Authors: Elif Kaya Çelik, Fatih Öner, Hatice Güzelküçük Akay
Categories: Original Article
Source: Annals of Saudi Medicine
Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular condition characterized by short-term vertigo attacks that significantly affect quality of life
Examine how well a single Epley maneuver worked in an outpatient setting for people with posterior canal benign paroxysmal positional vertigo (PC-BPPV) and whether they needed a second Dix-Hallpike maneuver.
Prospective.
Otorhinolaryngology department of a tertiary care center.
Sociodemographic data, body mass index (BMI), and systemic disease history of 75 patients diagnosed with PC-BPPV were recorded, and their relationship with success rates after the modified Epley maneuver was analyzed.
Detect cases that could not be repositioned with the diagnostic control Dix-Hallpike test performed 20 minutes after the modified Epley reposition maneuver in the same session in PC-BPPV patients.
75
Of the 75 patients, 31 were male (41.3%), 44 female (58.6%) with a mean (standard deviation) age of 58.6 (15.9) years age, 54.6% had one or more chronic diseases. BMI was 30 mg/kg^2^ and above in 31 patients (41.3%). The modified Epley maneuver was successful in 77.3%. No significant relationship was found between additional diseases or BMI in the patient group in whom the maneuver was unsuccessful.
The success rates of repositioning maneuvers in treating patients diagnosed with PC-BPPV are high. However, more than a single maneuver is required in some resistant patients. Second diagnostic and repositioning maneuvers performed in the same session will reduce multiple hospital admissions. While it is helpful to repeat the maneuver in the patient group where it was unsuccessful, other factors causing the failure should be investigated.
Lack of follow-up results of patients after 7-10 days.
Benign paroxysmal positional vertigo (BPPV) is characterized by brief episodes of vertigo associated with positional and/or positional nystagmus that occur in certain head positions. BPPV is caused by the dislocation of calcium carbonate crystals that move from the utricle into the semicircular canals or adhere to the cupula, making it susceptible to gravity. It is a disorder of the peripheral vestibular system characterized by recurrent episodes of positional vertigo lasting less than one minute.^1,2^ BPPV is the most common peripheral cause of vertigo.^3^ Although it is a benign disease, it is essential to make the diagnosis and appropriate treatment because it causes significant limitations in the daily activities of patients.^4^
Otoliths called otoconial debris passing from the utricular macula to the semicircular canal are responsible for the pathogenesis of BPPV. Displacement of otoliths can be effectively treated with repositioning maneuvers.^5^ The only proven method recommended by the American Academy of Neurology for treating posterior canal (PC) BPPV is the Epley maneuver.^6^ The prevalence of BPPV has been reported as 10.7-64 per 100 000 population.^7^ It mainly affects the geriatric age group. The age of onset is most commonly between the fifth and seventh decades of life.^8^ Posterior semicircular canal involvement is the most commonly affected canal, with 80% to 90% of BPPV cases. Involvement of the lateral semicircular canal (5-15%) and the anterior semicircular canal (1-2%) is seen less frequently.^9,10^
The Dix-Hallpike test has been accepted as the gold standard for diagnosing PC-BPPV.^11^ Most cases of PC-BPPV can be diagnosed in a single admission with the Dix-Hallpike test and then easily treated with a canalith repositioning maneuver.^12^ Performed as a single procedure lasting only a few minutes, the Semont maneuver, particularly the modified Epley maneuver, reliably resolves most PC-BPPV cases. The disappearance of nystagmus and other symptoms after performing canalith repositioning maneuver procedures strongly supports the diagnosis of PC-BPPV.^12,13^ However, patient compliance, disease variants, limited duration, and additional systemic diseases may play a role in the effectiveness of the maneuver.^13^
In our study, we aimed to determine the relationship between body mass index (BMI) and systemic diseases, which we evaluated with the control Dix-Hallpike test after a single session of the modified Epley maneuver for canalith reposition was applied to patients diagnosed with PC-BPPV.
This study included patients who applied to Tokat Gaziosmanpaşa University Otorhinolaryngology Department with vertigo and were treated with the modified Epley maneuver in which unilateral PC-BPPV was detected after the Dix-Hallpike test. The Ethics Committee of our institution approved the protocol of the study (decision 23-KAEK-093). All patients included in the study were informed, and their written consent was obtained. The data were recorded by questioning the patients regarding etiological factors and systemic diseases with a detailed anamnesis.
Patients with unilateral PC-BPPV detected after otolaryngologic examination and the diagnostic Dix-Hallpike test were included in the study. Patients under 18 years of age, other peripheral vertigo types other than BPPV, patients with BPPV with non-posterior canal or multiple canal involvement, and patients with mental health problems were excluded from the study. In addition, patients with cervical or lumbar vertebral pathologies that would prevent the modified Epley maneuver or who did not want to have the maneuver were excluded from the study. Demographic information of the patients, affected side, age, BMI, and current systemic diseases were documented.
