- Email: [email protected]
Effects of postural restriction after modified Epley maneuver on recurrence of benign paroxysmal positional vertigo
G Model
ANL-1858; No. of Pages 4 Auris Nasus Larynx xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl
Effects of postural restriction after modified Epley maneuver on recurrence of benign paroxysmal positional vertigo Hasan Huseyin Balikci MDa,*, Isa Ozbay MDb a b
Department of Otorhinolaryngology, Susehri State Hospital, Sivas, Turkey Department of Otorhinolaryngology, Dumlupinar University Hospital, Kutahya, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 January 2014 Accepted 2 May 2014 Available online xxx
Objective: In the present study, we calculated the success rate of the modified Epley maneuver and determined the effectiveness of post-maneuver positional restriction in terms of the prevention of early and late recurrence. Methods: The present study was conducted on 78 patients who had unilateral benign paroxysmal positional vertigo (BPPV) of the posterior semicircular canal (SCC) and who were treated in the Otorhinolaryngology Department of Susehri State Hospital. The Dix–Hallpike test was performed on all patients. After the involved canal was identified using this test, we guided patients through the modified Epley repositioning maneuver. A maximum of two maneuvers were performed in the same session. The patients were randomly divided into two groups. One group was not advised any positional restriction, while the second group was advised positional restriction for 10 days after the procedure. Recurrences during 1–90 days after the treatment were noted as early recurrences, while those that occurred after 90 days were noted as late recurrences. Results: In the restriction group (n = 39), repositioning was successful after a single maneuver in 32 (82.05%) patients and after two maneuvers in 5 (12.8%) patients. Repositioning failed in two (5.1%) patients. In the non-restriction group (n = 39), repositioning was successful after a single maneuver in 31 (79.4%) patients and after two maneuvers in 6 (15.3%) patients. Repositioning failed in two (5.1%) patients. Thus, the success rate was 94.8% in each group. Early recurrence occurred in 3 (8.1%) of 37 patients in the restriction group and 2 (5.4%) of 37 patients in the non-restriction group (p > 0.05). Late recurrence occurred in 5 (13.5%) of 37 patients in both the restriction and non-restriction groups (p > 0.05). Conclusion: Postural restriction after a canalith repositioning procedure does not improve procedural success or decrease early and late recurrence rates. However, the number of patients was too small to detect a difference between both treatment groups. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Vertigo Benign paroxysmal positional vertigo Canalith repositioning maneuver Posterior semicircular canals
1. Introduction Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo encountered in otology clinics. The characteristic clinical presentation of temporary vertigo attacks that last for seconds is generally believed to be caused by the detachment of otoconia from the macula of the utricle and their subsequent migration into the semicircular canals (SCCs) [1–3]. The posterior SCC is usually affected. Dix and Hallpike described
* Corresponding author at: Sus¸ehri Devlet Hastanesi, Kulak Burun Bogaz Klinigi, 58600 Sus¸ehri, Sivas, Turkey. Tel.: +90 346 311 40 08; fax: +90 346 311 48 03. E-mail address: [email protected] (H.H. Balikci).
this condition as the occurrence of a temporary vertigo attack (5– 30 s) at the end of a latency period [4]. There are two main hypotheses to explain the development of BPPV. The first is the cupulolithiasis theory, which is based on the attachment of otolithic debris to the cupula [2]. The second is the canalithiasis theory, which is based on the presence of free-floating debris in the SCC [5]. Resolution of vertigo and nystagmus is typical after a repositioning maneuver, e.g., Brandt and Daroff, Semont, and Epley maneuvers [6–8]. Postural restriction after repositioning maneuvers may improve the treatment outcome and prevent the recurrence of BPPV [9,10]. However, there is no agreement on the effectiveness or standard protocol of postural restriction. In the present study, we calculated the success rate of the modified Epley maneuver, and
http://dx.doi.org/10.1016/j.anl.2014.05.007 0385-8146/ß 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Balikci HH, Ozbay I. Effects of postural restriction after modified Epley maneuver on recurrence of benign paroxysmal positional vertigo. Auris Nasus Larynx (2014), http://dx.doi.org/10.1016/j.anl.2014.05.007
G Model
ANL-1858; No. of Pages 4 2
H.H. Balikci, I. Ozbay / Auris Nasus Larynx xxx (2014) xxx–xxx
determined the effectiveness of post-maneuver positional restriction in terms of prevention of early and late recurrence.
2. Patients and methods 2.1. Patient selection The present study was conducted on 78 patients who had unilateral BPPV of the posterior SCC and were treated in the Otorhinolaryngology Department of Susehri State Hospital between September 2012 and October 2013. All the patients had previously been examined in a neurology clinic. All the patients were queried for a history of etiological factors such as head and neck trauma. After a detailed ear–nose–throat examination, audiometric tests were conducted when indicated. Patients with central disorders or other types of peripheral vertigo (such as Meniere disease and vestibular neuronitis) and those who could not be followed-up regularly were excluded from the study. Patients who had BPPV with the involvement of other canals or bilateral BPPV were also excluded. Pharmacological agents were not used in this study. The protocol of this study was approved by our institution’s ethics committee. All the patients included in the study provided written informed consent.
