Clinical Characteristics and Risk Factors for the Recurrence of Benign Paroxysmal Positional Vertigo

Risk Factors for Recurrence of Benign Paroxysmal Positional Vertigo: A Prospective Study

OBJECTIVES

Benign paroxysmal positional vertigo (BPPV) can be treated successfully in most cases. However, recurrences are common. We aimed to prospectively investigate demographic and clinical risk factors for BPPV recurrence. Our second aim was to investigate whether seasonality affects recurrences.

METHODS

We recruited adult Dutch patients presenting at our dizziness clinic with a diagnosis of definite or possible BPPV for a prospective observational study with 1-year follow-up. Factors collected from patient history and questionnaires were age, sex, ethnicity, previous treatment for BPPV, duration of BPPV symptoms, number of treatment sessions for the initial BPPV episode, the affected canal, recent head trauma, and a history of vestibular neuritis, Menière's disease, (vestibular) migraine, gout, diabetes mellitus, and chronic renal failure. Factors derived from blood samples were uric acid, glycated hemoglobin, and 25-hydroxyvitamin D.

RESULTS

We included 139 subjects with a mean age of 65 (SD, 13) years, of whom 70% was female. A total of 48 subjects (34.5%) suffered from at least one recurrence during the 1-year follow-up. Independent risk factors for recurrence of BPPV were "multiple treatment sessions for the initial BPPV episode" (incidence rate ratio, 1.74; 95% confidence interval 1.06-2.85; p = 0.027) and history of gout (incidence rate ratio, 1.90; 95% confidence interval, 1.01-3.57; p = 0.045).

CONCLUSION

One-third of patients presenting in a tertiary dizziness clinic develop at least one recurrence of BPPV within 1 year. Multiple treatment sessions and a history of gout are independent risk factors for recurrence.

Risk factors for benign paroxysmal positional vertigo and construction of a nomogram predictive model

BACKGROUND

To analyze the risk factors for benign paroxysmal positional vertigo (BPPV) and to construct a predictive nomogram model.

METHODS

In this retrospective study, 312 participants were enrolled, including 164 BPPV patients and 148 healthy subjects without BPPV. Risk predictors for BPPV were identified using univariate and multivariate analyses, and a clinical nomogram was constructed. The predictive accuracy was assessed by unadjusted concordance index (C-index) and calibration plot.

RESULTS

Univariate and multivariate regression analysis identified stroke (95% CI, 0.575-5.954; P=0.022), hyperlipidemia (95% CI, 0.471-4.647; P=0.003), chronic suppurative otitis media (95% CI, 1.222-45.528; P=0.005), cervical spondylosis (95% CI, 1.232-3.017; P=0.005), and osteoporosis (95% CI, 1.130-3.071; P=0.001) were the independent risk factors for BPPV. These risk factors were used to construct a clinical predictive nomogram. The regression equation was: logit (P) = -6.820 + 0.450 * stroke + hyperlipidemia * 0.312 + chronic suppurative otitis media * 0.499 + cervical spondylosis * 0.916 + osteoporosis * 0.628. The calibration curves demonstrated excellent accuracy of the predictive nomogram. Decision curve analysis showed that the predictive model is clinically applicable when the threshold probability was between 20% and 60%.

CONCLUSIONS

Stroke, hyperlipidemia, chronic suppurative otitis media, cervical spondylosis and osteoporosis are independent risk predictors for BPPV. The developed nomogram is useful in predicting the risk of BPPV.

Assessing the impact of migraine on benign paroxysmal positional vertigo symptoms and recovery

BACKGROUND

During episodes of benign paroxysmal positional vertigo (BPPV), individuals with migraine, compared with individuals without migraine, may experience more severe vestibular symptoms because of their hyperexcitable brain structures, more adverse effects on quality of life, and worse recovery processes from BPPV.

METHODS

All patients with BPPV were assigned to the migraine group (MG, n = 64) and without migraine group (BPPV w/o MG, n = 64) and completed the Vertigo Symptom Scale (VSS), Vertigo Dizziness Imbalance Symptom Scale (VDI-SS), VDI Health-Related Quality of Life Scale (VDI-HRQoLS), Beck Anxiety Inventory (BAI), and Beck Depression Inventory (BDI) at the time of BPPV diagnosis (baseline) and on the one-month follow-up. Headache Impact Test-6 and Migraine Disability Assessment Scale were used for an assessment of headache. Motion sickness was evaluated based on the statement of each patient as present or absent.

RESULTS

Compared with the BPPV w/o MG, the MG had higher VSS scores at baseline [19.5 (10.7) vs. 11.3 (8.5); p < 0.001] and on one-month follow-up [10.9 (9.3) vs. 2.2 (2.7), p < 0.001]; experienced more severe dizziness and imbalance symptoms based on the VDI-SS at baseline (61.9% vs. 77.3%; p < 0.001) and after one month (78.9% vs. 93.7%, p < 0.001); and more significantly impaired quality of life according to the VDI-HRQoLS at baseline (77.4% vs. 91.8%, p < 0.001) and after one month (86.3% vs. 97.6%, p < 0.001). On the one-month follow-up, the subgroups of patients with moderate and severe scores of the BAI were higher in the MG (39.2%, n = 24) than in the BPPV w/o MG (21.8%, n = 14) and the number of patients who had normal scores of the BDI was lower in the MG than in the BPPV w/o MG (67.1% vs. 87.5%, p = 0.038).

