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Khoujah D, Naples JG, Silva LOJE, Edlow JA, Gerberi DJ, Carpenter CR, Bellolio F. Epley maneuver for benign paroxysmal positional vertigo: Evidence synthesis for guidelines for reasonable and appropriate care in the emergency department. Acad Emerg Med 2023. [PMID: 37186435 DOI: 10.1111/acem.14739] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/13/2023] [Accepted: 04/14/2023] [Indexed: 05/17/2023]
Abstract
BACKGROUND Canalith repositioning maneuvers (such as the Epley maneuver) are recommended by specialty guidelines for management of benign paroxysmal positional vertigo (BPPV) yet are frequently underutilized in the emergency department (ED). METHODS We conducted a systematic review of systematic reviews to summarize the evidence of Epley maneuver for the treatment of posterior canal (pc) BPPV in any setting. We included systematic reviews of randomized controlled trials (RCTs) that compared Epley to control in adult patients with pc-BPPV. Titles, abstracts, and full texts were screened in duplicate. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. Odds ratios (OR) and 95% confidence intervals (CI) are reported. Meta-analysis of individual studies was conducted with random and fixed effects. RESULTS From 2,228 titles, 7 systematic reviews were selected for quality assessment. One review was of higher methodological quality, included only RCTs, and was the most current and comprehensive. Five of the 11 RCTs of the review, including 312 patients with pc-BPPV diagnosed by Dix-Hallpike, were relevant to our question. Meta-analysis of 4 RCTs (251 patients) showed the use of Epley (as compared to control) was associated with higher complete resolution of vertigo at 1 week (OR 7.19, CI 1.52 to 33.98, moderate certainty). Meta-analysis of 3 RCTs (195 patients) showed the use of Epley was associated with higher conversion to negative Dix-Hallpike at 1 week (OR 6.67, CI 1.52 to 33.98, moderate certainty). The number-needed-to-treat was 3. Meta-analysis of the outcomes at 1 month, and when observational studies were included, showed similar results. No serious adverse effects were reported. CONCLUSIONS Symptoms of pc-BPPV improve with the Epley maneuver. Emergency clinicians should become familiar with performing the Epley for BPPV. Further studies on ED implementation and clinician education of Epley are needed.
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Affiliation(s)
- Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, AdventHealth Tampa, Tampa, Florida, USA
| | - James G Naples
- Center, Division of Otolaryngology-Head & Neck Surgery, Beth, Israel Deaconess Medical, Harvard Medical School, Boston, Massachusetts, USA
| | - Lucas Oliveira J E Silva
- Department of Emergency Medicine, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Christopher R Carpenter
- Department of Emergency Medicine, Washington University at St. Louis, St. Louis, Missouri, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
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2
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Ranju RL, Lepcha A, Mammen MD, Vasanthan LT, Augustine AM, Philip A. An Effective Home-Based Particle Repositioning Procedure for Posterior Canal Benign Paroxysmal Positional Vertigo (BPPV). Indian J Otolaryngol Head Neck Surg 2022; 74:516-523. [PMID: 36514424 PMCID: PMC9741680 DOI: 10.1007/s12070-021-03021-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 11/28/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- R. L. Ranju
- Department of ENT (Otology, Neurotology and Cochlear Implant Unit), Christian Medical College, Vellore, 632004 India
| | - Anjali Lepcha
- Department of ENT (Otology, Neurotology and Cochlear Implant Unit), Christian Medical College, Vellore, 632004 India
| | - Manju Deena Mammen
- Department of ENT (Otology, Neurotology and Cochlear Implant Unit), Christian Medical College, Vellore, 632004 India
| | - Lenny T. Vasanthan
- Department of Physiotherapy (Vestibular Physiotherapy), Christian Medical College, Vellore, India
| | - Ann Mary Augustine
- Department of ENT (Otology, Neurotology and Cochlear Implant Unit), Christian Medical College, Vellore, 632004 India
| | - Ajay Philip
- Department of ENT (Otology, Neurotology and Cochlear Implant Unit), Christian Medical College, Vellore, 632004 India
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Gupta D, Solanki B. Epley's Manoeuvre: A Single Line Treatment for Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo. Indian J Otolaryngol Head Neck Surg 2022; 74:3877-3882. [PMID: 36742929 PMCID: PMC9895745 DOI: 10.1007/s12070-021-02695-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 06/20/2021] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Diksha Gupta