All the patients in whom the repositioning procedure was successful were followed up on day 15, and any recurrences at this time were noted as early recurrences. Patients who developed recurrent symptoms at any other time within 90 days after the treatment were also noted to have early recurrence. All successfully treated patients were also followed up by clinical examination at the end of the third month (day 90), and any recurrences at this time were noted as late recurrences. Furthermore, patients who developed recurrent symptoms and referred us at any time after 90 days were also considered to have late recurrence. In addition to the follow-up examinations, we conducted telephone interviews to identify patients with early or late recurrence of BPPV. Briefly, early recurrences were identified as those that occurred between 0 and 90 days and late recurrences occurred over 90 days after treatment. The treatments and assessments were conducted by same physician. Therefore, the outcome assessment was not blinded. 2.4. Statistical analysis Statistical analysis of the results was performed using SPSS for Windows 19.0 (Chicago, IL, USA). Comparisons of data between groups were made using the Yates continuity correction and Fischer’s exact test and p < 0.05 was considered significant.
2.2. Dix–Hallpike test and modified Epley maneuver
3. Results
The Dix–Hallpike test was performed on all patients, and patients with vertigo and vertical upbeating and rotational nystagmus toward the lower ear were diagnosed with BPPV of the posterior SCC. After we performed the Dix–Hallpike test to locate the involved canal, we guided the patients through the modified Epley repositioning maneuver. During this maneuver, the patients were placed in a supine position on an examination table. The head was not rested on the examination table but was supported by the examiner. The neck was positioned slightly less than the maximal extension. In this position, the patient’s head could be turned 458 toward the affected ear, with the eyes kept open. Two minutes later, the head was slowly rotated 908 toward the opposite side over a period of approximately 1 min. Care was taken during this rotation to keep the patient’s head in extension. This position was held for a further 2 min, and then, the whole body was slowly turned 908 toward the opposite side over a period of approximately 1 min. In the last position, the patient was placed on lateral recumbent position, i.e. on either side to his or her shoulder. Two minutes later, the patient was placed in a seated position with the head at 308 of flexion. After another 2 min, the head was returned to the normal position, and the test was completed. Ten minutes later, the Dix–Hallpike maneuver was repeated. The absence of both nystagmus and vertigo after the maneuver was considered to indicate procedural success. If, however, these symptoms were present, the maneuver was repeated. Apparent failure was defined as the presence of nystagmus or vertigo after two Dix–Hallpike maneuvers.
3.1. Demographic data
2.3. Patient groups and follow-up The patients were randomly divided into two groups. Randomization was performed before treatment using the Epley technique. The first group was not advised positional restriction after treatment, while the second group was advised positional restriction for 10 days after the maneuver. Post-maneuver restrictions were explained to the patients in the restriction group, and included sleeping with several pillows, avoiding sudden head-tilts, avoiding cervical extension or rotation, avoiding sport and avoiding lying down on the affected side.
The mean age of the patients was 48.1 13.6 years (range, 23– 75 years). Of the 78 study patients, 42 (53.8%) were women, and 36 (46.61%) were men. The right posterior SCC was affected in 41 patients, and the left posterior SCC was affected in 37 patients. The positional restriction group included 39 (50%) patients, with a mean age of 50.6 years (range, 24–75 years). The group which was not advised any positional restriction also included 39 (50%) patients, with a mean age of 45.5 years (range, 26–73 years). In the restriction group, 6 (15.3%) patients had a history of head and neck trauma, and the remaining 33 (84.6) patients had idiopathic BPPV. In the nonrestriction group, 6 (15.3%) patients had a history of head and neck trauma, and 33 (84.6) patients had idiopathic BPPV. The mean duration of symptoms was 35.5 days (range, 2–290 days) in the restriction group and 34.1 days (range, 2–350 days) in the nonrestriction group. The mean follow-up duration was 8.93 2.7 months and 9.5 2.9 months in the restriction and non-restriction groups, respectively. 3.2. Procedural success In the restriction group (n = 39), successful repositioning occurred after the first Epley maneuver in 32 (82.05%) patients and after the second maneuver in 5 (12.8%) patients. Two (5.1%) patients showed only a partial response, which was recorded as a treatment failure. In the non-restriction group, repositioning was successful after the first maneuver in 31 (79.4%) of the 39 patients and after the second maneuver in 6 (15.3%) patients. Two (5.1%) patients with a partial response were deemed to have treatment failure. Thus, the success rate was 94.8% in each group (Table 1). 3.3. Early recurrence In the restriction group, one patient, who had a negative Dix– Hallpike test after her/his initial treatment, was found to have nystagmus after the Dix–Hallpike maneuver during the follow-up examination on day 15. In addition, two patients developed recurrent symptoms during the 1–90-day period (on days 10 and
Please cite this article in press as: Balikci HH, Ozbay I. Effects of postural restriction after modified Epley maneuver on recurrence of benign paroxysmal positional vertigo. Auris Nasus Larynx (2014), http://dx.doi.org/10.1016/j.anl.2014.05.007
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ANL-1858; No. of Pages 4 H.H. Balikci, I. Ozbay / Auris Nasus Larynx xxx (2014) xxx–xxx Table 1 Comparison of procedural success and recurrence rates between the restriction and non-restriction groups. No. of patients
p value
Restriction group
Non-restriction group
Total number of patients
39
39
Success rate after a single maneuver Success rate after two maneuvers Treatment failure after two maneuvers Early recurrence (1–90 days) Late recurrence (after 90 days) Total recurrence rate
32
31
1.000a
5 2
6 2
1.000a 1.000b
3 5 8
2 5 6
1.000b 1.000a 0.768a
a b
Yates continuity correction. Fisher’s exact test.