CONCLUSION

Clinicians are advised to inquire about migraine when evaluating patients with BPPV because it may lead to more intricate and severe clinical presentation. Further studies will be elaborated the genuine nature of the causal relationship between migraine and BPPV.

Clinical Outcomes in Patients With Benign Paroxysmal Positional Vertigo and Vitamin D Deficiency: A Singaporean Perspective

INTRODUCTION

Benign paroxysmal positional vertigo (BPPV) is the primary vestibular disorder causing peripheral vertigo. Given the role of vitamin D in maintaining otoconia homeostasis, its deficiency may elevate the risk of BPPV. Our study seeks to evaluate the correlation between vitamin D deficiency and clinical outcomes of patients with BPPV in the local Asian population.

METHODOLOGY

We performed a retrospective analysis of 149 consecutive adult patients referred to a tertiary center's Otolaryngology dizziness clinic between 2018 and 2021. All of these patients had both BPPV and vitamin D deficiency.

RESULTS

The mean serum vitamin D level was 19.4 ± 5.5 ng/mol. Approximately 51.7% (77/149) of patients experienced recurrent episodes of BPPV. Univariate Chi-square analyses demonstrated vitamin D levels (P < 0.001) and history of migraine (P = 0.04) were related to BPPV recurrence. On multivariate analyses, patients with higher serum vitamin D levels were 16.7% less likely to develop recurrent BPPV (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.76-0.90, P < 0.001). However, migraine history was not significantly related to BPPV recurrence (OR 0.38, 95% CI 0.14-1.00, P = 0.050). There was no statistically significant difference in the duration of BPPV episodes based on vitamin D levels (P = 0.327).

CONCLUSIONS

Patients with vitamin D deficiency are at higher risk of recurrent BPPV. Future research directions that would be beneficial include conducting a randomized controlled trial to evaluate both the effectiveness of vitamin D supplementation and its optimal dosage.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Adoption of clinical practice guidelines in cases of benign paroxysmal positional vertigo

PURPOSE

Despite being one of the most common types of the peripheral vertigo encountered in clinical practice, benign paroxysmal positional vertigo (BPPV) remains underdiagnosed and undertreated, even in affluent health care systems. The publication of fully updated clinical practice guidelines significantly facilitated the diagnosis and treatment of BPPV. This study evaluates the adoption of the guidelines in our clinical setting and reviews further recommendations for quality-of-care improvement.

METHODS

This retrospective cross-sectional survey included a total of 1155 adult patients diagnosed with BPPV at the biggest tertiary care center in the country during a 5-year period (2017-2021). The data for the first three years (2017-2020) and 919 patients were collected in full, and for the remaining 236 patients (2020-2021) only partially due to the disturbance in referrals caused by COVID-19 pandemic.

RESULTS

The familiarity with and adherence to the published clinical guidelines by physicians judged by patients' charts and our health care database were overall unsatisfactory. The adherence varied from 0 to 40.5% in our sample. The recommendations for making the diagnosis and for repositioning procedure as first-line therapy were followed in only 20-30% of cases.

CONCLUSION

There are large opportunities for improvement in quality of care of BPPV patients. Apart from constant and systematic education at the primary health care level, the health care system may need to adopt more advanced measures of ensuring better adherence to guidelines and subsequent reduction in medical costs.

Management of Migraine-Associated Vestibulocochlear Disorders

Migraine is a chronic neurological disorder that frequently coexists with different vestibular and cochlear symptoms (sudden hearing loss, tinnitus, otalgia, aural fullness, hyperacusis, dizziness, imbalance, and vertigo) and disorders (recurrent benign positional vertigo, persistent postural perceptual dizziness, mal de debarquement, and Menière's disease). Despite evidence of an epidemiological association and similar pathophysiology between migraine and these vestibulocochlear disorders, patients suffering from migraine-related symptoms are usually underdiagnosed and undertreated. Current migraine treatment options have shown success in treating vestibulocochlear symptoms. Lifestyle and dietary modifications (reducing stress, restful sleep, avoiding migraine dietary triggers, and avoiding starvation and dehydration) and supplements (vitamin B2 and magnesium) offer effective first-line treatments. Treatment with migraine prophylactic medications such as tricyclic antidepressants (e.g., nortriptyline), anticonvulsants (e.g., topiramate), and calcium channel blockers (e.g., verapamil) is implemented when lifestyle and dietary modifications are not sufficient in improving a patient's symptoms. We have included an algorithm that outlines a suggested approach for addressing these symptoms, taking into account our clinical observations. Greater recognition and understanding of migraine and its related vestibular and cochlear symptoms are needed to ensure the appropriate diagnosis and treatment of affected patients.

Cerebral Outflow Discrepancies in Recurrent Benign Paroxysmal Positional Vertigo: Focus on Ultrasonographic Examination

This prospective pilot study aimed to evaluate whether cerebral inflow and outflow abnormalities assessed by ultrasonographic examination could be associated with recurrent benign paroxysmal positional vertigo (BPPV). Twenty-four patients with recurrent BPPV, affected by at least two episodes, and diagnosed according to American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) criteria, evaluated at our University Hospital, between 1 February 2020 and 30 November 2021, have been included. At the ultrasonographic examination, 22 of 24 patients (92%) reported one or more alterations of the extracranial venous circulation, among those considered for the diagnosis of chronic cerebrospinal venous insufficiency (CCSVI), although none of the studied patients were found to have alterations in the arterial circulation. The present study confirms the presence of alterations of the extracranial venous circulation in recurrent BPPV; these anomalies (such as stenosis, blockages or regurgitation of flow, or abnormal valves, as per the CCSVI) could cause a disruption in the venous inner ear drainage, hampering the inner ear microcirculation and then possibly causing recurrent otolith detachment.