- Department of ENT, Dr. S.N. Medical college, Hostel no: 9, shastri nagar, Jodhpur, Rajasthan India
| | - Bharti Solanki
- Department of ENT, Dr. S.N. Medical college, Hostel no: 9, shastri nagar, Jodhpur, Rajasthan India
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4
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Sinsamutpadung C, Kulthaveesup A. Comparison of outcomes of the Epley and Semont maneuvers in posterior canal BPPV: A randomized controlled trial. Laryngoscope Investig Otolaryngol 2021; 6:866-871. [PMID: 34401514 PMCID: PMC8356850 DOI: 10.1002/lio2.619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 06/22/2021] [Accepted: 07/06/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES This study aims to compare the efficacy of the Epley and Semont maneuvers in relieving posterior canal benign paroxysmal positional vertigo (BPPV) arising in the in patients at the Outpatient Department of the Department of Otolaryngology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand. METHOD In this prospective, randomized, comparative study, patients were assigned to receive one of the two treatment methods. First, BPPV was diagnosed with the Dix-Hallpike test. Then, each patient was treated by either the Epley or Semont maneuver. Immediately afterward, the efficacy of treatments was evaluated with the Dix-Hallpike test, and dizziness intensity was assessed with the visual analog scale (VAS). RESULTS This study enrolled 80 patients with posterior canal BPPV, 40 of which underwent the Epley maneuver and the other 40 underwent the Semont maneuver. In the first week, The Epley maneuver cured 37 (92.5%) of the 40 patients, and the Semont maneuver cured 36 (90%) of the 40 patients. Statistical analysis revealed no significant difference in the efficacy of these treatments (P = .251). Regarding dizziness intensity, VAS scores decreased from 6.48 to 1.65 after the Epley maneuver and from 6.53 to 2.18 after the Semont maneuver. Statistical analysis revealed that the Epley maneuver was superior to the Semont maneuver (P = .009) in reducing dizziness intensity. CONCLUSIONS The Epley and Semont maneuvers had similar efficacy in curing posterior canal BPPV. Regarding the severity of dizziness after treatment, the Epley maneuver produced significantly better results than did the Semont maneuver.Level of Evidence: II.
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Affiliation(s)
- Chayada Sinsamutpadung
- Taksin Hospital, Medical Service DepartmentBangkok Metropolitan AdministrationBangkokThailand
| | - Anan Kulthaveesup
- Department of Otolaryngology, Faculty of Medicine Vajira HospitalNavamindradhiraj UniversityBangkokThailand
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5
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Dror AA, Taiber S, Sela E, Handzel O, Avraham KB. A mouse model for benign paroxysmal positional vertigo with genetic predisposition for displaced otoconia. GENES BRAIN AND BEHAVIOR 2020; 19:e12635. [PMID: 31898392 DOI: 10.1111/gbb.12635] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 12/29/2019] [Accepted: 12/30/2019] [Indexed: 12/26/2022]
Abstract
Abnormal formation of otoconia, the biominerals of the inner ear, results in balance disorders. The inertial mass of otoconia activates the underlying mechanosensory hair cells in response to change in head position primarily during linear and rotational acceleration. Otoconia associate exclusively with the two gravity receptors, the utricle and saccule. The cristae sensory epithelium is associated with an extracellular gelatinous matrix known as cupula, equivalent to otoconia. During head rotation, the inertia of endolymphatic fluids within the semicircular canals deflects the cupula of the corresponding crista and activates the underlying mechanosensory hair cells. It is believed that detached free-floating otoconia particles travel ectopically to the semicircular canal and cristae and are the culprit for benign paroxysmal positional vertigo (BPPV). The Slc26a4 mouse mutant harbors a missense mutation in pendrin. This mutation leads to impaired transport activity of pendrin and to defects in otoconia composition and distribution. All Slc26a4 loop/loop homozygous mutant mice are profoundly deaf but show inconsistent vestibular deficiency. A panel of behavioral tests was utilized in order to generate a scoring method for vestibular function. A pathological finding of displaced otoconia was identified consistently in the inner ears of mutant mice with severe vestibular dysfunction. In this work, we present a mouse model with a genetic predisposition for ectopic otoconia with a clinical correlation to BPPV. This unique mouse model can serve as a platform for further investigation of BPPV pathophysiology, and for developing novel treatment approaches in a live animal model.
