Efficacy of Epley's Maneuver in Treating BPPV Patients: A Prospective Observational Study

Epley's Manoeuvre vs. Semont's Maneuver in Post-Canal Benign Paroxysmal Positional Vertigo: A Comparative Study in a Tertiary Centre

Benign paroxysmal positional vertigo (BPPV) is a common vestibular disorder characterized by brief episodes of vertigo triggered by changes in head position. Epley's manoeuvre and Semont's manoeuvre are widely used canalith repositioning procedures for the treatment of BPPV. This study aimed to compare the effectiveness of these two manoeuvres in treating post-canal BPPV in a cohort of 100 patients.

METHODS

This was a prospective, comparative study conducted at a tertiary care hospital. One hundred patients diagnosed with post-canal BPPV were randomized into two groups: Group A (n = 50) underwent the Epley's manoeuvre, and Group B (n = 50) underwent the Semont's manoeuvre. The patients were assessed for the resolution of vertigo and nystagmus immediately after the manoeuvre and at a follow-up visit one week later. The resolution of symptoms was confirmed through Dix-Hallpike test.

RESULTS

In Group A, 46 patients (92%) reported complete resolution of vertigo immediately after Epley's manoeuvre, and 47 patients (94%) had no nystagmus on the Dix-Hallpike test at the one-week follow-up. In Group B, 42 patients (84%) reported complete resolution of vertigo immediately after Semont's manoeuvre, and 44 patients (88%) had no nystagmus on the DH test at the one-week follow-up. The difference in effectiveness between the two manoeuvres was not statistically significant (p > 0.05).

CONCLUSION

Both Epley's manoeuvre and Semont's manoeuvre are effective in treating post-canal BPPV, with similar success rates. The choice of manoeuvre may depend on patient preference, clinician expertise, and other individual factors. Further studies with larger sample sizes are warranted to validate these findings and explore other potential factors influencing the outcomes of canalith repositioning manoeuvres in BPPV.

Treatment efficacy of repositioning maneuvers in multiple canal benign paroxysmal positional vertigo: a systematic review and meta-analysis

Introduction

Benign paroxysmal positional vertigo (BPPV) involving the posterior canal is more common than other canals; however, simultaneous involvement of multiple canals can be seen up to 20% of all BPPV cases. The diagnosis and management of multiple canal BPPV can be quite challenging due to the complexity of findings. Therefore, this systematic review and meta-analysis aimed at unveiling the most effective repositioning strategy for the treatment of multiple canal BPPV.

Methods

A literature search through PubMed, Scopus, and Web of Science databases was conducted using search terms such as BPPV, multiple canals, bilateral BPPV, repositioning maneuvers etc. After duplicate removal, the retained articles underwent various stages of elimination by two independent reviewers, and a third reviewer resolved the discrepancy between them.

Results

A total of 22 articles were included in the systematic review. These publications documented 5,196 patients diagnosed with BPPV, of which 513 had multiple canal BPPV. Of 295 individuals with multiple canal BPPV, 58.9% were effectively treated in 1 session, whereas 18.3 and 4.4% achieved a symptom-free state after two and three sessions, respectively. Failure of treatment using repositioning maneuvers was found in 18.4%.

Possible implications

This study offers insight into the real world of BPPV management in single and multiple canal BPPV. It is evident that repositioning maneuvers provide rapid and long-lasting relief of BPPV in most single canal BPPV patients; however, multiple canal BPPV often requires repeated treatment, and the risk of recurrence is higher in this variety than the single canal BPPV.

Epleys Versus Semonts Manoeuvre in Posterior Canal Benign Paroxysmal Positional Vertigo

Introduction: Benign paroxysmal positional vertigo (BPPV), the most common vestibular disorder is characterized by short-lived episodes of rotatory vertigo in association with rapid changes in head position. Diagnosis of BPPV is clinical. The principle of treatment of BPPV involves maneuvers comprising of head movements, in order to bring the free debris from the semicircular canal back to the utricle. In this study we tried to evaluate and compare Epleys and the Semonts manoeuvre in the treatment of Benign paroxysmal positional vertigo of the posterior semicircular canal in terms of subjective and objective improvement. Materials and methods: Study Design: This prospective randomized study included 200 vertigo patients attending ENT OPD of tertiary care centre with Dix Hallpike positive status. (September 2017 -August 2019). Objective improvement was compared in terms of Dix Hallpike positivity between both groups on weekly follow up for four weeks. Subjective improvement was compared in both the groups by dizziness Handicapp index ( DHI) on follow-ups. Results: Total 200 patients formed part of study, with 100 in each group. On comparing Dix Hallpike positivity between both groups on weekly follow ups there was no significant difference between both the groups. DHI, compared between both groups showed that Semonts Maneouver was significantly better. Conclusion: In patients of BPPV both Epleys and Semonts are equally effective objectively. However the subjective improvement was better in patients on whom Semonts manoeuvre was performed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03624-5.