Assessment of Osteoporosis and Vitamin D3 Deficiency in Patients with Idiopathic Benign Paroxysmal Positional Vertigo (BPPV)

Background and objectives: Osteoporosis and vitamin D3 deficiency may be risk factors of benign paroxysmal positional vertigo (BPPV). The aim of this study was to assess the prevalence of osteoporosis and 25(OH) vitamin D3 deficiency in a group of patients with idiopathic benign paroxysmal positional vertigo. Materials and Methods: Thirty-five patients (twenty-eight women and seven men) with posterior semicircular canal BPPV were enrolled in the study. The subjects underwent hearing assessment (tonal audiometry and impedance audiometry) and the Dix-Hallpike maneuver. Serum 25(OH) vitamin D3 levels were determined and lumbar spine bone densitometry was performed. The relationships between sex, age, height, Body Mass Index (BMI), vitamin D3 levels and bone densitometry results were assessed. Results: The diagnosis of osteoporosis was confirmed in 1 patient (3%), 3 subjects were osteopenic (8.6%), and normal bone densitometry was found in 31 (88.6%) patients. Conclusions: We found no statistically significant relationships between age, BMI or vitamin D3 levels and bone densitometry results in patients with idiopathic BPPV.

The relationship between psychological conditions and recurrence of benign paroxysmal positional vertigo: a retrospective cohort study

BACKGROUND

Psychological conditions have been found to be associated with an increased risk of incident benign paroxysmal positional vertigo (BPPV). However, much less is known on whether and how psychological conditions such as anxiety, insomnia and obsessive-compulsive disorder (OCD) affect the recurrence of BPPV.

METHODS

A retrospective cohort study of 2,612 outpatients and inpatients diagnosed with BPPV between September 2012 and August 2020. BPPV recurrence was followed up until February 2021. The Cox proportional hazard regression was used to analyze the association between psychological conditions and the risk of the first recurrence. Poisson regression was applied to analyze the association between psychological conditions and the number of recurrences in patients with at least one relapse.

RESULTS

During the follow-up, 391 patients had at least one BPPV recurrence. Female BPPV patients were more likely than male patients to experience relapses than male patients, but the characteristics of BPPV recurrence (number of recurrences and duration between recurrences) did not differ between men and women. After adjustment for sex, age and comorbidities, a heightened risk of first BPPV recurrence was found to be associated with anxiety (hazard ratio [HR]: 1.30, 95% confidence interval [CI]: 1.01, 1.68) and OCD (HR: 2.15, 95% CI: 1.31, 3.52). An increased risk of first BPPV recurrence associated with insomnia was only observed in male patients (HR: 2.22, 95% CI: 1.24, 3.98) but not in female patients (HR: 0.91, 95% CI: 0.63, 1.31). None of these psychological conditions were associated with the number of recurrences in patients who experienced recurrence.

CONCLUSIONS

The presence of anxiety and OCD increased the risk of first BPPV recurrence, as well as insomnia for male patients. These psychological conditions were not associated with the number of BPPV recurrences. Diagnosis and treatment of these psychological conditions could be a useful strategy to prevent the recurrence of BPPV.

Relationship of vitamin D levels with clinical presentation and recurrence of BPPV in a Southeastern United States institution

OBJECTIVE

To examine the relationship of 25hydroxyvitamin D serum levels with BPPV incidence and recurrence rates.

METHODS

A retrospective cross-sectional, case-controlled study with follow-up phone survey was performed on patients diagnosed with BPPV between 05/2017-05/2020, who had available 25hydroxyvitamin D serology. Patients were seen at a multidisciplinary, vestibular-focused, neurotology clinic at a tertiary referral center. Controls consisted of subjects from the National Health and Nutrition Examination Survey (NHANES), and a locoregional age, sex, and race-matched group of patients from our institution.

RESULTS

Our BPPV cohort consisted of 173 patients (mean age 66.2 ± 11.8 years), who were predominately female (75.7%) and Caucasian (76.3%). Almost all age subgroups (BPPV, NHANES, and locoregional groups) ≤60 years old had insufficient levels of vitamin D. However, the overall BPPV cohort had a significantly higher vitamin D level than the NHANES control (31.4 ± 16.5 v. 26.0 ± 11.2 ng/mL, d=0.474 [0.323, 0.626]). There was no significant difference when compared to the overall locoregional control (31.4 ± 20.5 ng/mL). Migraines were significantly correlated to increased BPPV recurrence rates on univariate (beta=0.927, p=0.037, 95% CI: [0.057, 1.798]) and multiple regression analyses (beta=0.231, 95% CI: [0.024, 2.029], p=0.045). Furthermore, patients with BPPV recurrences had significantly lower levels of vitamin D at initial presentation when compared to patients with no recurrences (29.0 ± 12.0 v. 37.6 ± 18.3 ng/mL, d=0.571[0.139,1.001]).

