Questionnaire-based diagnosis of benign paroxysmal positional vertigo

Comparison of outcomes of the Epley and self-Epley maneuvers in PC-BPPV: A randomized controlled trial

OBJECTIVES

This study aimed to compare the efficacy of the self-Epley and Epley maneuvers in treating posterior canal benign paroxysmal positional vertigo (PC-BPPV) in patients at the outpatient clinic at the Department of Otolaryngology, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.

METHODS

In this prospective, randomized, comparative study, patients with PC-BPPV were randomized to receive the self-Epley or Epley maneuver. The self-Epley maneuver group received illustrated instructions and a video of how to perform the self-Epley maneuver. They then performed the first self-Epley maneuver under supervision in the clinic. The efficacy of the treatment was evaluated with the Dix-Hallpike test at the 1-week follow-up visit.

RESULTS

Sixty-four patients with PC-BPPV were enrolled, 32 patients were the self-Epley maneuver group and the other 32 patients were the Epley maneuver group. After 1 week, 29 of the 32 patients (90.62 %) in the self-Epley maneuver group were cured, while 28 of the 32 patients (87.5 %) in the Epley maneuver group were cured. The Kaplan-Meier survival estimates with a log-rank test for cumulative therapeutic effects at 1 week showed no statistically significant difference between the groups (P = 0.755).

CONCLUSIONS

The twice-a-day self-Epley maneuver had a high success rate and could be used for patients who cannot reach a hospital or needs quarantine due to covid-19. For the self-Epley maneuver, adequate instruction is important to obtain a good result.

LEVEL OF EVIDENCE

II.

The reliability of a subtype-determining questionnaire in efficient benign paroxysmal positional vertigo diagnosis in geriatrics

Introduction

Benign paroxysmal positional vertigo (BPPV), the most common cause of dizziness, especially for older adults, exposes patients to the lethal risk of falling. However, the diagnosis of BPPV in this population can be more elusive as they present few characteristic symptoms. Therefore, we explored the application of a subtype-determining questionnaire in BPPV diagnosis among the geriatric population.

Methods

Patients were assigned to the aware and unaware groups. In the aware group, the technician would directly test the suspected canal indicated by the questionnaire, whereas, in the unaware group, the technician performed the regular positional test. The diagnostic parameters of the questionnaire were examined.

Results

The accuracy, sensitivity, and specificity of questions 1-3 for diagnosing BPPV were 75.8, 77.6, and 74.7%, respectively. Question 4 demonstrated an accuracy of 75.6% in ascertaining the BPPV subtype, question 5 showed an accuracy of 75.6% in determining the affected side, and question 6 yielded an accuracy of 87.5% in distinguishing canalithiasis or cupulolithiasis. Examination time was shorter in the aware group than that in the unaware group (P < 0.05). No difference was found between the two groups for treatment time (P = 0.153).

Conclusion

This subtype-determining questionnaire is practical in daily use and capable of providing instructive information for an efficient diagnosis in geriatric patients with BPPV.

Evaluating a Questionnaire in Telephone Balance Consultations during the Coronavirus Disease 2019 Pandemic

INTRODUCTION

During the coronavirus disease 2019, pandemic clinical practice had to change, and this study trialled a diagnostic questionnaire to assess patients with dizziness over the telephone.

METHODS

All 115 patients awaiting otorhinolaryngological assessment for balance were randomised to receive a dizziness questionnaire in the post prior to their telephone consultation or not. Consultation outcomes were recorded by the clinicians conducting the consultation. Follow-up data were collected in June 2022 for final outcomes.

RESULTS

82/115 patients had consultations with complete data collection: 35 in the questionnaire group (QG) and 47 in the no questionnaire group (NQG), with a 70% response rate in the QG. Clinicians made a diagnosis in 27/35 QG consultations versus 27/47 NQG consultations. Nine out of 35 QG patients required additional investigations compared to 34/47 in the NQG (p < 0.05). Only 6/35 QG patients needed additional telephone follow-up, compared to 20/47 NQG patients (p < 0.05).