65, respectively). Thus, early recurrence occurred in 3 (8.1%) of the 37 successfully treated patients in the restriction group. In the non-restriction group, one patient who had a negative Dix–Hallpike test after their initial treatment was found to have nystagmus after the Dix–Hallpike maneuver during the follow-up examination on day 15. Another patient from this group developed recurrent symptoms during the 1–90-day period (on day 22). Thus, early recurrence occurred in 2 (5.4%) of the 37 successfully treated patients in the non-restriction group. There was no statistically significant difference in the rates of early recurrence between these two groups (p > 0.05; Table 1). All the five patients with early recurrence again underwent the modified Epley maneuver, which was successful in all patients. Only one of these five patients had a history of head and neck trauma. Thus, early recurrence occurred in 1 (9.09%) of the 11 patients with a history of trauma and in 4 (5.9%) of the 67 patients without a history of trauma. 3.4. Late recurrence In the restriction group, late recurrence was detected in 5 (13.5%) of 37 patients, at 4 months (2 patients) and at 6, 9, and 10 months (1 patient each). None of these patients had early recurrence. In the non-restriction group, late recurrence was found in 5 (13.5%) of 37 patients, at 4 months (3 patients) and at 9 and 12 months (1 patient each). Of these five patients, one had had an early recurrence. There was no statistically significant difference in the rate of late recurrence between the two groups (p > 0.05; Table 1). All the 10 patients with late recurrence underwent the modified Epley maneuver again, and the procedure was successful in all of them. Two of the patients with late recurrence had a history of trauma. Thus, late recurrence occurred in 2 (18.1%) of the 11 patients with a history of trauma and in 8 (11.9%) of the 67 patients without a history of trauma. In total, 3 of the 11 patients with trauma had early or late recurrence. 4. Discussion Both the cupulolithiasis and canalithiasis theories state that vertigo is caused by the presence of foreign particles in the SCC; these particles are generally believed to originate from the calcium carbonate otoliths in the macula of the utricle. The liberating maneuver devised by Semont et al. [11] and the canalith repositioning procedure (CRP) created by Epley [12] are associated with high success rates, even after the performance of a single maneuver. Epley [12], Parnes and Price-Jones [13], Harvey et al. ¨ zturan et al. [16] have reported [14], Herdman et al. [15] and O
3
97.7%, 56.7%, 44%, 57%, and 88% success rates, respectively, after a single CRP, along with 30%, 17%, 0%, 10%, and 11.7% recurrence rates, respectively. In the present study, we obtained an 80.7% success rate after a single maneuver, along with an 18.4% rate of recurrence (both early and late). These variable outcomes can be attributed to the different modifications of the CRP used in the studies. In Epley’s study, the duration was based on nystagmus time, with a typical pause of 6–13 s in each position [17]. Harvey et al. [14] kept patients in the first position after disappearance of nystagmus and turned the head 15–208 in the opposite direction, with 30 s in each position. In the study by Herdman et al. [15], the patients were kept in the first position for 4 min, with the head turned 908 to the opposite site slowly over a period of 1 min; after 4 min, the patients slowly sat up. Further modifications of the CRP have been described [18–20]. In our study, we changed head positions after 2 min in each position, with the head turned slowly over a period of 1 min between positions. We achieved a 94.9% success rate after two maneuvers performed in a single treatment session. The repetition of a repositioning maneuver in the same session is a controversial subject. Epley [12] recommends repeating maneuvers during a single treatment session, while other authors perform the maneuver only once per session [14,20]. Cakir et al. [21] reported that they used a single maneuver per session to avoid patient fatigability and to minimize the re-entry of otoconial debris into the posterior SCC. However, in the present study, we conducted two maneuvers in a single session in 13 patients, and repositioning was successful in 11 of these patients. Furthermore, only 1 of the 11 patients developed recurrence (early). A number of studies have demonstrated that postural restriction does not significantly increase the success rate of the CRP or affect the recurrence rate after the procedure [20,22–25]. A recent meta-analysis, which included nine studies, concluded that there were no significant differences with regard to the presence or absence of post-maneuver symptoms between patients who were instructed to restrict their posture after a repositioning maneuver and those who were allowed to move freely after a repositioning maneuver [25]. Massoud and Ireland [26] found postural restriction unnecessary, but recommended that patients avoid sudden head movements. However, Sato et al. [9] and Shim et al. [27] reported that postural restriction had a positive effect on the rate of recurrence. Li et al. [28] claimed that BPPV patients showed poor compliance to postural restriction. Moreover, the side on which patients habitually slept was typically the side affected by BPPV, and patients who slept on the affected side had a higher recurrence rate than those who slept in a different position during the first week after the repositioning maneuver [28]. Cakir et al. [21] reported that postural restriction had positive effects on early recurrences, but not on late recurrences. In addition, another recent meta-analysis identified nine studies that compared the effectiveness of postural restrictions following an Epley maneuver to the Epley maneuver alone. In this study, the control groups revealed that postural restrictions after the Epley maneuver were more effective than the Epley maneuver alone, but the effect size was small [10]. However, the majority of these studies did not show a significant difference between both treatment groups. In the present study, we also found that postural restriction was not related to early or late recurrences. However, the number of patients in this study was too small to detect a difference between both treatment groups. We hypothesize that the different results between the studies could be because of different modifications of the Epley maneuver as described above and/or the insufficient number of patients involved in these studies. In a recent study, De Stefano et al. [29] reported that the presence of a systemic disease (hypertension, diabetes, osteoarthrosis, osteoporosis, and depression) could worsen the status of
