Efficacy of particle repositioning maneuver in BPPV: a prospective study

Original Contributions Efficacy of Particle Repositioning Maneuver in BPPV: A Prospective Study Simhadri Sridhar, MS, DNB,* Naresh Panda, MS, DNB, FRCS(Ed),* and Meena Raghunathan, MSc, PhD† Purpose: A single blinded prospective randomized controlled trial was conducted in 40 patients with benign paroxysmal positional vertigo (BPPV) to determine the efficacy of particle repositioning maneuver (PRM). Materials and Methods: Out of 40 patients, 20 underwent PRM with the rest receiving a placebo treatment. Postprocedural instructions were given to all the patients who underwent PRM. Follow-up was for 1 year at regular intervals. Analysis was based on the symptomatic status and the Hallpike maneuver at each visit. Results: After the initial week, 95% showed complete resolution of symptoms with none reporting a recurrence after PRM. On the contrary, only 15% of the controls had complete resolution with 14 out of 20 reporting a recurrence of BPPV. Results remained more or less the same at the end of 4 weeks. Six months after PRM, 19 of 20 patients had no vertigo with a meager 5% showing recurrence versus 75% of controls reporting a recurrence with only 3 of 20 reporting a favorable symptom status. At the end of 1 year, 18 of 20 patients had complete relief from symptoms with only 10% showing Hallpike maneuver positive in the study group compared with 3 of 20 reporting a relief from symptoms with 90% turning out to be Hallpike maneuver positive in the control group. Conclusions: This study establishes the efficacy of PRM in short- and long-term management of BPPV; the procedure is easy and simple. (Am J Otolaryngol 2003;24:355-360. © 2003 Elsevier Inc. All rights reserved.)

Benign paroxysmal positional vertigo (BPPV) is characterized by brief episodes of vertigo, experienced by attaining certain provocative positions. The condition was first described by Adler1 in 1897 and then by Barany2 in 1921. Dix and Hallpike3 in 1952 developed the Hallpike maneuver to show nystagmus in patients with BPPV. The first attempt to determine the pathogenesis of BPPV was made by Schuknecht and Ruby.4 They postulated the theory of cupulolithiasis based on their finding of basophilic

From the Departments of *Otolaryngology, Head and Neck Surgery and †Audiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Address correspondence to Naresh K. Panda, MS, DNB, FRCS(Ed), Department of Otolaryngology and Head and Neck Surgery, Pgimer, Chandigarh, 160012 India. E-mail: [email protected] © 2003 Elsevier Inc. All rights reserved. 0196-0709/03/2406-0000$30.00/0 doi:10.1053/S0196-0709(03)00069-3

deposits over the cupula of the posterior semicircular canal. Brandt and Daroff5 in 1980 reported a remarkable success with their physical therapy in the treatment of BPPV. Hall et al6 and Epley7 considered free-floating particles located in the posterior semicircular canal as an explanation for symptoms of BPPV. Epley7 developed canalith repositioning maneuver based on his theory of canalolithiasis. He reported a success rate of 90 to 97% with the maneuver. Parnes and PriceJones8 modified Epley’s maneuver and renamed it as particle repositioning maneuver (PRM). They reported 88.2% success rate with the new therapy. Many modifications were later made by Harvey et al,9 and Welling and Barnes.10 The phenomenon of spontaneous resolution of BPPV has questioned the efficacy of PRM. Blakely11 in his study concluded that the maneuver was no better than doing nothing. Although his opinion was contrary to the

American Journal of Otolaryngology, Vol 24, No 6 (November-December), 2003: pp 355-360

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general consensus, PRM is still considered to be the treatment of choice in BPPV. This article makes an attempt to determine the shortterm and long-term efficacy of PRM by comparing it with the placebo treatment. MATERIAL AND METHODS Forty patients diagnosed to have BPPV between July 1, 2000, to November 1, 2001, were included in this study. The diagnosis was made on the basis of clinical history and response to the Hallpike maneuver. This single-blinded prospective study was based on a computer generated randomization code to assign patients into 2 equal groups. Twenty out of 40 patients with BPPV were subjected to PRM and the remaining to placebo treatment.

Procedure for Study Group The diagnosis of BPPV and the identification of the offending ear were established by Hallpike maneuver. The patient was seated on the examination table close enough to the end, so that the neck may be extended over the edge of table when the patient becomes supine. Position 1. The patient was seated and subsequently placed into supine position with the head rotated 45° from vertical plane toward the affected ear. The head was allowed to subtend an angle of 30° to the horizontal plane. Various characteristics of nystagmus (latency, duration, type, and direction) and vertigo were recorded. Position 2. The head was turned by 90° toward the contralateral side from position 1 (ie, 45° to the vertical plane towards opposite ear). Position 3. Later on the head was rotated by a further 90° in the same direction. To ease the head movement, the body was rotated by 90° toward the opposite ear, thus making the head to attain 135° from supine position. Position 4. The patient was brought back to sitting position with the head in the same position as in position 3. Position 5. The patient’s head was later turned by 45° to bring it in line with the rest of the body. In each position, the patient was allowed to rest for 2 minutes after cessation of nystagmus. Various features of nystagmus and vertigo were recorded.