CONCLUSION

Using a diagnostic questionnaire increased clinicians' ability to come to a diagnosis in telephone consultations.

Evaluation of a questionnaire as a screening tool for benign paroxysmal position vertigo

OBJECTIVE

To determine the value of a questionnaire as a screening tool for benign paroxysmal position vertigo (BPPV).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care centers.

METHODS

A total of 520 vertigo adults completed the questionnaire before the diagnosis was confirmed. After vestibular function examination and other diagnostic examination, the diagnosis of all participants was confirmed by experts. By validating valuable items from the questionnaire with 47 items, a new questionnaire of 5 items was formed to quickly diagnose BPPV. The internal consistency of the new questionnaire and validity were evaluated. The correlation between the score obtained from the new questionnaire and diagnosis was investigated. The mean score was also compared between groups with and without BPPV and diagnostic precision measures were calculated.

RESULTS

520 vertigo participants answered all the question completely and BPPV was identified in 138 participants (26.5%). The responses to questionnaire revealed preferable reproducibility (r = 0.898, P < 0.05) and internal consistency (Cronbach's α = 0.702) as well as the validity (Kaiser-Meyer-Olkin, KMO = 0.731). The higher the individual score, the more likely to be BPPV (B = 2.082; P < 0.05). The mean score of answers was greater in the group with a clinical diagnosis of BPPV compared to those without BPPV (F = 58.459, P < 0.05). The sensitivity of the screening tool was 92.8% and specificity was 88.5%, with an area under the ROC curve of 0.946 (95% confidence interval 0.926-0.965; P < 0.05).

CONCLUSION

The questionnaire proved to be of great value to screen for individuals with possible BPPV.

Effect of Self-treatment of Recurrent Benign Paroxysmal Positional Vertigo: A Randomized Clinical Trial

Importance

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

Objective

To determine the efficacy of a web-based diagnosis and treatment of BPPV when it recurs in patients with confirmed and treated BPPV.

Design, Setting, and Participants

This randomized, controlled, parallel-group, double-blind trial took place in multiple referral-based university hospitals in South Korea between July 2017 and February 2020. Of 728 patients (age ≥20 years) with diagnosed and treated BPPV, 585 were enrolled after excluding 143 who declined participation, could not use the internet, or had spinal problems, multicanal BPPV, or cognitive dysfunction. Patients were followed up for recurrence at least for 2 years until February 2022.

Interventions

Patients were randomly assigned (1:1) to the treatment or control group. The patients in the treatment group completed a questionnaire for diagnosis and received a video clip for self-administration of canalith repositioning maneuver (CRM) according to the type of BPPV diagnosed when they experienced positional vertigo again. Patients in the control group received a video clip for self-administration of CRM according to the type of BPPV that had been diagnosed on enrollment.

Main Outcomes and Measures

The primary outcome was self-reported resolution of positional vertigo post-CRM. Secondary outcomes included difficulties and requirement for assistance when using the program and any falls or other adverse events related to CRM. The primary outcome was analyzed using both intention-to-treat and per-protocol methods.

Results

Of 585 patients enrolled, 292 were randomized to the treatment group (mean [SD] age, 60.3 [12.8] years, 37 [64%] women) and 293 were randomized to the control group (mean [SD] age, 61.1 [13.2] years; 50 [71%] women). Overall, 128 (21.9%) had recurrence (58 in the treatment group and 70 in the control group), and 109 (85.2%) successfully used the web-based system. In the intention-to-treat analysis, 42 of 58 individuals (72.4%) in the treatment group and 30 of 70 individuals (42.9%) in the control group reported vertigo resolution (χ2 test: 95% CI, 0.13-0.46; P < .001).

Conclusions and Relevance

This trial proved the efficacy of a web-based system for the diagnosis and treatment of recurrent BPPV. Use of this system may play an important role in telemedicine for vestibular disorders.

Trial Registration

Clinical Research Information Service Identifier: KCT0002364.

Significance of subtype-determining questionnaire in efficient diagnosis and treatment of BPPV

BACKGROUND

Rapid recognition of benign paroxysmal positional vertigo (BPPV) matters in many ways, questionnaires evolve as a new alternative for diagnosis. A subtype-determining questionnaire is a more advanced but rarely studied type.