The Dix-Hallpike test was applied to all patients. According to the information obtained from the patient, the test was started from the side where vertigo and/or nystagmus did not have a trigger position. If the patient did not know which position triggered vertigo, the maneuver was started from the right side. During this maneuver, the patients were quickly brought from the sitting position to the supine position, with the head 45 degrees to the side and the head 45 degrees below the horizontal, with the support of the physician on the examination table. Patients with vertigo and geotropic rotational nystagmus were diagnosed with PC-BPPV.
The modified Epley maneuver was initiated after identifying the affected canal using the Dix-Hallpike test. In the supine position, the patient's head was turned 45° towards the affected ear, keeping the eyes open. After a two-minute waiting period, as a second movement, the patient's head was slowly turned 90° towards the opposite side for approximately one minute. During this slow rotation movement, the patient's head was kept in this position for two minutes, taking care to keep it in extension. As the third maneuver, the body was slowly turned 90° to the opposite side for approximately one minute, keeping the head position and angle. After a two-minute waiting period, the fourth and final maneuver was started. The patient was seated with the head in 30° flexion, and the maneuver was completed. Twenty minutes later, the Dix-Hallpike test was repeated, and the success of the modified Epley maneuver was checked. The absence of nystagmus and vertigo after Dix-Hallpike was considered a successful procedure.
Analyses were evaluated with version 22 of IBM SPSS (IBM SPSS, Armonk, NY: IBM Corp.). Descriptive data are shown as number and percentage values for categorical data and mean and standard deviation values for continuous data. Chi-square analysis was used to compare categorical variables between groups. The conformity of continuous variables to a normal distribution was evaluated by the Kolmogorov-Smirnov test. A t-test was used for the comparison of paired groups. Logistic regression analysis was performed to calculate the risk of failure. The statistical significance level in the analysis was accepted as P<.05.
A total of 75 patients, 31 (41.3%) male and 44 (58.7%) female, were included in the study. The mean (SD) age of the patients was 57.1 (15.5) (range: 23 to 90) years, while the BMI of 44 (58.7%) patients was below 30; 31 (41.3%) had a BMI of 30 and above (Figure 1). Systemic disease was present in 41 (54.7%) of 75 patients. Right-sided PC-BPPV was detected in 52 (69.3%) patients, while left-sided PC-BPPV was detected in 23 (30.7%) patients. While the modified Epley maneuver was successful in the first session in 58 (77.3%) patients, it was unsuccessful in 17 (22.7%) patients (Table 1).
Figure 1. The BMI values of the patient population below 30 were significantly higher in males than females (P=.022).
The success rate in male patients was 90.3%, significantly higher than the success rate in female patients (68.2% P=.024) (Figure 2). There was no significant difference between the modified Epley maneuver success and age (P=.114). The success rate with the first Epley maneuver in patients with a BMI below 30 was greater than in patients with a BMI of 30 and above (84.1% and 67.7%, respectively). However, no statistically significant difference was observed between them (P=.096). While success was achieved in 82.9% of patients with additional systemic disease and 70.6% without additional disease, no significant difference was observed (P=.204). While 80.8% of those in the right-sided localization and 69.6% of those in the left localization were successful with the first Epley maneuver, there was no significant difference between them (P=.285) (Table 2).
Figure 2. The success rate of the Epley maneuver in men was significantly higher (P=.024).
According to the univariate logistic analysis to calculate the maneuver failure risk, being a woman constitutes a 4.356 (95% CI=1.130-16.786) times greater risk of failure than being a man (P=.033) (Table 3). The rate for men with a BMI score of 30 and above (25.8%) was significantly lower than the rate for women (52.3%) (P=.022). There was no significant difference between the genders in terms of age (P=.693), the presence of additional disease (P=.165), and side of the head (P=.802) (Table 4).
In this study, we aimed to contribute to the literature by evaluating the effectiveness of a single-session Epley maneuver after the descriptive Dix-Hallpike test in patients diagnosed with PC-BPPV and re-evaluate the success rate with the Dix-Hallpike test. The disease has a higher incidence in women and is most common in the fifth and seventh decades of life.^14^ The mean age of our patients was 57.1 (15.5), and 58.7% were women, which was similar to other reports.