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

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

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.

Falls at advanced age - The importance to search for benign paroxysmal positional vertigo (BPPV)

INTRODUCTION

One of the most important geriatric syndromes is dizziness in conjunction with gait disorder and consequent falls. There are various differential diagnoses for dizziness, one of them is benign paroxysmal positional vertigo (BPPV).

OBJECTIVES

A targeted diagnostic work-up and treatment of BPPV can prevent subsequent falls and a decline in the patients' quality of life, prolonged hospitalization with unnecessary examinations and medication.

DESIGN

Prospective examination of patients with a positive medical history of BPPV.

SETTING AND PARTICIPANTS

All patients treated within the Department of Geriatrics between 05/2015 and 03/2018 were included. A total of n = 5166 patients were screened (n = 2651 geriatrics; n = 2515 controls).

METHODS

All patients from other wards subjected to a neurological examination due to vertigo served as controls. Patients with typical hints in the medical history for a BPPV were subjected to the diagnostic Dix-Hallpike maneuver and, if positive, subsequent canalith repositioning maneuvers. The percentage of successful positional treatments was determined in both groups.

RESULTS

N = 254 patients (4.9 %) had indications in the medical history for a BPPV. For 71 of n = 254 patients (28 %; in total 1.4 %; mean age: 78.4 ± 12.3 years) the diagnosis of BPPV was proven by a positive Dix-Hallpike maneuver. N = 39 (54.9 %) patients belong to the geriatric group (mean age 82 years) and n = 32 (45.1 %) to the control group (mean age 73.9 years). The frequency of BPPV was similar in both groups (1.3-1.5 %). In 91.9 % of patients the BPPV was localized in the posterior semicircular canal. Up to 93 % were asymptomatic after one or repeated canalith repositioning maneuvers.

CONCLUSIONS AND IMPLICATIONS

The BPPV should be considered as an important differential diagnosis for geriatric patients with dizziness and falls. After therapeutic repositioning maneuvers most of the patients are asymptomatic. Therefore, targeted screening and therapy ("theragnostic") of BPPV at an advanced age increases diagnostic accuracy and prevents unnecessary examinations, medications and future falls.

Clinical Study of BPPV and the Effectiveness of Canalolith Repositioning Manoeuvre in Subjects of BPPV

Vertigo is an illusion of motion, either of one self or of the environment. Vertigo in BPPV is a very devastating experience for the patient who experiences it. However, it can be reversible with vestibular rehabilitation, with very good results. A study on 72 patients attending Otoneurology clinic in our hospital, diagnosed as BPPV with history and examination were subjected to DHI (Dizziness Handicap Index) questionnaire prior to and after intervention and results were analyzed. BPPV is more commonly seen in elderly individuals above 45 yrs, females and posterior semi circular canal. A significant improvement was noted in all the three components of DHI index in patients treated with CRM (Canalolith Repositioning Manoeuver) when compared to the patients who received only reassurance. CRM is a very safe and effective treatment of BPPV which has the added advantage of being noninvasive procedure, with excellent results.

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.

A comparative study of two methods for treatment of benign paroxysmal positional vertigo in the emergency department

Introduction

Posterior canal benign paroxysmal positional vertigo (PC-BPPV) is considered the most common cause of peripheral vertigo in the emergency department (ED). Although the canalith repositioning maneuver (CRM) is the standard of care, the most effective method to deliver it in the ED has been poorly studied.

Objective

To compare two protocols of the Epley maneuver for the treatment of PC-BPPV.

Patients and methods

We prospectively recruited 101 patients with unilateral PC-BPPV on physical examination, randomizing them to either a single Epley maneuver (EM) (n = 46) or multiple maneuvers (n = 55) on the same visit. Measured outcomes included presence/absence of positional nystagmus, resolution of vertigo, and score on the dizziness handicap inventory (DHI) at follow-up evaluations. The DHI was stratified into mild (≤30) and moderate-severe (>30).