OBJECTIVE

To explore the practicability of a subtype-determining questionnaire in facilitating diagnosis and treatment of BPPV.

METHODS

A BPPV subtype-determining questionnaire was applied to vertiginous patients. All patients underwent the positional test, performed by one technician, who was either informed or uninformed about questionnaire results randomly. In the informed group, the technician checked the canal indicated by the questionnaire straightforwardly; in the uninformed group, she performed the conventional positional test. Diagnostic parameters of the questionnaire and disparities between the 2 groups were investigated.

RESULTS

The accuracy, sensitivity, specificity of question 1-3 for diagnosing BPPV is 74.4%, 90.9%, 66.6% respectively. Question 4 shows an accuracy of 80.7% in determining BPPV subtype, question 5 yields an accuracy of 78.7% in ascertaining the affected side, question 6 exhibits an accuracy of 87.2% in deciding canalithiasis or cupulolithiasis. Both examination and treatment time were shorter in the informed group (p < .05).

CONCLUSION

This subtype-determining questionnaire has appealing diagnostic ability. It provides valuable information that's conducive to fast diagnosis and efficient treatment of BPPV.

The Prevalence of Symptom Reporting for Benign Paroxysmal Positional Vertigo in a Traumatic Brain Injury Population

OBJECTIVE

To assess the prevalence of benign paroxysmal positional vertigo (BPPV) in traumatic brain injury population.

STUDY DESIGN

In this cross-sectional design, each subject completed screening for BPPV, which included subjective questioning and positional testing. Subjects were asked if they experienced dizziness with bed mobility. All were tested with the Dix-Hallpike and the roll test to determine if nystagmus consistent with BPPV was present.

SETTING

Brain injury inpatient rehabilitation unit.

PARTICIPANTS

Subjects admitted to the rehabilitation unit during a 6-month time frame who had a traumatic mechanism of brain injury or experienced a fall resulting from a neurologic event.

INTERVENTIONS

Diagnostic interventions included the Dix-Hallpike and roll tests.

MAIN MEASURES

The primary outcomes of this study were the prevalence of BPPV and symptom reports.

RESULTS

Seventy-six subjects met the inclusion criteria. Three subjects were transferred to acute care before screening for BPPV could be completed. Of the 73 subjects who completed the screening process, 42 (58%) tested positive for BPPV, of which only 7 (10%) reported subjective symptoms of dizziness and/or vertigo. χ2 Analysis of the two screening methods demonstrated a statistically significant difference in the positivity rate between tests (χ21 = 5.715, p = 0.017, Cohen's W = 0.279). If subjects responded yes to both screening questions, they were significantly more likely to test positive for BPPV with a moderate effect size of 0.279.

CONCLUSION

There was a high prevalence of BPPV within an inpatient rehabilitation facility in subjects with traumatic brain injury, with a small percentage of patients reporting dizziness with subjective questioning.

A Questionnaire-Based Ensemble Learning Model to Predict the Diagnosis of Vertigo: Model Development and Validation Study

Background

Questionnaires have been used in the past 2 decades to predict the diagnosis of vertigo and assist clinical decision-making. A questionnaire-based machine learning model is expected to improve the efficiency of diagnosis of vestibular disorders.

Objective

This study aims to develop and validate a questionnaire-based machine learning model that predicts the diagnosis of vertigo.

Methods

In this multicenter prospective study, patients presenting with vertigo entered a consecutive cohort at their first visit to the ENT and vertigo clinics of 7 tertiary referral centers from August 2019 to March 2021, with a follow-up period of 2 months. All participants completed a diagnostic questionnaire after eligibility screening. Patients who received only 1 final diagnosis by their treating specialists for their primary complaint were included in model development and validation. The data of patients enrolled before February 1, 2021 were used for modeling and cross-validation, while patients enrolled afterward entered external validation.