Please cite this article in press as: Balikci HH, Ozbay I. Effects of postural restriction after modified Epley maneuver on recurrence of benign paroxysmal positional vertigo. Auris Nasus Larynx (2014), http://dx.doi.org/10.1016/j.anl.2014.05.007
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the posterior labyrinth causing a more frequent otolith detachment and this condition increased the risk for patients suffering BPPV to have recurrent episodes, even if correctly managed by repositioning maneuvers. Moreover, the combination of two or more of aforementioned comorbidities further increased the risk of relapsing BPPV, worsened by the presence of osteoporosis. However, in the present study, there was no recorded data related to this topic. Patients who develop BPPV after trauma and those with ipsilateral Meniere disease have been shown to have a high BPPV recurrence rate [30,31]. In the study by Harvey et al. [14], one of the three patients (33%) had a history of head trauma, and none of the patients developed recurrence. In the present study, 3 of the 11 patients with a history of head trauma showed recurrence (1, early recurrence; 2, late recurrence). 5. Conclusion The modified Epley maneuver is an effective repositioning method for patients with BPPV, and has a high success rate. Postmaneuver postural restriction does not decrease early and late recurrence rates. However, the number of patients was too small to detect a difference between both treatment groups. Funding None. Conflict of interest None. References [1] Hall SF, Ruby RR, McClure JA. The mechanics of benign paroxysmal vertigo. J Otolaryngol 1979;8:151–8. [2] Schuknecht HF. Cupulolithiasis. Arch Otolaryngol 1969;90:765–78. [3] Schuknecht HF. Positional vertigo: clinical and experimental observations. Trans Am Acad Ophthalmol Otolaryngol 1962;66:319–32. [4] Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Proc Soc Med 1952;45: 341–54. [5] Hall SF, Ruby RRF, McClure JA. The mechanics of benign paroxysmal positional vertigo. J Otolaryngol 1979;8:151–8. [6] Wanamaker HH. Surgical treatment of benign paroxysmal positional vertigo: operative techniques. Oper Tech Otolaryngol Head Neck Surg 2001;12:124–8. [7] Baloh RW, Sakala SM, Honrubia V. Benign paroxysmal positional nystagmus. Am J Otolaryngol 1979;1:1–6. [8] Toupet M, Ferrary E, Bozorg Grayeli A. Effect of repositioning maneuver type and postmaneuver restrictions on vertigo and dizziness in benign positional paroxysmal vertigo. Scientific World Journal 2012;2012:162123. [9] Sato G, Sekine K, Matsuda K, Takeda N. Effects of sleep position on time course in remission of positional vertigo in patients with benign paroxysmal positional vertigo. Acta Otolaryngol 2012;132:614–7.
[10] Hunt WT, Zimmermann EF, Hilton MP. Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV). Cochrane Database Syst Rev 2012;4:CD008675. [11] Semont A, Freyss G, Vitte E. Curing the BPPV with a liberatory maneuver. Adv Otorhinolaryngol 1988;42:290–3. [12] Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399– 404. [13] Parnes LS, Price-Jones RG. Particle repositioning maneuver for benign paroxysmal positional vertigo. Ann Otol Rhinol Laryngol 1993;102:325–31. [14] Harvey SA, Hain TC, Adamiec LC. Modified liberatory maneuver: effective treatment for benign paroxysmal positional vertigo. Laryngoscope 1994;104:1206–12. [15] Herdman SJ, Tusa RJ, Zee DS, Proctor LR, Mattox DE. Single treatment approaches to benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg 1993;119:450–4. ¨ zturan O, C¸okkeser Y, Saydam L, Kizilay A, Solmaz F. Benign paroksismal [16] O pozisyonel vertigo ve kanalit repozisyon prosedu¨ru¨. Kulak Burun Boðaz Ihtis Derg 1998;5:16–21. [17] Epley JM. Caveats in particle repositioning for treatment of canalithiasis (BPPV). Oper Tech Otolaryngol Head Neck Surg 1997;8:68–76. [18] Ruckenstein MJ. Therapeutic efficacy of the Epley canalith repositioning maneuver. Laryngoscope 2001;111:940–5. [19] Tirelli G, D’Orlando E, Giacomarra V, Russolo M. Benign positional vertigo without detectable nystagmus. Laryngoscope 2001;111:1053–6. [20] Moon SJ, Bae SH, Kim HD, Kim JH, Cho YB. The effect of postural restrictions in the treatment of benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol 2005;262:408–11. [21] Cakir BO, Ercan I, Cakir ZA, Turgut S. Efficacy of postural restriction in treating benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg 2006;132:501–5. [22] Devaiah AK, Andreoli S. Postmaneuver restrictions in benign paroxysmal positional vertigo: an individual patients meta-analysis. Otolaryngol Head Neck Surg 2010;142:155–9. [23] Jia J, Chang D, Dai S, Sang Y, Tai X, Sun X, et al. The necessity of post-maneuver postural restriction in treating benign paroxysmal positional vertigo. Lin Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi 2013;27:910–2. [24] Casqueiro JC, Ayala A, Monedero G. No more postural restrictions in posterior canal benign paroxysmal vertigo. Otol Neurotol 2008;29:706–9. [25] Mostafa BE, Youssef TA, Hamad AS. The necessity of postmaneuver postural restriction in treating benign paroxysmal positional vertigo: a