Results

Normalization of the Dix-Hallpike maneuver at day 5 was observed in 38% of the single EM group and 44.4% in the multiple EM group (p = 0.62). The DHI showed reduction from 42.2 (SD 18.4) to 31.9 (SD 23.7) in the single EM group and from 43.7 (SD 22.9) to 33.5 (SD 21.5) in the multiple EM group (p = 0.06). A higher number of patients improved from moderate-severe to mild DHI (p = 0.03) in the single EM group compared to the multi-EM group (p = 0.23).

Conclusion

There was no statistically significant difference between performing a single EM versus multiple EMs for treatment of PC-BPPV in the emergency department. The single EM approach is associated with shorter physical contact between patients and examiner, which is logically safer in a pandemic context.

Short Term Efficacy of Modified Epley’s Maneuvre Assisted by Visual Aid Dynamic Device Versus Unassisted Maneuvre for the Treatment of Posterior Canal BPPV

Introduction:

Modified Epley’s maneuver is the recommended treatment for the Posterior Canal (PC) BPPV. To enhance the efficacy of this maneuver, an easy to perform visual aid device (DizzyFIX) guided modified Epley’s maneuver was studied.

Material and Methods:

This prospective, double-blind, randomized study included consecutive patients with PC-BPPV based on clinical history, neuro-otological examination, and positive Dix- Hallpike (DHP) test from January 2018 to March 2019 at a neurology clinic of western India. Patients were randomly assigned treatment with either visual aid device assisted modified Epley’s maneuver, which constituted the case group or by a placebo device guided modified Epley’s maneuver, which constituted the control group. DizzyFIX was used as a visual aid device in the case group. Patients were followed up at one hour and 24 hours with DHP by the blinded examiners to observe for remission.

Results:

Out of 280 patients (140 patients in each group), 6 from the case, and 2 from the controls were lost from the follow-up. Overall, 134 cases were compared to 138 controls. The success rate of remission in the case and the control group at one-hour was 79.19% vs. 48.30%, respectively, with a p-value of 0.003. Similarly, the success rate in the case and control group at 24 hours was 95.27% vs. 80.62%, respectively, with a p-value of 0.011. At 1 hour, unadjusted Odd Ratio (OR) was 4.13, (C.I. 95% 2.02- 8.46) and at 24 hours, it was 4.37, (C.I. 95% 1.39-13.77), which was significant even after adjustment of co-variables (OR 4.02, C.I. 95% 2.34- 8.26) and (OR 4.11, C.I. 95% 2.30- 14.26), respectively.

Conclusion:

For short term treatment of PC-BPPV, DizzyFIX assisted modified Epley’s maneuver is more efficacious than unassisted modified Epley’s maneuver.

Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV

OBJECTIVE

To check the value of home particle repositioning maneuver in the prevention of the recurrence of posterior canal benign paroxysmal positional vertigo (pc-BPPV).

METHODS

In this study, patients diagnosed as unilateral posterior canal BPPV were selected following an accurate evaluation using video goggle VNG system. All patients were managed by particle repositioning maneuver (PRM). Patients were instructed to do home PRM once weekly for five years. Then, they were divided into two groups (according to choice of patient to do PRM). The first group (control group) consisted of 144 patients who did not do home PRM; whereas the second group (study group) included 165 patients who performed home PRM. All patients (control & study groups) were followed up every four months for five years.

RESULTS

The study found out that the recurrence rate of pc-BPPV in control group was 33 patients in the first year (27.2%), 11 patients in second year (9%), 5 patients in third year (4%), 3 patients in fourth year (2.5%) and 3 patients in fifth year (2.5%). The recurrence of pc-BPPV in the treated side (study group) of patients was reported as 5 patients in the first year (3.5%), 3 patients in the second year (2%), 2 patients in the third year (1.4%), 2 patients in the fourth year (1.4%), and 1 patient in the fifth year (0.7%). There was statistically significant difference between the control and the study groups regarding the recurrence rates in the first year follow up which was the highest in first four months.

CONCLUSION

Home particle repositioning maneuver has the capacity to prevent the recurrence of pc-BPPV. It proved to be more successful and functional in minimizing the recurrence of the disease in the study than in the control group. Hence, home particle repositioning maneuver is highly recommended for one year at least in pc-BPPV.