CONCLUSION

Many BPPV patients in our cohort had insufficient vitamin D levels, and patients with BPPV recurrences had insufficient and significantly lower vitamin D levels than those without. As a readily available and affordable supplement, vitamin D may be used as an adjunct treatment but prospective studies should be done to confirm if it can prevent or reduce recurrence.

Experiences of patients and their health care providers with canalith repositioning maneuvers for benign paroxysmal positional vertigo: a qualitative systematic review protocol

OBJECTIVE

This review will synthesize the evidence on the experiences of patients undergoing canalith repositioning maneuvers (provided both by health care providers and by the patients themselves) and of health care providers offering canalith repositioning maneuvers in patients with benign paroxysmal positional vertigo.

INTRODUCTION

Despite having proven effectiveness for treating benign paroxysmal positional vertigo, the underutilization of canalith repositioning maneuvers by health care providers is a concern. Understanding the experiences of patients receiving canalith repositioning maneuvers and the experiences of the health care providers repositioning the canalith is imperative for the effective implementation of these maneuvers.

INCLUSION CRITERIA

This review will include qualitative studies describing the experiences of health care providers or patients with canalith repositioning maneuvers provided by health care providers or by patients themselves for benign paroxysmal positional vertigo, with or without other interventions, in any setting. Canalith repositioning maneuvers provided by non-qualified health professionals, non-professional caregivers, family caregivers, volunteer caregivers, or other informal caregivers will be excluded.

METHODS

MEDLINE, Embase, Cochrane CENTRAL, PsycINFO, Scopus, Web of Science, and CINAHL will be searched. Gray literature will be searched using OpenGrey, PsyArXiv, bioRxiv, medRxiv, and Google Scholar. Articles published in English will be considered, regardless of the publication date. Studies will be screened and critically appraised for methodological quality by 2 independent reviewers. The standardized JBI data extraction tool will be used, and the meta-aggregation approach for data synthesis and the ConQual approach for confidence evaluation will be followed.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021292993.

Analysis of Bone Mineral Density and Bithermal Caloric Test Results in Unilateral Idiopathic Benign Paroxysmal Positional Vertigo Patients

OBJECTIVE

Benign paroxysmal positional vertigo (BPPV) is the most frequently diagnosed type of peripheral vestibular vertigo. Studies have reported a possible association between BPPV and osteoporosis; however, there is still a lack of evidence. This study aimed to investigate the characteristics of bone mineral density (BMD) and bithermal caloric test results in patients with unilateral posterior canal idiopathic benign paroxysmal positional vertigo (pc-iBPPV).

METHODS

BMD was measured in 65pc-iBPPV menopausal female patients and 65 healthy controls using dual-energy xray absorptiometry and then compared the T-score of BMD between the two groups. The bithermal caloric test was also performed with video nystagmography and the relationship between canal paresis, directional preponderance, T-score, and recurrence were analyzed.

RESULTS

Lower T-scores were observed in pc-iBPPV patients compared with the normal subjects. Among 65 pc-iBPPV patients, free recurrence was observed in 38 (58.5%), single recurrence was noted in 14 (21.5%), and multiple recurrences were seen in 13 (20%) patients. The proportion of positive T-score and CP value increased with the pc-BPPV recurrence frequency. Statistically, a significant difference was found only in T-score, indicating that recurrence was raised with a decrement of T-score. The proportion of positive CP values tended to increase as BMD decreased.

CONCLUSION

The decrement of BMD might be one of the pathogeneses in patients with unilateral pc-iBPPV and associated with multiple recurrences. Moreover, positive CP value cannot be regarded as a predictive factor for recurrence; however, there is a clear association between CP and BMD.

Apogeotropic Horizontal Canal Benign Paroxysmal Positional Vertigo: Zuma e Maia Maneuver versus Appiani Variant of Gufoni

Benign paroxysmal positional vertigo (BPPV) is one of the most common disorders that causes dizziness. The incidence of horizontal semicircular canal (HSC) BPPV ranges from 5% to 40.5% of the total number of BPPV cases diagnosed. Several studies have focused on establishing methods to treat BPPV caused by the apogeotropic variant of the HSC, namely, the Appiani maneuver (App). In 2016, a new maneuver was proposed: the Zuma e Maia maneuver (ZeM), based on inertia and gravity. The aim of this study is to analyze the efficacy of App versus ZeM in the resolution of episodes of BPPV produced by an affectation of the horizontal semicircular canal with apogeotropic nystagmus (Apo-HSC). A retrospective, quasi-experimental study was conducted. Patients attended in office (November 2014–February 2019) at a third-level hospital and underwent a vestibular otoneurology assessment. Those who were diagnosed with Apo-HSC, treated with App or ZeM, were included. To consider the efficacy of the maneuvers, the presence of symptoms and/or nystagmus at the first follow up was studied. Patients classified as “A” were those with no symptoms, no nystagmus; “A/N+”: no symptoms, nystagmus present during supine roll test; “S”: symptoms present. Previous history of BPPV and/or otic pathology and calcium levels were also compiled. From the 54 patients included, 74% were women. The average age was 69. Mean follow-up: 52.51 days. In those patients without previous history of BPPV (n = 35), the probability of being group “A” was 63% and 56% (p = 0.687) when treated with App and ZeM, respectively, while being “A/N+” was 79% and 87% for App and ZeM (p = 0.508). Of the 19 patients who had previous history of BPPV, 13% and 64% were group “A” when treated with App and ZeM (p = 0.043), and 25% and 82% were “A/N+” after App and ZeM, respectively (p = 0.021). In conclusion, for HSC cupulolithiasis, ZeM is more effective than App in those cases in which there is a history of previous episodes of BPPV (“A”: 64% (p = 0.043); “A/N+”: 82% (p = 0.021)).