meta-analytic study. Eur Arch Otorhinolaryngol 2013;270:849–52. [26] Massoud EAS, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol 1996;25:121–5. [27] Shim DB, Kim JH, Park KC, Song MH, Park HJ. Correlation between the headlying side during sleep and the affected side by benign paroxysmal positional vertigo involving the posterior or horizontal semicircular canal. Laryngoscope 2012;122:873–6. [28] Li S, Tian L, Han Z, Wang J. Impact of postmaneuver sleep position on recurrence of benign paroxysmal positional vertigo. PLoS ONE 2013;8: e83566. http://dx.doi.org/10.1371/journal.pone.0083566. [29] De Stefano A, Dispenza F, Suarez H, Perez-Fernandez N, Manrique-Huarte R, Ban JH, et al. A multicenter observational study on the role of comorbidities in the recurrent episodes of benign paroxysmal positional vertigo. Auris Nasus Larynx 2013;6. http://dx.doi.org/10.1016/j.anl.2013.07.007. pii: S0385-8146 (13)00155-7. [30] Gordon CR, Levite R, Joffe V, Gadoth N. Is posttraumatic benign paroxysmal positional vertigo different from the idiopathic form? Arch Neurol 2004;61: 1590–3. [31] Soto-Varela A, Rossi-Izquierdo M, Martinez-Capoccioni G, Labella-Caballero T, Santos-Perez S. Benign paroxysmal positional vertigo of the posterior semicircular canal: efficacy of Santiago treatment protocol, long-term follow up and analysis of recurrence. J Laryngol Otol 2012;126:363–71.
Please cite this article in press as: Balikci HH, Ozbay I. Effects of postural restriction after modified Epley maneuver on recurrence of benign paroxysmal positional vertigo. Auris Nasus Larynx (2014), http://dx.doi.org/10.1016/j.anl.2014.05.007
ANL-1858; No. of Pages 4 Auris Nasus Larynx xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl
Effects of postural restriction after modified Epley maneuver on recurrence of benign paroxysmal positional vertigo Hasan Huseyin Balikci MDa,*, Isa Ozbay MDb a b
Department of Otorhinolaryngology, Susehri State Hospital, Sivas, Turkey Department of Otorhinolaryngology, Dumlupinar University Hospital, Kutahya, Turkey
A R T I C L E I N F O
A B S T R A C T
Article history: Received 8 January 2014 Accepted 2 May 2014 Available online xxx
Objective: In the present study, we calculated the success rate of the modified Epley maneuver and determined the effectiveness of post-maneuver positional restriction in terms of the prevention of early and late recurrence. Methods: The present study was conducted on 78 patients who had unilateral benign paroxysmal positional vertigo (BPPV) of the posterior semicircular canal (SCC) and who were treated in the Otorhinolaryngology Department of Susehri State Hospital. The Dix–Hallpike test was performed on all patients. After the involved canal was identified using this test, we guided patients through the modified Epley repositioning maneuver. A maximum of two maneuvers were performed in the same session. The patients were randomly divided into two groups. One group was not advised any positional restriction, while the second group was advised positional restriction for 10 days after the procedure. Recurrences during 1–90 days after the treatment were noted as early recurrences, while those that occurred after 90 days were noted as late recurrences. Results: In the restriction group (n = 39), repositioning was successful after a single maneuver in 32 (82.05%) patients and after two maneuvers in 5 (12.8%) patients. Repositioning failed in two (5.1%) patients. In the non-restriction group (n = 39), repositioning was successful after a single maneuver in 31 (79.4%) patients and after two maneuvers in 6 (15.3%) patients. Repositioning failed in two (5.1%) patients. Thus, the success rate was 94.8% in each group. Early recurrence occurred in 3 (8.1%) of 37 patients in the restriction group and 2 (5.4%) of 37 patients in the non-restriction group (p > 0.05). Late recurrence occurred in 5 (13.5%) of 37 patients in both the restriction and non-restriction groups (p > 0.05). Conclusion: Postural restriction after a canalith repositioning procedure does not improve procedural success or decrease early and late recurrence rates. However, the number of patients was too small to detect a difference between both treatment groups. ß 2014 Elsevier Ireland Ltd. All rights reserved.
Keywords: Vertigo Benign paroxysmal positional vertigo Canalith repositioning maneuver Posterior semicircular canals
1. Introduction Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo encountered in otology clinics. The characteristic clinical presentation of temporary vertigo attacks that last for seconds is generally believed to be caused by the detachment of otoconia from the macula of the utricle and their subsequent migration into the semicircular canals (SCCs) [1–3]. The posterior SCC is usually affected. Dix and Hallpike described
* Corresponding author at: Sus¸ehri Devlet Hastanesi, Kulak Burun Bogaz Klinigi, 58600 Sus¸ehri, Sivas, Turkey. Tel.: +90 346 311 40 08; fax: +90 346 311 48 03. E-mail address: [email protected] (H.H. Balikci).
this condition as the occurrence of a temporary vertigo attack (5– 30 s) at the end of a latency period [4]. There are two main hypotheses to explain the development of BPPV. The first is the cupulolithiasis theory, which is based on the attachment of otolithic debris to the cupula [2]. The second is the canalithiasis theory, which is based on the presence of free-floating debris in the SCC [5]. Resolution of vertigo and nystagmus is typical after a repositioning maneuver, e.g., Brandt and Daroff, Semont, and Epley maneuvers [6–8]. Postural restriction after repositioning maneuvers may improve the treatment outcome and prevent the recurrence of BPPV [9,10]. However, there is no agreement on the effectiveness or standard protocol of postural restriction. In the present study, we calculated the success rate of the modified Epley maneuver, and
http://dx.doi.org/10.1016/j.anl.2014.05.007 0385-8146/ß 2014 Elsevier Ireland Ltd. All rights reserved.