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Affiliation(s)
- Amiel A Dror
- Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel.,Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Shahar Taiber
- Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Sela
- Department of Otolaryngology-Head and Neck Surgery, Galilee Medical Center, Nahariya, Israel.,Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Ophir Handzel
- Department of Otolaryngology Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Karen B Avraham
- Department of Human Molecular Genetics and Biochemistry, Sackler Faculty of Medicine and Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
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6
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Panuganti A, Loka SR, Tati S, Punga AK. Comparative Study of Management of BPPV (Benign Paroxysmal Positional Vertigo) with only Drugs Versus Drugs Plus Epley Manoeuvre. Indian J Otolaryngol Head Neck Surg 2019; 71:1183-1186. [PMID: 31750147 PMCID: PMC6841758 DOI: 10.1007/s12070-018-1255-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 01/30/2018] [Indexed: 10/17/2022] Open
Abstract
Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder, accounting for 20% of all vertigo cases. Idiopathic BPPV is most common between the ages of 50 and 70, although the condition is found in all age groups. The importance of early diagnosis and treatment can lead to a much improved quality of life for patients afflicted by this ailment. It is presently common for physicians to treat these patients mainly with benzodiazepines, antihistamines, and anticholinergic medications, especially if the history and physical is consistent with BPPV. This method of treatment has had questionable success. Several reviews of the management of vertigo have shown that no medication in current use has well established curative or prophylactic value or is suitable for long-term treatment. Epleys manoeuvre is also used in the treatment of BPPV. This manoeuvre relocates free floating particles from the affected semi-circular canals back into utricle, thus relieving the symptoms of vertigo. The purpose of this study is to compare the efficacy of Epleys manoeuvre with conventional drug therapy versus conventional therapy alone in patients who present with vertigo. The purpose of this study to evaluate and examine two methods of treatment.
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7
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Meurer WJ, Beck KE, Rowell B, Brown D, Tsodikov A, Fagerlin A, Telian SA, Damschroder L, An LC, Morgenstern LB, Ujhely M, Loudermilk L, Vijan S, Kerber KA. Implementation of evidence-based practice for benign paroxysmal positional vertigo: DIZZTINCT- A study protocol for an exploratory stepped-wedge randomized trial. Trials 2018; 19:697. [PMID: 30577834 PMCID: PMC6303863 DOI: 10.1186/s13063-018-3099-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 12/02/2018] [Indexed: 11/18/2022] Open
Abstract
Background Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder, and accounts for 8% of individuals with moderate or severe dizziness. BPPV patients experience substantial inconveniences and disabilities during symptomatic periods. BPPV therapeutic processes – the Dix-Hallpike Test (DHT) and the Canalith Repositioning Maneuver (CRM) – have an evidence base that is at the clinical practice guideline level. The most commonly used CRM is the modified Epley maneuver. The DHT is the gold standard test for BPPV and the CRM is supported by numerous randomized controlled trials and systematic reviews. Despite this, BPPV care processes are underutilized. Methods/design This is a stepped-wedge, randomized clinical trial of a multi-faceted educational and care-process-based intervention designed to improve the guideline-concordant care of patients with BPPV presenting to the emergency department (ED) with dizziness. The unit of randomization and target of intervention is the hospital. After an initial observation period, the six hospitals will undergo the intervention in five waves (two closely integrated hospitals will be paired). The order will be randomized. The primary endpoint is measured at the individual patient level, and is the presence of documentation of either the Dix-Hallpike Test or CRM. The secondary endpoints are referral to a health care provider qualified to treat dizziness for CRM and 90-day stroke rates following an ED dizziness visit. Formative evaluations are also performed to monitor and identify potential and actual influences on the progress and effectiveness of the implementation efforts. Discussion If this study safely increases documentation of the DHT/CRM, this will be an important step in implementing the use of these evidenced-based processes of care. Positive results will support conducting larger-scale follow-up studies that assess patient outcomes. The data collection also enables evaluation of potential and actual influences on the progress and effectiveness of the implementation efforts. Trial registration ClinicalTrials.gov, ID: NCT02809599. The record was first available to the public on 22 June 2016 prior to the enrollment of the first patients in October 2016. Electronic supplementary material The online version of this article (10.1186/s13063-018-3099-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- William J Meurer
