPV associated with Menière’s disease, vertigo and positioning nystagmus were eliminated with one, two or three Epley maneuvers. BPPV recurrence was resolved by using a specific maneuver for the affected canal.

Manobra de Epley na vertigem posicional paroxística benigna associada à doença de Ménière

Os efeitos da manobra de Epley na vertigem posicional paroxística benigna (VPPB) associada à doença de Ménière são controvertidos. OBJETIVO: Avaliar a vertigem e o nistagmo de posicionamento após uma ou mais manobras de Epley na vertigem posicional paroxística benigna (VPPB) associada à doença de Ménière e na recorrência da VPPB. MATERISL E MÉTODO: Estudo retrospectivo de 62 pacientes com VPPB associada à doença de Ménière submetidos à manobra de Epley e acompanhados durante 12 meses após a extinção do nistagmo de posicionamento. RESULTADOS: Para abolir o nistagmo de posicionamento, foi necessária uma manobra de Epley em 80,7% dos pacientes, duas em 16,1% e três em 3,2%. A vertigem foi eliminada em 71,0% dos pacientes, melhorou em 27,4% e permaneceu inalterada em 1,6%. Quatro semanas após a extinção do nistagmo de posicionamento, todos os pacientes ficaram assintomáticos. Recorrência da VPPB foi observada em 19,4% dos casos, com eliminação da vertigem e nistagmo de posicionamento à manobra específica para o canal afetado. CONCLUSÕES: Na VPPB associada à doença de Ménière, vertigem e nistagmo de posicionamento foram eliminados com uma, duas ou três manobras de Epley. A recorrência da VPPB foi resolvida com uma manobra para o canal envolvido.

Repeated Epley’s maneuver in the same session in benign positional paroxysmal vertigo

Aim

To assess whether more than one Epley’s maneuver in the same session, compared to a single one, decreases the number of sessions necessary to suppress positional nystagmus.

Method

Epley’s maneuver was done in 123 patients with BPPV due to unilateral posterior semicircular canal canalolithiasis. The number of sessions for positional nystagmus suppression was compared in two groups of patients. Group I consisted of 75 patients submitted to a single Epley’s maneuver on weekly sessions and group II consisted of 48 patients that were submitted to four Epley’s maneuvers during the first session.

Results

Group II showed greater nystagmus latency and duration than group I (p<0.05). The number of sessions and standard deviation showed by group I was greater than in group II (p=0.008). We observed a significant association between number of sessions and group (p=0.039) studied. Group II had 21.4% more nystagmus-free patients following only one session (CI95% [7.7% - 35.1%]).

Conclusion

Repeated Epley’s maneuvers in less sessions rendered more positional nystagmus-free patients when compared to those submitted to more sessions of single maneuvers.

Short-term efficacy of Epley's manoeuvre: a double-blind randomised trial

BACKGROUND

Benign paroxysmal positional vertigo of the posterior canal (PC-BPPV) is a common vestibular disorder and can be easily treated with Epley's manoeuvre. Thus far, the short-term efficacy of Epley's manoeuvre for treatment of PC-BPPV is unknown.

OBJECTIVES

To evaluate the efficacy of Epley's manoeuvre for treatment of PC-BPPV 24 h after applying the manoeuvre.

METHODS

The short-term efficacy of Epley's manoeuvre was compared with a sham procedure in 66 patients with PC-BPPV by using a double-blind randomised study design.

RESULTS

24 h after treatment, 28 of 35 (80%) patients in the Epley's manoeuvre group had neither vertigo nor nystagmus on positional testing compared with 3 of 31 (10%) patients in the sham group (p<0.001).

CONCLUSION

Epley's manoeuvre is shown to resolve PC-BPPV both effectively and rapidly.

Nystagmus: an update on treatment in adults

Recent developments in the treatment of nystagmus in adults have changed the traditional approach to such illnesses as benign paroxysmal positional vertigo, vestibular neuritis, Meniere's disease, superior canal dehiscence syndrome, vestibular paroxysmia, superior oblique myokymia, downbeat/upbeat nystagmus and acquired pendular nystagmus, as well as periodic alternating nystagmus. Treatments reported to suppress nystagmus, with tolerable side effects, are now available for some of these syndromes. Due to the absence of large controlled studies, however, treatment recommendations rest only on class C evidence.

Restrições posturais não interferem nos resultados da manobra de reposição canalicular

A Vertigem Posicional Paroxística Benigna (VPPB) é uma das mais comuns doenças da orelha interna que cursam com tontura, porém o seu tratamento ainda é algo de inúmeras controvérsias. OBJETIVO: Avaliar a influência das orientações posturais na evolução precoce de pacientes com diagnóstico de VPPB de canal semicircular posterior, submetidos à manobra de Epley. FORMA DE ESTUDO: Prospectivo randomizado. MATERIAL E MÉTODO: Foram avaliados 50 pacientes com diagnóstico de VPPB de canal semicircular posterior submetidos à manobra de reposição canalicular de Epley, divididos em Grupo de Estudo - 23 pacientes - que receberam orientações de restrição postural pós-manobra e Grupo Controle - 27 pacientes - que não receberam orientações. RESULTADOS: Não houve diferença estatisticamente significante entre os grupos estudados quanto à resolução dos sintomas da VPPB independentemente de sexo e idade. CONCLUSÃO: A eficácia da Manobra de Reposição Canalicular de Epley não é influenciada pelo uso ou não das restrições posturais.

Episodic vertigo

PURPOSE OF REVIEW

This review focuses on three neuro-otological syndromes, which are all marked by rapid scientific progress on the one hand but under-recognition or undertreatment on the other: benign paroxysmal positional vertigo and its variants, superior semicircular canal dehiscence syndrome, and migrainous vertigo.

RECENT FINDINGS

The efficacy of Epley's maneuver for treatment of benign paroxysmal positional vertigo has been convincingly demonstrated by a meta-analysis of nine randomized controlled trials. Head vibration during Epley's procedure and keeping upright for 48 h after effective treatment do not improve the outcome. Superior canal dehiscence syndrome presents not only with sound and pressure-induced vertigo but also with conductive hearing loss at low frequencies. Migrainous vertigo may present not only with spontaneous attacks but also with positional vertigo or with chronic dizziness and imbalance. Vestibular rehabilitation has been proven to relieve chronic dizziness and visual vertigo.

SUMMARY

Recent studies have eliminated several white spots on the neuro-otological map. However, many areas are still unexplored, particularly with regard to treatment of specific vestibular syndromes where randomized controlled trials are just at their beginning.

Posture restrictions do not interfere in the results of canalith repositioning maneuver

Benign Paroxysmal Positional Vertigo (BPPV) is a frequent cause of dizziness and despite of the excellent results with its treatment, there is some controversy about management.

Aim

To assess the efficacy of Epley Maneuver with and without post-maneuver restrictions.

Study design

Prospective randomized.

Material and Method

Fifty patients presenting BPPV of the posterior semicircular canal, treated with Epley Maneuver and divided into two groups: study group – 23 patients – with post-maneuver restrictions, and control group – 27 patients – without post-maneuver restrictions.

Results

No significant difference was found between the studied and the control group.

Conclusion

Post-maneuver restrictions do not influence the efficacy of Epley Maneuver for BPPV management.