Please cite this article in press as: Balikci HH, Ozbay I. Effects of postural restriction after modified Epley maneuver on recurrence of benign paroxysmal positional vertigo. Auris Nasus Larynx (2014), http://dx.doi.org/10.1016/j.anl.2014.05.007
G Model
ANL-1858; No. of Pages 4 2
H.H. Balikci, I. Ozbay / Auris Nasus Larynx xxx (2014) xxx–xxx
determined the effectiveness of post-maneuver positional restriction in terms of prevention of early and late recurrence.
2. Patients and methods 2.1. Patient selection The present study was conducted on 78 patients who had unilateral BPPV of the posterior SCC and were treated in the Otorhinolaryngology Department of Susehri State Hospital between September 2012 and October 2013. All the patients had previously been examined in a neurology clinic. All the patients were queried for a history of etiological factors such as head and neck trauma. After a detailed ear–nose–throat examination, audiometric tests were conducted when indicated. Patients with central disorders or other types of peripheral vertigo (such as Meniere disease and vestibular neuronitis) and those who could not be followed-up regularly were excluded from the study. Patients who had BPPV with the involvement of other canals or bilateral BPPV were also excluded. Pharmacological agents were not used in this study. The protocol of this study was approved by our institution’s ethics committee. All the patients included in the study provided written informed consent.
All the patients in whom the repositioning procedure was successful were followed up on day 15, and any recurrences at this time were noted as early recurrences. Patients who developed recurrent symptoms at any other time within 90 days after the treatment were also noted to have early recurrence. All successfully treated patients were also followed up by clinical examination at the end of the third month (day 90), and any recurrences at this time were noted as late recurrences. Furthermore, patients who developed recurrent symptoms and referred us at any time after 90 days were also considered to have late recurrence. In addition to the follow-up examinations, we conducted telephone interviews to identify patients with early or late recurrence of BPPV. Briefly, early recurrences were identified as those that occurred between 0 and 90 days and late recurrences occurred over 90 days after treatment. The treatments and assessments were conducted by same physician. Therefore, the outcome assessment was not blinded. 2.4. Statistical analysis Statistical analysis of the results was performed using SPSS for Windows 19.0 (Chicago, IL, USA). Comparisons of data between groups were made using the Yates continuity correction and Fischer’s exact test and p < 0.05 was considered significant.
2.2. Dix–Hallpike test and modified Epley maneuver
3. Results
The Dix–Hallpike test was performed on all patients, and patients with vertigo and vertical upbeating and rotational nystagmus toward the lower ear were diagnosed with BPPV of the posterior SCC. After we performed the Dix–Hallpike test to locate the involved canal, we guided the patients through the modified Epley repositioning maneuver. During this maneuver, the patients were placed in a supine position on an examination table. The head was not rested on the examination table but was supported by the examiner. The neck was positioned slightly less than the maximal extension. In this position, the patient’s head could be turned 458 toward the affected ear, with the eyes kept open. Two minutes later, the head was slowly rotated 908 toward the opposite side over a period of approximately 1 min. Care was taken during this rotation to keep the patient’s head in extension. This position was held for a further 2 min, and then, the whole body was slowly turned 908 toward the opposite side over a period of approximately 1 min. In the last position, the patient was placed on lateral recumbent position, i.e. on either side to his or her shoulder. Two minutes later, the patient was placed in a seated position with the head at 308 of flexion. After another 2 min, the head was returned to the normal position, and the test was completed. Ten minutes later, the Dix–Hallpike maneuver was repeated. The absence of both nystagmus and vertigo after the maneuver was considered to indicate procedural success. If, however, these symptoms were present, the maneuver was repeated. Apparent failure was defined as the presence of nystagmus or vertigo after two Dix–Hallpike maneuvers.
3.1. Demographic data
2.3. Patient groups and follow-up The patients were randomly divided into two groups. Randomization was performed before treatment using the Epley technique. The first group was not advised positional restriction after treatment, while the second group was advised positional restriction for 10 days after the maneuver. Post-maneuver restrictions were explained to the patients in the restriction group, and included sleeping with several pillows, avoiding sudden head-tilts, avoiding cervical extension or rotation, avoiding sport and avoiding lying down on the affected side.