High Serum Levels of Otolin-1 in Patients With Benign Paroxysmal Positional Vertigo Predict Recurrence

Background

Otolin-1 is an inner ear-specific protein that is exclusively expressed in otoconia and vestibule and cochlea cells. Recent investigations reported that otolin-1 can cross the blood-labyrinthine barrier and that the levels in serum well-reflected otolith status. Serum otolin-1 levels in patients with benign paroxysmal positional vertigo (BPPV) are significantly elevated compared with healthy controls. We aimed to explore whether otolin-1 can also serve as a biomarker for predicting BPPV recurrence.

Method

Patients at our institution with new-onset of idiopathic BPPV between May, 2017 and May, 2018 were recruited and followed up for 2 years. All demographic data of the patients were collected, and serum levels of otolin-1 and other laboratory indicators were measured and compared according to the recurrence status.

Results

A total of 74 patients, who met the inclusion criteria were enrolled in this study, of which 27 (36.5%) patients had suffered one or more episodes of recurrence after undergoing canal repositioning treatments during the study. The serum levels of otolin-1 in patients with recurrent BPPV were significantly higher than those in patients without recurrent BPPV (363.9 vs. 309.8 pg/ml, p = 0.001). In multivariate analysis comparing the second to fourth quartiles (Q2–Q4) against the first quartile (Q1) of otolin-1, the level of otolin-1 in Q4 could significantly predict BPPV recurrence, and the odds ratio (OR) was elevated by approximately 812% (OR = 9.12; 95% confidence interval [CI]: 1.44–57.9; p = 0.019).

Conclusion

High serum levels of otolin-1 were associated with an increased risk of BPPV recurrence, and further investigation is required to confirm this association and clarify the exact mechanism.

The influence of cerebral small vessel diseases on the efficacy of repositioning therapy and prognosis of benign paroxysmal positional vertigo

Background: Although vascular risk factors have been found to be closely related to the development of benign paroxysmal positional vertigo (BPPV), the relationship between BPPV and cerebral small vessels diseases (CSVDs) has rarely been discussed in literature. This study set out to investigate the efficacy of repositioning therapy and prognosis among BPPV patients with CSVDs. Methods: We enrolled 553 BPPV patients who had undergone brain MRI, and categorized them into two groups based on the presence or absence of CSVDs. After controlling for other confounders using a propensity score matching (PSM) approach, we compared the incidence of recurrence and residual dizziness (RD). Then, we analyzed the recurrence rate and RD incidence in 176 BPPV patients with CSVDs, and assessed potential risk factors. Results: White matter hyperintensity (WMH, 72.2%) and lacunar infarction (LI, 65.9%) were the two CSVDs that were present in the highest proportion among the BPPV patients. The incidence of RD in patients with CSVDs was significantly higher compared to subjects without CSVDs. Patients with RD (n=100, 56.8%) were older, had more severe WMH, and had a higher incidence of brain atrophy; age and higher Fazekas score were independent risk factors. Among the recurrent patients (n=61, 34.7%), the ages were older, the Fazekas score of WMH was higher, and number of LIs was increased; age was the sole independent risk factor. Conclusion: BPPV patients with a combination of CSVD comorbidities, especially elderly patients with WMHs, are more likely to develop RD, which needs to be paid more attention.

Tongxinluo prevents chronic obstructive pulmonary disease complicated with atherosclerosis by inhibiting ferroptosis and protecting against pulmonary microvascular barrier dysfunction

Cardiovascular comorbidities are pervasive in chronic obstructive pulmonary disease (COPD) and often result in serious adverse cardiovascular events. Tongxinluo (TXL) has been clinically verified to treat atherosclerosis (AS), improve lung function and alleviate dyspnoea. The present study aimed to explore the effect of lung microvascular barrier dysfunction on AS in COPD and the potential pulmonary protective mechanisms of TXL in COPD complicated with AS. COPD complicated with AS was induced in mice by cigarette smoke (CS) exposure and high-fat diet (HFD) feeding. The mice were treated with atorvastatin (ATO), TXL or combination therapy (ATO+TXL) for 20 weeks. Pulmonary function, lung pathology, serum lipid levels, atherosclerotic plaque area and indicators of barrier function, oxidative stress and ferroptosis in lung tissue were evaluated. In vitro, human pulmonary microvascular endothelial cells (HPMECs) were pretreated with TXL for 4 h and then incubated with cigarette smoke extract (CSE) and homocysteine (Hcy) for 36 h to induce barrier dysfunction. Then the indicators of barrier function, oxidative stress and ferroptosis were measured. The results demonstrate that CS aggravated dyslipidaemia, atherosclerotic plaque formation, pulmonary function decline, pathological injury, barrier dysfunction, oxidative stress and ferroptosis in the HFD-fed mice. However, these abnormalities were partially reversed by ATO and TXL. Similar results were observed in vitro. In conclusion, pulmonary microvascular barrier dysfunction plays an important role by which COPD affects the progression of AS, and ferroptosis may be involved. Moreover, TXL delays the progression of AS and reduces cardiovascular events by protecting the pulmonary microvascular barrier and inhibiting ferroptosis.