- Department of Emergency Medicine, University of Michigan, TC B1-354 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA. .,Department of Neurology, University of Michigan, Ann Arbor, MI, USA. .,Stroke Program, University of Michigan, Ann Arbor, MI, USA. .,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | | | - Brigid Rowell
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Devin Brown
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Stroke Program, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Alexander Tsodikov
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Angela Fagerlin
- Department of Population Health Sciences, University of Utah, Salt Lake City, USA.,Salt Lake City VA Center for Informatics Decision Enhancement and Surveillance (IDEAS), Salt Lake City, USA
| | - Steven A Telian
- Department of Otolaryngology, University of Michigan, Ann Arbor, MI, USA
| | | | - Lawrence C An
- Department of Internal Medicine, University of Michigan, Ann Arbor, USA.,Center for Health Communication and Research, University of Michigan, Ann Arbor, USA
| | - Lewis B Morgenstern
- Department of Emergency Medicine, University of Michigan, TC B1-354 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.,Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Stroke Program, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Misty Ujhely
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Laura Loudermilk
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Sandeep Vijan
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.,Department of Internal Medicine, Division of General Medicine, University of Michigan, Ann Arbor, USA
| | - Kevin A Kerber
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Stroke Program, University of Michigan, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
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8
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Effectiveness of the Epley manoeuvre in posterior canal benign paroxysmal positional vertigo: a randomised clinical trial in primary care. Br J Gen Pract 2018; 69:e52-e60. [PMID: 30510098 DOI: 10.3399/bjgp18x700253] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 07/17/2018] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Evidence on the effectiveness of the Epley manoeuvre in primary care is scarce. AIM To evaluate effectiveness at 1 week, 1 month, and 1 year of a single Epley manoeuvre versus a sham manoeuvre in primary care. DESIGN AND SETTING Multicentre, double-blind randomised controlled trial in two primary care practices in Spain from November 2012 to January 2015. METHOD Patients were ≥18 years diagnosed with subjective or objective posterior benign paroxysmal positional vertigo (vertigo only, or vertigo and nystagmus after a Dix-Hallpike test [DHT]). The intervention group received the Epley manoeuvre, and the control group received a sham manoeuvre. Betahistine was prescribed following the same regimen in both groups. The main outcome measures were the DHT result classified as negative (neither vertigo nor nystagmus) or positive. Positive results were further divided into a positive result for both vertigo and nystagmus (positive DHT with nystagmus), and a positive result for vertigo only (positive DHT without nystagmus); self-reported resolution of vertigo; and self-reported severity of vertigo evaluated on a 10-point Likert scale (10 = worst imaginable vertigo). RESULTS In total, 134 patients were randomised to either the intervention group (n = 66) or the sham group (n = 68). The intervention group showed better results in the unadjusted analyses at 1 week, with a lower rate of positive DHT with nystagmus (P = 0.022). A positive baseline DHT with nystagmus was associated with a reduction in vertigo severity (marginal effect for 10-point Likert-like question -1.73, 95% confidence interval [CI] = -2.95 to -0.51) and better positive DHT rates in the intervention group (adjusted odds ratio 0.09, 95% CI = 0.01 to 0.92) in the multivariate analyses. CONCLUSION A single Epley manoeuvre performed in primary care is an effective treatment for reversing a positive DHT and reducing vertigo severity in patients with baseline nystagmus in the DHT.