The mean age of the patients was 48.1 13.6 years (range, 23– 75 years). Of the 78 study patients, 42 (53.8%) were women, and 36 (46.61%) were men. The right posterior SCC was affected in 41 patients, and the left posterior SCC was affected in 37 patients. The positional restriction group included 39 (50%) patients, with a mean age of 50.6 years (range, 24–75 years). The group which was not advised any positional restriction also included 39 (50%) patients, with a mean age of 45.5 years (range, 26–73 years). In the restriction group, 6 (15.3%) patients had a history of head and neck trauma, and the remaining 33 (84.6) patients had idiopathic BPPV. In the nonrestriction group, 6 (15.3%) patients had a history of head and neck trauma, and 33 (84.6) patients had idiopathic BPPV. The mean duration of symptoms was 35.5 days (range, 2–290 days) in the restriction group and 34.1 days (range, 2–350 days) in the nonrestriction group. The mean follow-up duration was 8.93 2.7 months and 9.5 2.9 months in the restriction and non-restriction groups, respectively. 3.2. Procedural success In the restriction group (n = 39), successful repositioning occurred after the first Epley maneuver in 32 (82.05%) patients and after the second maneuver in 5 (12.8%) patients. Two (5.1%) patients showed only a partial response, which was recorded as a treatment failure. In the non-restriction group, repositioning was successful after the first maneuver in 31 (79.4%) of the 39 patients and after the second maneuver in 6 (15.3%) patients. Two (5.1%) patients with a partial response were deemed to have treatment failure. Thus, the success rate was 94.8% in each group (Table 1). 3.3. Early recurrence In the restriction group, one patient, who had a negative Dix– Hallpike test after her/his initial treatment, was found to have nystagmus after the Dix–Hallpike maneuver during the follow-up examination on day 15. In addition, two patients developed recurrent symptoms during the 1–90-day period (on days 10 and
Please cite this article in press as: Balikci HH, Ozbay I. Effects of postural restriction after modified Epley maneuver on recurrence of benign paroxysmal positional vertigo. Auris Nasus Larynx (2014), http://dx.doi.org/10.1016/j.anl.2014.05.007
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ANL-1858; No. of Pages 4 H.H. Balikci, I. Ozbay / Auris Nasus Larynx xxx (2014) xxx–xxx Table 1 Comparison of procedural success and recurrence rates between the restriction and non-restriction groups. No. of patients
p value
Restriction group
Non-restriction group
Total number of patients
39
39
Success rate after a single maneuver Success rate after two maneuvers Treatment failure after two maneuvers Early recurrence (1–90 days) Late recurrence (after 90 days) Total recurrence rate
32
31
1.000a
5 2
6 2
1.000a 1.000b
3 5 8
2 5 6
1.000b 1.000a 0.768a
a b
Yates continuity correction. Fisher’s exact test.
65, respectively). Thus, early recurrence occurred in 3 (8.1%) of the 37 successfully treated patients in the restriction group. In the non-restriction group, one patient who had a negative Dix–Hallpike test after their initial treatment was found to have nystagmus after the Dix–Hallpike maneuver during the follow-up examination on day 15. Another patient from this group developed recurrent symptoms during the 1–90-day period (on day 22). Thus, early recurrence occurred in 2 (5.4%) of the 37 successfully treated patients in the non-restriction group. There was no statistically significant difference in the rates of early recurrence between these two groups (p > 0.05; Table 1). All the five patients with early recurrence again underwent the modified Epley maneuver, which was successful in all patients. Only one of these five patients had a history of head and neck trauma. Thus, early recurrence occurred in 1 (9.09%) of the 11 patients with a history of trauma and in 4 (5.9%) of the 67 patients without a history of trauma. 3.4. Late recurrence In the restriction group, late recurrence was detected in 5 (13.5%) of 37 patients, at 4 months (2 patients) and at 6, 9, and 10 months (1 patient each). None of these patients had early recurrence. In the non-restriction group, late recurrence was found in 5 (13.5%) of 37 patients, at 4 months (3 patients) and at 9 and 12 months (1 patient each). Of these five patients, one had had an early recurrence. There was no statistically significant difference in the rate of late recurrence between the two groups (p > 0.05; Table 1). All the 10 patients with late recurrence underwent the modified Epley maneuver again, and the procedure was successful in all of them. Two of the patients with late recurrence had a history of trauma. Thus, late recurrence occurred in 2 (18.1%) of the 11 patients with a history of trauma and in 8 (11.9%) of the 67 patients without a history of trauma. In total, 3 of the 11 patients with trauma had early or late recurrence. 4. Discussion Both the cupulolithiasis and canalithiasis theories state that vertigo is caused by the presence of foreign particles in the SCC; these particles are generally believed to originate from the calcium carbonate otoliths in the macula of the utricle. The liberating maneuver devised by Semont et al. [11] and the canalith repositioning procedure (CRP) created by Epley [12] are associated with high success rates, even after the performance of a single maneuver. Epley [12], Parnes and Price-Jones [13], Harvey et al. ¨ zturan et al. [16] have reported [14], Herdman et al. [15] and O