The Relationship Between Disorders of Bone Metabolism and Benign Paroxysmal Positional Vertigo: A Systematic Review

OBJECTIVES

Several studies have reported an association between benign paroxysmal positional vertigo (BPPV) and bone mineral density or serum vitamin D levels. The aim of this review is to provide further clarification regarding the relationship between BPPV and calcium metabolism.

DESIGN

PubMed and MEDLINE databases were systematically reviewed to identify all English language papers regarding the relationship between BPPV and the following terms: osteoporosis, osteopenia, bone mineral density, serum vitamin D levels, and bone metabolism.

RESULTS

Of the 456 identified records, 28 studies were eligible for this review. Most were retrospective studies with inherent limitations and often conflicting results. While the literature is not conclusive, osteoporosis in patients of at least 50 years old appears to have an association with BPPV. Similarly, an association was observed between recurrent BPPV and vitamin D deficiency.

CONCLUSION

There is only weak evidence to support the relationship between BPPV and osteoporosis or low serum 25-hydroxyvitamin D levels. Further prospective studies with more robust methodologies are needed to clarify the association between BPPV and disorders of bone metabolism.

A Review of the Quality of Life after Therapeutic Maneuvers in Patients with Benign Paroxysmal Positional Vertigo

INTRODUCTION

Benign paroxysmal positional vertigo (BPPV) is a common cause of peripheral vestibular disturbances. Particle repositioning or liberatory maneuvers provide relief of symptoms in the majority of patients. However, studies mainly focus on success. This study aims to review the conditions that may have an impact on residual dizziness or recurrence following therapeutic maneuvers in patients with BPPV.

MATERIALS AND METHODS

A review of the literature about the analysis of quality of life after therapeutic maneuvers was conducted. Three hundred and seven articles after search in the PubMed database were classified into eight main groups after exclusion of those that are not suitable to predetermined criteria.

RESULTS

Thirty-eight articles for residual dizziness in BPPV, eighty-three articles for the duration of BPPV, forty articles for the type of canal involvement, forty-three articles for the impact of age, one hundred and nine articles for the gender difference, forty-seven articles for co-morbid conditions, one hundred and twenty-four articles for medication and sixty-eight articles for vestibular exercises in BPPV were selected.

CONCLUSION

VEMP abnormality is a reliable indicator to demonstrate the risk of recurrence. Duration of dizziness has no significant impact on recurrence. But the length of duration is important for residual dizziness. Vestibular rehabilitation or medication alone has no place in treatment but may help to reduce the symptoms in addition to maneuver. Self-perceived evaluation of balance after therapeutic maneuvers is recommended for the selection of those who need rehabilitation or additional medication.

Effect of age on treatment outcomes in benign paroxysmal positional vertigo: A systematic review

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) can lead to an increased fall risk in older adults. Therefore, we examined the influence of age on the effectiveness of canalith-repositioning procedures (CRPs) for the treatment of BPPV.

METHODS

Pubmed, Web of Science, and the bibliographies of selected articles were searched for studies conducted before September 2020 that examined the effectiveness of treatments for BPPV in various age groups. Meta-analyses were performed to compare treatment effectiveness and recurrence rates for younger and older adults. Odds ratios were calculated in a random-effects model. Mean differences were calculated using a fixed-effects model. A significance level of p < 0.05 (95% confidence interval) was set. The risk of bias and the methodological quality of all included articles were examined.

RESULTS

Forty-five studies were retrieved after full-text screening, of which 29 studies were included for a qualitative review. The remaining 16 studies were eligible for inclusion in the meta-analysis (3267 participants with BPPV). The success rate of a single CRP was higher in the younger group (72.5% vs. 67%, p < 0.001). An average of 1.4 and 1.5 CRPs was needed for complete recovery in the younger and older groups, respectively (p = 0.02). However, global treatment success did not differ between these groups (97.5% vs. 94.6%, p = 0.41). The recurrence rate was higher in the older population (23.2% vs. 18.6%, p = 0.007).

CONCLUSIONS

Although more CRPs are needed, the rate of complete recovery in older adults is similar to that observed in younger adults.

Risk Factors for Recurrence of Benign Paroxysmal Positional Vertigo. A Clinical Review

Benign paroxysmal positional vertigo (BPPV) is one of the most common peripheral vestibular dysfunctions encountered in clinical practice. Although the treatment of BPPV is relatively successful, many patients develop recurrence after treatment. Our purpose is to evaluate the mean recurrence rate and risk factors of BPPV after treatment. A review of the literature on the risk factors of BPPV recurrence was performed. A thorough search was conducted using electronic databases, namely Pubmed, CINAHL, Academic Search Complete and Scopus for studies published from 2000 to 2020. Thirty studies were included in this review with 13,358 participants. The recurrence rate of BPPV ranged from 13.7% to 48% for studies with follow-up <1 year, and from 13.3% to 65% for studies with follow-up ≥2 years. Pathophysiologic mechanisms and implication of each of the following risk factors in the recurrence of BPPV were described: advanced age, female gender, Meniere’s disease, trauma, osteopenia or osteoporosis, vitamin D deficiency, diabetes mellitus, hypertension, hyperlipidemia, cardiovascular disease, migraine, bilateral/multicanal BPPV, cervical osteoarthrosis and sleep disorders. Patients with hyperlipidemia and hypertension had the highest recurrence rates of BPPV, 67.80% and 55.89%, respectively, indicating that vascular comorbidities increase the risk of BPPV recurrence. In addition, more than half of patients (53.48%) with diabetes mellitus and BPPV experienced recurrence of BPPV. Knowledge and awareness of risk factors for recurrence of BPPV are essential for the assessment and long-term prognosis of patients. Identification of these relapse risk factors may enhance the ability of clinicians to accurately counsel patients regarding BPPV and associated comorbidities.