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9
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Çınar Y, Bayram A, Culfa R, Mutlu C. Analyses with the Video Head Impulse Test During the Canalith Repositioning Maneuver in Patients with Isolated Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo. Turk Arch Otorhinolaryngol 2018; 56:81-84. [PMID: 30197804 DOI: 10.5152/tao.2018.3166] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 02/20/2018] [Indexed: 11/22/2022] Open
Abstract
Objective To evaluate the posterior semicircular canal (PSCC) functions using video head impulse test (vHIT) during canalith repositioning maneuver (CRM) treatment in patients with isolated, posterior semicircular canal benign paroxysmal positional vertigo (PSCC-BPPV). Methods A total of 44 subjects comprising of 24 subjects with isolated PSCC-BPPV and 20 age- and sex-matched healthy control subjects were enrolled in the present study. vHIT was performed for the affected PSCC before and just after CRM and at the third and seventh day and first month to evaluate vestibulo-ocular reflex (VOR) gain, gain asymmetry (GA), and corrective saccades. Repeated determinations of VOR gain and GA were compared to evaluate the time course of vHIT measurements during CRM treatment in isolated PSCC-BPPV patients, and the values were also compared with the control group. Results VOR gains and GA values were not statistically different before and after CRM and at the third-day, seventh-day and first-month visits for the affected PSCC. Moreover, values did not differ between the BPPV and control groups, and none of the subjects demonstrated corrective saccades. Conclusion To our knowledge, this study is the first report to investigate vHIT measurements with a time course of alterations during CRM treatment in PSCC-BPPV patients. vHIT may not provide an additional contribution for evaluating vestibular dysfunction during the diagnosis and treatment of isolated PSCC-BPPV.
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Affiliation(s)
- Yusuf Çınar
- Department of Otorhinolaryngology, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Ali Bayram
- Department of Otorhinolaryngology, Kayseri Training and Research Hospital, Kayseri, Turkey
| | - Ramazan Culfa
- Department of Otorhinolaryngology, Sorgun State Hospital, Yozgat, Turkey
| | - Cemil Mutlu
- Department of Otorhinolaryngology, Kayseri Training and Research Hospital, Kayseri, Turkey
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10
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Moore P, Le T, Blakley B, Beiko J, Meen E. Hemorrhagic stroke after Epley maneuver: a case report. J Otolaryngol Head Neck Surg 2018; 47:25. [PMID: 29631624 PMCID: PMC5891963 DOI: 10.1186/s40463-018-0268-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Accepted: 03/12/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This is the first case to our knowledge of a serious adverse event following the Epley maneuver, which is the treatment of choice for benign paroxysmal positional vertigo (BPPV), the most common vestibular disorder in adults. CASE PRESENTATION A 77 year old female presented for outpatient evaluation of vertigo at a tertiary otolaryngology clinic. She was found to have BPPV clinically, and elected to have a particle repositioning maneuver (Epley maneuver) performed in clinic. Immediately following Epley maneuver, she had severe nausea and vomiting, with evolving visual changes. A CT angiogram of the brain was performed urgently through the emergency department and demonstrated an acute intraparenchymal hemorrhage in the occipital lobe. After medical stabilization and rehabilitation, the patient continues to have a permanent visual field deficit. CONCLUSION The Epley maneuver is safe and effective, and there are no prior reports of serious adverse events associated with its use. This case, in which a patient experienced a hemorrhagic stroke after undergoing the Epley maneuver, is the first and sole case in the medical literature of an Epley-associated serious adverse event. The indirect causation and extreme rarity of this event do not warrant any change to patterns of practice.
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Affiliation(s)
- Paige Moore
- Department of Otolaryngology - Head & Neck Surgery, University of Manitoba, GB421 - 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada.
