Elsevier

American Journal of Otolaryngology

Volume 33, Issue 5, September–October 2012, Pages 528-532
American Journal of Otolaryngology

Original contribution
Comparison of repositioning maneuvers for benign paroxysmal positional vertigo of posterior semicircular canal: advantages of hybrid maneuver,☆☆

https://doi.org/10.1016/j.amjoto.2011.12.002Get rights and content

Abstract

Objective

The prevalence of benign paroxysmal positional vertigo (BPPV) is becoming more frequent in elderly population. The presence of comorbid factors has to be considered before assessment as well as before commencing any repositioning treatment. Our aims were evaluation of the maneuvers efficacy and evaluation of the applicability of hybrid maneuver (HM) in patients with physical limitation.

Study design and setting

This is a randomized study in 2 tertiary referral centers.

Intervention

This is a therapeutic intervention.

Patients

All consecutive patients with diagnosis of BPPV of posterior canal matching the inclusion criteria were enrolled. Patients underwent treatment soon after the initial diagnosis in all cases with a repositioning maneuver. The maneuver was casually selected among Semont, Epley, and hybrid. Patients were divided into 3 groups according to the maneuver adopted.

Results

Eighty-eight patients with posterior canal BPPV were enrolled for treatment. Fisher exact test showed that no statistical differences exist between HM and other maneuvers in terms of efficacy. Latency of repositioning nystagmus appeared longer in HM in comparison with other maneuvers (P < .05). Efficacy of maneuvers used for BPPV decreases in case of cupulolithiasis (P < .0001). We found no relationship between age, sex, and length of disturbance on response to maneuvers.

Conclusions

All maneuvers evaluated demonstrated similar efficacy. The HM, as our data showed, allows us to obtain a good percentage of success similar to most maneuvers used. It is also more comfortable for the patients with hip or neck functional limitation allowing an effective treatment of the posterior canal BPPV.

Introduction

Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo. It accounts for approximately 24% of all cases of peripheral vestibular disorders [1], and the incidence is approximately 64 of 100 000 per year [2]. Patients present with a history of vertigo arising in certain head positions or during some movements of the head with respect to the horizontal plane.

Symptoms of this inner ear disease are thought to arise when otoconia move from the utricle into semicircular canals. Displacement of such debris, called otoconia, determines an endolymphatic fluid movement leading to a stimulation of ampullar receptors, thereby eliciting vertigo.

Classic BPPV involves the posterior semicircular canal (PSC) and represents the most common type of BPPV [3], [4], [5], [6]. Lateral semicircular canal BPPV accounts approximately for only 10% to 20% of all the patients presenting with BPPV [7]. Development of an anterior semicircular canal BPPV does not occur frequently because of the anatomical position of the semicircular canal, which is anterior with respect to the utricle.

Exact etiology of BPPV is still debatable. More than 50% of all reported cases are idiopathic in nature [8]. Adler [9] was the first to describe manifestations of BPPV in posttraumatic cases. A whiplash injury may be a cause of otoconia detachment with subsequent BPPV [10]. Generally, patients affected by idiopathic BPPV are older than those due to posttraumatic ones. Occasionally, BPPV has been described to be secondary to inner ear disorders [11], after stapes surgery or other otologic procedures [12]. When an inner ear cause is thought to be the origin of BPPV, it should be described as secondary BPPV [13]. Diagnosis of posttraumatic or secondary BPPV is not different from the idiopathic form, but the treatment may require more canalith repositioning maneuvers (CRM) to achieve satisfactory results [10]. Fortunately, in patients affected by vertigo crisis due to idiopathic BPPV, correct diagnostic evaluation and appropriate management allow, in most cases, to solve the problem quickly, without the need for any medical treatment.

Several effective repositioning maneuvers exist to manage PSC-BPPV. The methods proposed by Semont et al [14] and Epley [15], although differing in their position and movements, act with the mechanism of displacement of the otoconial debris around the long arm of the posterior canal, through the common crus, and back into the utricle. This rule is well applied with these maneuvers that reach a very good recovery rate. Eighty percent of patients become free of symptoms after a single maneuver [14], [15], [16].

A hybrid maneuver (HM) for PSC BPPV was recently described to treat those patients who exhibit contraindications to neck hyperextension or patients with hip, back, or other diseases that may affect mobility. This maneuver, until now, has only been reported by the authors who originally described the procedure [17].

We report a comparative study between 3 types of CRMs to treat PSC BPPV. Our aims were (1) evaluation of the maneuvers efficacy and (2) evaluation of the applicability of maneuvers in patients with physical limitation.

Section snippets

Materials and methods

All consecutive patients with diagnosis of BPPV of PSC referred to our centers were enrolled in this study in the period of March 2011 to July 2011. We recorded data of the patients: anagraphic data, history, and symptoms. All patients underwent a complete otoneurologic examination including otoscopy, pure tone audiometry, tympanometry, and nystagmus observation under infrared videonystagmoscopy. The diagnosis was based on clinical examination with a side-lying maneuver to test the involved

Results

During the period of study, 88 patients with PSC BPPV were enrolled for treatment. Forty-eight of the patients were females, whereas the remaining 40 patients were males. The patients belonged to the age range between 32 and 80 years with a mean of 52.56 years. The symptom period varied between 5 days to 2 months. No patients included in the study were treated previously for BPPV. All patients of the series matched the inclusion criteria stated above. The groups' subdivision is summarized in

Discussion

Pathophysiology of BPPV is described based on 2 main hypotheses. Canalithiasis is the most widely accepted theory to justify the symptoms of BPPV [21], [22]. In this theory, it is proposed that otoconia, usually fixed within the utricle, become free and fall into semicircular canals (PSC is the most commonly involved). When head is moved into the stimulating position, the particles move initially consensually with the head and then fall following the direction of gravity dragging the endolymph

Conclusions

Repositioning maneuvers are the most effective treatment modality for BPPV. Although there are well known techniques to manage the BPPV, sometimes, such maneuvers have to be applied to patients with problems, often due to comorbidities entailing limitation of body movements. All the maneuvers evaluated demonstrated similar efficacy without any statistically significant differences. The HM, as our data showed, allows us to obtain a good percentage of success similar to most CRMs used. It is also

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    Financial disclosure: No fund was obtained to complete this work.

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    Conflict of interest: No conflicts of interest are present.

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