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97.7%, 56.7%, 44%, 57%, and 88% success rates, respectively, after a single CRP, along with 30%, 17%, 0%, 10%, and 11.7% recurrence rates, respectively. In the present study, we obtained an 80.7% success rate after a single maneuver, along with an 18.4% rate of recurrence (both early and late). These variable outcomes can be attributed to the different modifications of the CRP used in the studies. In Epley’s study, the duration was based on nystagmus time, with a typical pause of 6–13 s in each position [17]. Harvey et al. [14] kept patients in the first position after disappearance of nystagmus and turned the head 15–208 in the opposite direction, with 30 s in each position. In the study by Herdman et al. [15], the patients were kept in the first position for 4 min, with the head turned 908 to the opposite site slowly over a period of 1 min; after 4 min, the patients slowly sat up. Further modifications of the CRP have been described [18–20]. In our study, we changed head positions after 2 min in each position, with the head turned slowly over a period of 1 min between positions. We achieved a 94.9% success rate after two maneuvers performed in a single treatment session. The repetition of a repositioning maneuver in the same session is a controversial subject. Epley [12] recommends repeating maneuvers during a single treatment session, while other authors perform the maneuver only once per session [14,20]. Cakir et al. [21] reported that they used a single maneuver per session to avoid patient fatigability and to minimize the re-entry of otoconial debris into the posterior SCC. However, in the present study, we conducted two maneuvers in a single session in 13 patients, and repositioning was successful in 11 of these patients. Furthermore, only 1 of the 11 patients developed recurrence (early). A number of studies have demonstrated that postural restriction does not significantly increase the success rate of the CRP or affect the recurrence rate after the procedure [20,22–25]. A recent meta-analysis, which included nine studies, concluded that there were no significant differences with regard to the presence or absence of post-maneuver symptoms between patients who were instructed to restrict their posture after a repositioning maneuver and those who were allowed to move freely after a repositioning maneuver [25]. Massoud and Ireland [26] found postural restriction unnecessary, but recommended that patients avoid sudden head movements. However, Sato et al. [9] and Shim et al. [27] reported that postural restriction had a positive effect on the rate of recurrence. Li et al. [28] claimed that BPPV patients showed poor compliance to postural restriction. Moreover, the side on which patients habitually slept was typically the side affected by BPPV, and patients who slept on the affected side had a higher recurrence rate than those who slept in a different position during the first week after the repositioning maneuver [28]. Cakir et al. [21] reported that postural restriction had positive effects on early recurrences, but not on late recurrences. In addition, another recent meta-analysis identified nine studies that compared the effectiveness of postural restrictions following an Epley maneuver to the Epley maneuver alone. In this study, the control groups revealed that postural restrictions after the Epley maneuver were more effective than the Epley maneuver alone, but the effect size was small [10]. However, the majority of these studies did not show a significant difference between both treatment groups. In the present study, we also found that postural restriction was not related to early or late recurrences. However, the number of patients in this study was too small to detect a difference between both treatment groups. We hypothesize that the different results between the studies could be because of different modifications of the Epley maneuver as described above and/or the insufficient number of patients involved in these studies. In a recent study, De Stefano et al. [29] reported that the presence of a systemic disease (hypertension, diabetes, osteoarthrosis, osteoporosis, and depression) could worsen the status of
Please cite this article in press as: Balikci HH, Ozbay I. Effects of postural restriction after modified Epley maneuver on recurrence of benign paroxysmal positional vertigo. Auris Nasus Larynx (2014), http://dx.doi.org/10.1016/j.anl.2014.05.007
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the posterior labyrinth causing a more frequent otolith detachment and this condition increased the risk for patients suffering BPPV to have recurrent episodes, even if correctly managed by repositioning maneuvers. Moreover, the combination of two or more of aforementioned comorbidities further increased the risk of relapsing BPPV, worsened by the presence of osteoporosis. However, in the present study, there was no recorded data related to this topic. Patients who develop BPPV after trauma and those with ipsilateral Meniere disease have been shown to have a high BPPV recurrence rate [30,31]. In the study by Harvey et al. [14], one of the three patients (33%) had a history of head trauma, and none of the patients developed recurrence. In the present study, 3 of the 11 patients with a history of head trauma showed recurrence (1, early recurrence; 2, late recurrence). 5. Conclusion The modified Epley maneuver is an effective repositioning method for patients with BPPV, and has a high success rate. Postmaneuver postural restriction does not decrease early and late recurrence rates. However, the number of patients was too small to detect a difference between both treatment groups. Funding None. Conflict of interest None. References [1] Hall SF, Ruby RR, McClure JA. The mechanics of benign paroxysmal vertigo. J Otolaryngol 1979;8:151–8. [2] Schuknecht HF. Cupulolithiasis. Arch Otolaryngol 1969;90:765–78. [3] Schuknecht HF. Positional vertigo: clinical and experimental observations. Trans Am Acad Ophthalmol Otolaryngol 1962;66:319–32. [4] Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Proc Soc Med 1952;45: 341–54. [5] Hall SF, Ruby RRF, McClure JA. The mechanics of benign paroxysmal positional vertigo. J Otolaryngol 1979;8:151–8. [6] Wanamaker HH. Surgical treatment of benign paroxysmal positional vertigo: operative techniques. Oper Tech Otolaryngol Head Neck Surg 2001;12:124–8. [7] Baloh RW, Sakala SM, Honrubia V. Benign paroxysmal positional nystagmus. Am J Otolaryngol 1979;1:1–6. [8] Toupet M, Ferrary E, Bozorg Grayeli A. Effect of repositioning maneuver type and postmaneuver restrictions on vertigo and dizziness in benign positional paroxysmal vertigo. Scientific World Journal 2012;2012:162123. [9] Sato G, Sekine K, Matsuda K, Takeda N. Effects of sleep position on time course in remission of positional vertigo in patients with benign paroxysmal positional vertigo. Acta Otolaryngol 2012;132:614–7.
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Please cite this article in press as: Balikci HH, Ozbay I. Effects of postural restriction after modified Epley maneuver on recurrence of benign paroxysmal positional vertigo. Auris Nasus Larynx (2014), http://dx.doi.org/10.1016/j.anl.2014.05.007