| | - Trung Le
- Department of Otolaryngology - Head & Neck Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Brian Blakley
- Department of Otolaryngology - Head & Neck Surgery, University of Manitoba, GB421 - 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada
| | - Jason Beiko
- Department of Neurosurgery, University of Manitoba, Winnipeg, MB, Canada
| | - Eric Meen
- Department of Otolaryngology - Head & Neck Surgery, University of Manitoba, GB421 - 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada
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11
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Natural history of horizontal canal benign paroxysmal positional vertigo is truly short. J Neurol 2014; 262:74-80. [PMID: 25305003 DOI: 10.1007/s00415-014-7519-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Revised: 09/24/2014] [Accepted: 09/25/2014] [Indexed: 10/24/2022]
Abstract
The objective of the study is to characterize the natural course of positional vertigo and nystagmus in patients with horizontal canal benign paroxysmal positional vertigo (h-BPPV) and to analyze the difference in the natural course between the two variants of h-BPPV. We conducted a prospective study in 106 patients with geotropic type h-BPPV [h-BPPV (Geo)] (n = 43) and apogeotropic type h-BPPV [h-BPPV (Apo)] (n = 63) who agreed and signed the written informed consent of no treatment. All patients were asked to answer a detailed interview about the onset time of positional vertigo and to visit the hospital every 1-3 days. At every visit, they were interviewed about cessation time of positional vertigo and positional nystagmus was assessed. The mean period ± SD between the onset and remission of vertigo in the h-BPPV (Geo) was 6.7 ± 6.3 days, whereas that in the h-BPPV (Apo) was 3.7 ± 4.1 days. In addition, the mean period ± SD from the initial diagnosis to the disappearance of positional nystagmus in the h-BPPV (Geo) was 4.7 ± 3.9 days, whereas that in the h-BPPV (Apo) was 4.4 ± 5.0 days. Although the duration until natural remission of positional nystagmus did not differ between the two variants of h-BPPV, the remission of vertigo occurred faster in h-BPPV (Apo) than h-BPPV (Geo) (p < 0.05). The natural course of h-BPPV is much shorter than that indicated in previous reports. The positional vertigo disappeared faster in the h-BPPV (Apo) compared to the h-BPPV (Geo) unlike the positional nystagmus.
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Abstract
The article focuses on the evidence basis for the management of benign paroxysmal positional vertigo, the most common diagnosis of vertigo in both primary care and subspecialty settings. An overview is presented, along with evidence-based clinical assessment, diagnosis, and management. Summaries of differential diagnosis of vertigo and outcomes are presented.
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Affiliation(s)
- Anh T Nguyen-Huynh
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health & Science University, 3181 Sam Jackson Park Road PV01, Portland, OR 97239, USA.
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The Role of Postural Restrictions after BPPV Treatment: Real Effect on Successful Treatment and BPPV's Recurrence Rates. Int J Otolaryngol 2012; 2012:932847. [PMID: 22518162 PMCID: PMC3299224 DOI: 10.1155/2012/932847] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Revised: 10/30/2011] [Accepted: 11/01/2011] [Indexed: 11/17/2022] Open
Abstract
Background. Canalith repositioning techniques are adequately established in the literature, as the treatment of choice for benign paroxysmal positional vertigo. However, the role of the posttreatment instructions is still not clearly defined. Patients and Methods. A retrospective chart review of 82 patients was conducted in order to determine the efficacy of postural restrictions, when combined with the classic canalith repositioning techniques, in terms of successful treatment and recurrence rates. Follow-up period reached at least 12 months after the initial treatment. Results. In this study, postural restrictions did not appear to significantly affect the outcomes of repositioning maneuvers, as well as the recurrence rate. Conclusions. Although this study, as well as most recent control studies, states that there is no significant effect of postmaneuver postural restrictions on both treatment and recurrence rates, larger multicentric research projects, adopting improved methodology, are still necessary in order to determine the contribution of such restrictions to both the therapeutic results and the prevention of recurrence. Adequate followup, focusing on the first six months after the initially successful repositioning maneuver, is also of paramount importance.