Results

A total of 1693 patients were enrolled, with a response rate of 96.2% (1693/1760). The median age was 51 (IQR 38-61) years, with 991 (58.5%) females; 1041 (61.5%) patients received the final diagnosis during the study period. Among them, 928 (54.8%) patients were included in model development and validation, and 113 (6.7%) patients who enrolled later were used as a test set for external validation. They were classified into 5 diagnostic categories. We compared 9 candidate machine learning methods, and the recalibrated model of light gradient boosting machine achieved the best performance, with an area under the curve of 0.937 (95% CI 0.917-0.962) in cross-validation and 0.954 (95% CI 0.944-0.967) in external validation.

Conclusions

The questionnaire-based light gradient boosting machine was able to predict common vestibular disorders and assist decision-making in ENT and vertigo clinics. Further studies with a larger sample size and the participation of neurologists will help assess the generalization and robustness of this machine learning method.

Changing Paradigm for Vertigo/Dizziness Patients: a Retrospective Before-After Study from Tertiary Hospitals in Northwestern China

BACKGROUND

Single disciplinary management of patients with vertigo and dizziness is an important challenge for most physicians in China.

OBJECTIVE

To assess the impact of a new paradigm of practice (Clinic for Vertigo and Dizziness, CVD) performed by a multidisciplinary team (MDT) on diagnostic spectrum, medical costs, and patient satisfaction.

DESIGN

Retrospective before-after study.

PARTICIPANTS

Sample of 29,793 patients with vertigo/dizziness as primary complaint.

MEASURES

Changes in diagnostic spectrum, medical costs, and patient satisfaction before and after the establishment of a CVD based on a 4-year database in three tertiary hospitals in northwestern China.

KEY RESULTS

The most common diagnoses of patients with vertigo and dizziness were Meniere's disease (25.77%), cervical disease (25.00%), cerebral vascular disease (13.96%), vestibular syndrome (10.57%), and other etiologies (6.34%) before the CVD establishment. In contrast, after the CVD establishment, the most common diagnoses were BPPV (23.92%), vestibular migraine (15.83%), Meniere's disease (14.22%), CSD/PPPD (11.61%), and cerebral vascular diseases (4.45%). Extended implementation of a structured questionnaire for vertigo/dizziness and vestibular-oriented examinations (nystagmus, positional tests, HINTS) at the CVD resulted in a remarkable decline in the utility of CT/MRI and X-ray examination (p < 0.001). Meanwhile, medical costs in patients with vertigo/dizziness dropped by 11.5% (p < 0.001), with a significant improvement in patient satisfaction after the establishment of CVD (p < 0.001).

CONCLUSIONS AND RELEVANCE

Our study suggested that the MDT paradigm of CVD practice may facilitate the medical management of patients with vertigo/dizziness and improve patient satisfaction.

Imbalance Associated With Cisplatin Chemotherapy in Adult Cancer Survivors: A Clinical Study

OBJECTIVE

This study investigated balance problems and vestibular function in adult cancer survivors who had completed cisplatin chemotherapy treatment.

STUDY DESIGN

Observational cross-sectional study.

SETTING

Tertiary care center.

PATIENTS

Adult survivors of cancer who had completed cisplatin treatment.

MAIN OUTCOME MEASURES

Patient-reported balance symptoms were evaluated by a semistructured clinical interview. Patients underwent bedside clinical tests including Dynamic Visual Acuity test, Modified Clinical Testing of Sensory Interaction and Balance (CTSIB-m), and vibration sense testing to detect peripheral neuropathy. The video Head Impulse Test (vHIT) of all semicircular canals was performed.

RESULTS

Eleven of 65 patients (17%) reported some balance symptoms after cisplatin therapy, including vertigo, dizziness, unsteadiness, and falls. Vertigo was the most common balance symptom, reported by six patients (9.2%), and the clinical histories of these patients were consistent with benign paroxysmal positional vertigo. Three patients (5%) had abnormal results of the CTSIB-m test, and they were the same patients who reported falls. There was a significant association of peripheral neuropathy detected by vibration test and balance symptoms. All patients had normal vHIT results in all semicircular canals.