Failure to diagnose BPPV in patients with dizziness causes recurrent hospital admissions. Wang et al reported that patients with BPPV visited the hospital an average of eight times before the final diagnosis.^15^ There are varying practices since there is yet to be a clear consensus on the number of corrective maneuvers.^16^ Publications state that multiple repositioning maneuvers are required in more than one-third of patients.^17^ In their single-center study investigating the effectiveness of repositioning maneuvers in the elderly population, Nahm et al reported that they achieved a 66% success rate with a single-session maneuver for PC-BPPV.^18^ Dorigueto et al^14^ reported that an average of 2.13 maneuvers were required for complete recovery, and a single maneuver was sufficient in only 40% of patients in their study of controlling 60 patients with a weekly Dix-Hallpike test. Wang et al^15^ reported that they achieved successful results in 80.65% of the patients after the first session of the reposition maneuver. We found that the repositioning maneuver was successful in 58 (77.3%) of 75 patients when we checked with the early Dix-Hallpike.
In some studies, the effectiveness of the maneuvers was evaluated by making additional recommendations to the patients to increase the maneuver success rates. Taçalan et al^19^ added Cawthorne-Cooksey exercises to the Epley maneuver and evaluated the results. They found that these exercises did not contribute to the treatment of PC-BPPV. Balıkçı et al^20^ stated that there was no significant effect on the results in the group in which they applied postural restraint after the Epley maneuver. In our study, we made no additional recommendations or restrictions to the Epley maneuver.
The repeated Dix-Hallpike test will be a guide for the clinician in self-control. Although some clinicians apply the Dix-Hallpike test (re-test) to predict treatment success after the Epley maneuver, but it has not been defined in the literature. In clinical practice, the control Dix-Hallpike test is not a standard procedure. Some authors argue that the repetitive maneuver will complicate the situation, causing the otoliths to migrate from the posterior semicircular canal to the anterior semicircular canal. There are studies on this subject with conflicting results. In another study evaluating otolith escape into another duct after the control Dix-Hallpike test, the authors mention that this rate is 16%, and they recommend waiting 15 minutes for re-testing after the Epley maneuver to prevent this.^21^ In our study, we performed our control Dix-Hallpike test 20 minutes after the end of the Epley maneuver, and we did not detect otolith leakage into another canal in any of our patients.
Power et al^1^ also recommended repetitive diagnostic and treatment maneuvers in their study. Korn et al^22^ mentioned that maneuvers repeated at intervals in the same session are more successful than a single maneuver per session. From another point of view, since BPPV mainly affects the geriatric population, ongoing vertigo attacks can cause a wide range of negative consequences, ranging from disruption of the daily life flow through the restriction of social activities of patients to serious injuries that may occur as a result of accidents such as falls. Based on our conclusions, it is more appropriate to apply repetitive maneuvers in a single session to reduce the cost to the patient and the public budget.
Due to being overweight, some patients had difficulties in positioning during the maneuver, which is also challenging for clinicians. Our study found a lower success rate in those with a BMI of 30 and above compared to those with a lower BMI (67.7% and 84.1% respectively). However, this difference was not statistically significant. We believe that an early control test to confirm otolith repossession in obese patients is appropriate.
In other studies, the success rates of reposition maneuvers in BPPV are similar, but not in other patients. The existing medical comorbidities of the patients may affect the success of the repositioning maneuvers. Talaat et al reported that low vitamin-D3 levels are associated with the development of BPPV and very low vitamin-D3 levels are associated with the recurrence of the disease.^23^ Chen et al also confirmed the relationship between low vitamin-D3 levels and recurrent BPPV in their study.^24^ On the contrary, Orczyek et al investigated the relationship between BMI and vitamin-D3 levels in PC-BPPV and could not find any significant results between them.^25^ In the study of Altın et al^26^ they did not find a significant relationship between the presence of chronic disease in BPPV and the recovery process and recurrence of BPPV. In our study, we did not find a significant relationship between chronic systemic disease and the success of the Epley maneuver. However, in our study, we did not examine the relationship between PC-BPPV and chronic diseases and the effect of each existing disease on the treatment response in detail. These relationships can be examined more fully in studies with a larger sample size.
Our study shows that the patients who did not have repeated Dix-Hallpike tests to evaluate their later results was a weakness. Considering the BPPV treatment algorithm, the possibility of spontaneous remission makes this weakness less of a consideration. Lou et al^27^ evaluated maneuver effectiveness on the 3rd, 7th, and 14th days. They found that while a significant difference was observed on the 3rd day, there was no significant difference on the 14th day.^27^ Based on this information, early evaluation results would be more objective. In addition, we see in various publications that the Epley maneuver decreases the anxiety level of BPPV patients and increases life comfort.^28^ Since approximately one-quarter of patients with PC-BPPV fail to achieve success after a single session of the modified Epley maneuver, we can improve this success rate by performing a control test 20 minutes later. While achieving similar results, it would be more appropriate to plan the process in a way that will least affect the comfort of life.
In conclusion, our post-Epley success rates are consistent with the literature. Additional systemic diseases or high BMI of the patients did not significantly affect Epley maneuver success in PC-BPPV. Considering the patient's social life and public health expenditures, performing control maneuvers in the same session would be beneficial.
None.