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Cohen HS, Sangi-Haghpeykar H. Canalith repositioning variations for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2010; 143:405-12. [PMID: 20723779 DOI: 10.1016/j.otohns.2010.05.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2010] [Revised: 05/04/2010] [Accepted: 05/17/2010] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To determine if variations in common treatments for benign paroxysmal positional vertigo (BPPV) affected efficacy. STUDY DESIGN Prospective, pseudo-randomized study. SETTING Outpatient practice in a tertiary care facility. SUBJECTS AND METHODS Patients (n = 118) with unilateral BPPV of the posterior canal, including 13 patients with BPPV of the lateral canal, were tested at a tertiary care center on one of five interventions: canalith repositioning maneuver (CRP), CRP plus home exercise, modified CRP, CRP for patients with involvement of two semicircular canals, and self-CRP home exercise. Self-CRP was also compared to previously published data on efficacy of the Brandt Daroff exercise. Main outcome measures were vertigo intensity and frequency, presence/absence of Dix-Hallpike responses, Vestibular Disorders Activities of Daily Living Scale (VADL), and computerized dynamic posturography. RESULTS Vertigo intensity and frequency and Dix-Hallpike responses decreased significantly, and posturography and VADL improved significantly from pre- to post tests. No other significant changes were found. The groups did not differ significantly. Vertigo intensity and frequency were not strongly related at pretest but were related at post-test. Length of illness and age did not influence the results. CONCLUSION However the head is moved, as long as it is moved rapidly enough and through the correct planes in space, repositioning treatments are likely to be effective. Therefore, clinicians have a range of choices in selecting the treatment best suited for each patient's unique needs.
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Affiliation(s)
- Helen S Cohen
- Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, TX, USA.
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von Brevern M, Seelig T, Radtke A, Tiel-Wilck K, Neuhauser H, Lempert T. Short-term efficacy of Epley's manoeuvre: a double-blind randomised trial. J Neurol Neurosurg Psychiatry 2006; 77:980-2. [PMID: 16549410 PMCID: PMC2077628 DOI: 10.1136/jnnp.2005.085894] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Benign paroxysmal positional vertigo of the posterior canal (PC-BPPV) is a common vestibular disorder and can be easily treated with Epley's manoeuvre. Thus far, the short-term efficacy of Epley's manoeuvre for treatment of PC-BPPV is unknown. OBJECTIVES To evaluate the efficacy of Epley's manoeuvre for treatment of PC-BPPV 24 h after applying the manoeuvre. METHODS The short-term efficacy of Epley's manoeuvre was compared with a sham procedure in 66 patients with PC-BPPV by using a double-blind randomised study design. RESULTS 24 h after treatment, 28 of 35 (80%) patients in the Epley's manoeuvre group had neither vertigo nor nystagmus on positional testing compared with 3 of 31 (10%) patients in the sham group (p<0.001). CONCLUSION Epley's manoeuvre is shown to resolve PC-BPPV both effectively and rapidly.
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Affiliation(s)
- M von Brevern
- Department of Neurology, Charité, Campus Virchow-Klinkum, Berlin, Germany.
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Abstract
Advances in understanding the organization of the ocular motor system, including its anatomy and pharmacology, have provided new insights into the pathogenesis of various forms of nystagmus. The discoveries of fibromuscular pulleys that govern the pulling directions of the extraocular muscles has provided a new conceptual framework to account for the different axes of rotation of vestibular and other types of movements that may contribute to nystagmus. Theoretical and experimental evidence has suggested that acquired pendular nystagmus, which is commonly due to multiple sclerosis, arises from the neural network that normally guarantees steady gaze by integrating premotor signals. Pharmacologic inactivation studies have implicated both gamma-aminobutyric acid (GABA) and glutamate as important transmitters in the neural integrator and suggested new drug therapies. New electro-optic devices may eventually prove to be effective treatment for the visual symptoms cause by acquired nystagmus. The demonstration of proprioceptive mechanisms in the distal extraocular muscles has provided a rationale for new operative treatments for congenital nystagmus.
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Affiliation(s)
- J S Stahl
- Department of Neurology, University Hospitals, 11100 Euclid Avenue, Cleveland, OH 44106-5040, USA
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Abstract
Benign paroxysmal positional vertigo (BPPV) is the most common and most treatable cause of vertigo. In most cases, a simple maneuver that takes less than a few minutes to do resolves the problem. BPPV is caused by misplaced calcium carbonate crystals (otoconia) in the semicircular canal of the inner ear that have broken free from the utricle. When these crystals break free, they either remain loose in one of three different semicircular canals or attach to the hair cells within a canal. Several different types of treatment maneuvers have been described. The maneuver to use varies according to the semicircular canal involved and whether the crystals are loose or attached to the hair cells.
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Affiliation(s)
- R J Tusa
- Department of Neurology, Center for Rehabilitation Medicine, Emory University, 1441 Clifton Road, NE, Atlanta, GA 30322, USA.
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