Migraine Features in Patients With Recurrent Benign Paroxysmal Positional Vertigo

OBJECTIVES

To identify migraine features present in a cohort of patients with recurrent benign paroxysmal positional vertigo (BPPV).

METHODS

Patients presenting with recurrent BPPV were surveyed. Recurrent BPPV was defined as three episodes or greater in 6 months before presentation, with resolution of symptoms after Epley maneuver. Current or past migraine headache (MH) diagnosis was made according to the International Headache Society guidelines.

RESULTS

Fifty-eight patients with recurrent BPPV with a mean age of 53.8 ± 17.4 years were included. Half (29 patients) fulfilled criteria for MH and half (29 patients) did not meet the criteria for MH (non-MH). No statistically significant difference was found in a majority of migraine-related symptoms between the MH and non-MH cohorts with recurrent BPPV. History of migraine medication usage (p = 0.008), presence of a weekly headache (p = 0.01), and duration of dizziness after positional vertigo (p = 0.01) were the only variables that were different on multivariate analysis between the MH and non-MH cohorts.

CONCLUSIONS

Half of recurrent BPPV patients suffer from migraine headaches. The other half presented with migraine-related symptoms, but do not meet criteria for MH. The high comorbidity of MH in our recurrent BPPV cohort as well as the absence of a statistically significant difference in a majority of migraine-related features among patients who did and did not fulfill criteria for MH may suggest that recurrent BPPV has a relationship with migraine. Recurrent BPPV may potentially be a manifestation of migraine in the inner ear, which we term otologic migraine including cochlear, vestibular, or cochleovestibular symptoms.

Assessment, diagnosis and management of the dizzy patient

Dizziness and balance disorders are very common problems. Having a structured approach, including adequate history taking and clinical examination, in a multidisciplinary environment allows for effective management of patients with these complex symptoms. Hearing assessment is an integral part of the assessment of patients with dizziness, along with the occasional need for further testing. Identifying red flags, along with the ability to involve different medical specialties, are prerequisites for safe management and a successful outcome. While surgical intervention has a small role in the management of balance disorders, vestibular rehabilitation remains the cornerstone of treatment, along with different supportive measures. This article outlines the approach used in the authors' centre to manage patients with dizziness and balance disorders.

Unhealthy Lifestyle Is an Important Risk Factor of Idiopathic BPPV

Background: Benign paroxysmal positional vertigo (BPPV) is a self-limiting and recurrent disease but the cost is considerable. The number of patients with BPPV increased significantly under the quarantine policy in Hangzhou. The unhealthy lifestyle risk factors of BPPV have not yet been investigated. Thus, the objective is to analyze whether an unhealthy lifestyle is a risk factor of BPPV. Methods: One hundred and sixty three patients with idiopathic BPPV aged 22-87 years (BPPV group), and 89 aged 23-92 years sex-matched control subjects (non-BPPV group) were enrolled in this study. All BPPV patients received a definitive diagnosis which excluded secondary BPPV. Non-BPPV cases excluded BPPV, sudden deafness, Meniere's disease, ear or craniofacial surgery, vestibular neuritis, and head trauma history. We obtained a blood lipids profile, serum uric acid, total bilirubin, and related diagnostic information through the electronic medical record system. To get the time of physical activities and recumbent positions, we asked the patient or their family from February 2020 to June 2020, and the rest of the patient's information was acquired by phone or WeChat. Data Analyses: The t-test or chi-squared test, univariate, and multiple logistic regression analyses were performed for the two groups. For each factor, odds ratios were calculated with 95% confidence intervals (CIs). Moreover, test equality of two or more receiver operating characteristic (ROC) analyses were applied to the physical activities, and recumbent position time; area under curve (AUC) measures were calculated with 95% CIs and compared with each other. Results: The BPPV group had unhealthy lifestyles such as poor physical activities, prolonged recumbent position time, and low rate of calcium or VD supplementation in univariate logistic regression analyses (P < 0.05). Poor physical activities and prolonged recumbent position time were independently associated with BPPV in multiple logistic regression models (OR = 18.92, 95% CI: 6.34-56.43, p = 0.00 and OR = 1.15, 95% CI: 1.01-1.33, p < 0.04). In the comparison of ROC curves of recumbent position time and physical activities in identifying BPPV, AUCs were 0.68 (0.61-0.74), and 0.68 (0.63-0.73), respectively. Conclusion: We conclude that poor physical activities and prolonged recumbent position time may be independent risk factors for BPPV patients, but hypertension, hyperuricemia, hyperlipidemia, hemoglobin, diabetes, serum bilirubin, CHD, and CI, may not be.

Do Night Shifts Increase the Risk of Benign Paroxysmal Positional Vertigo Among Doctors and Nurses?