CONCLUSIONS

Balance symptoms after cisplatin treatment occurred in 17% of adult cancer survivors. Patients with peripheral neuropathy were more likely to have balance symptoms. The CTSIB-m test is a useful bedside physical examination to identify patients with a high risk of fall. Though there was no vestibular dysfunction detected by the vHIT in cancer survivors after cisplatin therapy, benign paroxysmal positional vertigo was relatively prevalent in this group of patients.

Consensus on Virtual Management of Vestibular Disorders: Urgent Versus Expedited Care

The virtual practice has made major advances in the way that we care for patients in the modern era. The culture of virtual practice, consulting, and telemedicine, which had started several years ago, took an accelerated leap as humankind was challenged by the novel coronavirus pandemic (COVID19). The social distancing measures and lockdowns imposed in many countries left medical care providers with limited options in evaluating ambulatory patients, pushing the rapid transition to assessments via virtual platforms. In this novel arena of medical practice, which may form new norms beyond the current pandemic crisis, we found it critical to define guidelines on the recommended practice in neurotology, including remote methods in examining the vestibular and eye movement function. The proposed remote examination methods aim to reliably diagnose acute and subacute diseases of the inner-ear, brainstem, and the cerebellum. A key aim was to triage patients into those requiring urgent emergency room assessment versus non-urgent but expedited outpatient management. Physicians who had expertise in managing patients with vestibular disorders were invited to participate in the taskforce. The focus was on two topics: (1) an adequate eye movement and vestibular examination strategy using virtual platforms and (2) a decision pathway providing guidance about which patient should seek urgent medical care and which patient should have non-urgent but expedited outpatient management.

Two Symptoms Strongly Suggest Benign Paroxysmal Positional Vertigo in a Dizzy Patient

Introduction: This prospective cohort study determined which questions in patient history are most likely to identify symptoms that are independently associated with a diagnosis of benign paroxysmal positional dizziness (BPPV) in patients presenting with dizziness, and to evaluate whether the patient's age and type of BPPV are of influence. Methods: We included adult patients with dizziness referred to our dizziness center, Apeldoorn, the Netherlands, from December 2018 to November 2019. All patients completed a questionnaire, underwent vestibular testing and received a diagnosis. Symptoms strongly suggesting BPPV were tested with multivariable analysis to determine their independent associations with BPPV. Subgroup analysis was performed for patient age, and the type of BPPV. Results: We included a total of 885 patients, 113 of whom (13%) were diagnosed with BPPV. The duration of dizziness spells <1 min (Q2) and dizziness provoked by rolling over in bed (Q4) were independently associated with the diagnosis BPPV. Q2 showed a sensitivity of 43%, and a specificity of 75%; Q4 scored 81% and 68%, respectively. Overall, the way patients perceived their dizziness (vertigo, light-headedness or instability) was not independently associated with the diagnosis BPPV. In younger patients, light-headedness and instability decreased the likelihood of BPPV compared to vertigo. Conclusion: The most reliable predictors for BPPV in patient history are a short duration of the dizziness spell and provocation of dizziness by rolling over in bed. Unlike younger patients, elderly patients with BPPV do not only perceive the dizziness as vertigo, but also as a feeling of instability.

Opinion and Special Articles: Remote Evaluation of Acute Vertigo: Strategies and Technological Considerations

Patients with acute vestibular disorders are often a diagnostic challenge for neurologists, especially when the evaluation must be conducted remotely. The clinical dilemma remains: Does the patient have a benign peripheral inner ear problem or a worrisome central vestibular disorder, such as a stroke? The use of a focused history and the virtual HINTS (head impulse test, nystagmus evaluation, and test of skew) examination are key steps towards correctly diagnosing and triaging the acute vertiginous patient. When looking for signs of vestibulo-ocular dysfunction, there are important technological and practical considerations for an effective clinical interpretation.

Update on benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo worldwide. This review considers recent advances in the diagnosis and management of BPPV including the use of web-based technology and artificial intelligence as well as the evidence supporting the use of vitamin D supplements for patients with BPPV and subnormal serum vitamin D.