Background

Night shift work is one of the significant and most frequent reasons for circadian rhythm disruptions, resulting in the alteration of biological functions and sleep. These factors can affect the psychological and physical well-being and also negatively impact an individual’s performance at work. Sleep disturbance has been associated with increased risk of several medical conditions such as benign paroxysmal positional vertigo (BPPV), hypertension, diabetes, high cholesterol, chronic obstructive pulmonary disease, and others.

Objective

To determine whether the night shift increases the risk of BPPV by reviewing a 7-year retrospective data.

Methods

The cross-sectional research study was conducted at the emergency department of a tertiary care teaching hospital in Qatar. A total of 69 doctors and nurses who suffered from vertigo in a period of seven years were consented and considered for the study. We excluded 12 patients with vertigo due to causes rather than BPPV. Fifty-seven patients who were diagnosed with BPPV based on examination using the Dix–Hallpike bedside test. They were treated by particle repositioning maneuvers in the emergency department.

Results

Approximately, 93% (n = 53) of participants had posterior canal BPPV and 7% (n = 4) had lateral canal BPPV (n = 5) between 2013 and 2019. Anterior canal BPPV was not reported. Chi-square test showed that night shift was associated with a high prevalence of first BPPV episode (P ≥0.001) with less likelihood of diabetes and hypertension (P ≥0.001).

Conclusion

Retrospective data review indicates a possible association between night shifts and BPPV development in doctors and nurses.

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

Background and Purpose: The lifetime prevalence of benign paroxysmal positional vertigo (BPPV) is high, especially in the elderly. Patients with BPPV are more susceptible to ischemic stroke, dementia, and fractures, severely reducing quality of life of patients. Many studies have analyzed risk factors for the occurrence of BPPV. However, the results of these studies are not identical. We performed this meta-analysis to determine potential risk factors associated with the occurrence of BPPV.

Methods: PubMed, EMBASE, and the Cochrane Library (January 2000 through March 2020) were systematically searched for eligible studies analyzing risk factors for the occurrence of BPPV. Reference lists of eligible studies were also reviewed. We selected observational studies in English with a control group and sufficient data. Pooled odds ratios (ORs) or the mean differences (MDs) and 95% confidence intervals (CIs) were calculated to measure the impacts of all potential risk factors. Heterogeneity among studies was evaluated using the Q-test and I² statistics. We used the random-effect model or the fixed-effect model according to the heterogeneity among the included studies.

Results: We eventually included 19 studies published between 2006 and 2019, including 2,618 patients with BPPV and 11,668 participants without BPPV in total. In this meta-analysis, the occurrence of BPPV was significantly associated with female gender (OR = 1.18; 95% CI, 1.05–1.32; P = 0.004), serum vitamin D level (MD = −2.12; 95% CI, −3.85 to −0.38; P = 0.02), osteoporosis (OR = 2.49; 95% CI, 1.39–4.46; P = 0.002), migraine (OR = 4.40; 95% CI, 2.67–7.25; P < 0.00001), head trauma (OR = 3.42; 95% CI, 1.21–9.70; P = 0.02), and total cholesterol level (MD = 0.32; 95% CI, 0.02–0.62; P = 0.03).

Conclusion: Female gender, vitamin D deficiency, osteoporosis, migraine, head trauma, and high TC level were risk factors for the occurrence of BPPV. However, the effects of other risk factors on BPPV occurrence need further investigations.

Efficacy of BPPV diagnosis and treatment system for benign paroxysmal positional vertigo

OBJECTIVES

To evaluate the efficacy of automatic benign paroxysmal positional vertigo (BPPV) diagnosis and treatment system for BPPV compared with the manual repositioning group.

METHODS

Two hundred thirty patients diagnosed as idiopathic BPPV who were admitted from August 2018 to July 2019 in Zhejiang Hospital were included. Among them, 150 patients of posterior semicircular canal BPPV(pc-BPPV), 53 patients of horizontal semicircular canal BPPV(hc-BPPV), and 27 patients of horizontal semicircular canal calculus (hc-BPPV-cu) were randomly treated with BPPV diagnosis and treatment system(the experimental group) or manual repositioning (the control group). Resolution of vertigo and nystagmus on the Dix-Hallpike and Roll test on day 3,day 7,day 14 and day 28 follow-up after first treatment was the main outcome measure to assess the efficacy of treatment.

RESULTS

At 3-day and 7-day follow-up after treatment with BPPV diagnosis and treatment system, 79%, 91%had complete resolution of vertigo and nystagmus, the effective rate in the experimental group were significantly higher than those in the control group, the differences were statistically significant(P < .05). On day 14, the effective rate in the experimental group (96%) was slightly higher than that in the control group(91%), but there was no significant difference between the two groups. And at 28-day after the first treatment, the effective rate was 100% in the experimental group and the control group. The repositioning efficiency of pc-BPPV (the first, second, third treatment), hc-BPPV (the first, second, third treatment), hc-BPPV-cu(the first, second treatment) in the experimental group were higher than the control group, and the secondary reposition of pc-BPPV in the experimental group was significantly higher than the control group(96%vs.84%; P < .05). While for the hc-BPPV-cu patients, the effective rate of the third treatment in the experimental group was slightly lower than that of the control group, but the differences were not statistically significant.

CONCLUSIONS

BPPV diagnosis and treatment system is effective for the treatment of BPPV, with a better effective rate than those treated with manual maneuver, and is safe and easy to perform on patients.