Procedure for Control Group The patient was seated with the eyes open and tilted laterally to the precipitating position, thus

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bringing the lateral aspect of skull in contact with the bed. The position was maintained for 2 minutes after the nystagmus had subsided after which the patient was brought back to the original sitting position. The maneuver was carried out by the patient himself every 3 hours while awake. In bilateral presentations, the ear with maximum symptoms was treated initially. The second ear was subjected to the therapy after an interval of 2 weeks. A maximum of 3 sittings per session with an interval of 2 hours between each was advocated for both the procedures. No mastoid vibrators or vestibular sedatives were used.

Postprocedural Instructions All patients who had undergone PRM were asked to sleep in an upright position with the head elevated at an angle no less than 45° from the bed for the next 48 hours. The patients were allowed to resume normal activities after 2 days. Follow-up. The period of follow-up for all cases was for a minimum of 1 year. Patients were reviewed after 1 week, 4 weeks, and 3 months after the procedure. Later on, they were asked to come after every 3 months for the next 9 months. At each visit, the Hallpike maneuver was repeated and the symptomatic status revised. Assessment. Symptomatic status at each visit was graded as (1) Grade I, complete resolution of symptoms; (2) Grade II, partial resolution of symptoms; and (3) Grade III, no resolution or worsening of symptoms. Grade II and III are considered as failure of procedure. All cases with Hallpike maneuver positive on follow-up were considered as having recurrence. The data was analyzed mainly by using ␹2 test. Fischer exact test was used to compare post traumatic and idiopathic etiology with respect to the side involved (Table 1).

RESULTS The ages ranged from 18 to 72 years with the median age of the study group being at 38.5 years and that of the control group at 45 years. Nine cases out of 40 had shown bilateral involvement. Male to female ratio was at 1:1. Thirty-one out of 40 had symptom duration less than 6 months with 17 belonging to study group and 14 to control group. On subjecting the patients to the Hallpike maneuver, latency of nystagmus ranged from 2 to 10 seconds with the study group mean at 5.2 seconds and the control at 6.45 seconds. All cases showed duration of nystagmus and vertigo lasting for less than half a minute. Fifty

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TABLE 1. Showing Etiology of BPPV* Sex

Idiopathic Posttraumatic Miscellaneous Migraine Post angioplasty Senile Dementia Cardiac dysfunction

‡

Side Involved*

Study

Control

P Value

Male

Female

Right†

Left†

P Value

11 8

9 8

⬎0.1 ⬎0.1

8 11 1

11 5 3

9 4

8 8

⬎0.1 ⬎0.1

1

— 1 1 1

0 1 1 0

*Fischer exact test was used to compare posttraumatic and idiopathic etiology. Nine cases were bilateral. ‡ Chi-square test was used to compare idiopathic and posttraumatic cases only. †

percent of BPPV patients were secondary to idiopathic etiology with 40% being because of trauma. Four patients (10%) had BPPV secondary to miscellaneous causes. Posttraumatic BPPV was more common in men than women. Right ear was found to more affected in cases with idiopathic etiology (Table 1). Follow-up After 1 Week and 4 Weeks At the end of 1 week, 19 out of 20 patients of study group (95%) had complete resolution of symptoms (Grade I) with 1 patient showing partial resolution (Grade II). No recurrences were recorded. On the contrary, only 3 (15%) patients in the control group showed complete symptomatic relief with 17 patients showing partial resolution. Fourteen (70%) cases out of 20 had recurrence of BPPV. At the end of 4 weeks, 95% of patients who underwent PRM had complete relief (Fig 1), with 1 showing recurrence compared with only 15%

Fig 1.

Symptom status during follow-up.

of controls showing complete relief with 14 out 20 cases showing recurrence (Fig 2). Statistically significant differences were noted after 1 week and 4 weeks (P ⬍ .001) (Table 2). 3 Months and 6 Months Three months after PRM, 19 out of 20 patients (95%) showed complete resolution of symptoms compared with 3 out of 20 (15%) in the controls (Table 3). The recurrence rate after PRM was 10% compared with 70% after the placebo. The fraction of patients showing symptomatic improvement after the procedure remained the same after 6 months (Fig 1). Only 1 out of 20 patients subjected to PRM showed recurrence compared with 15 out of 20 patients subjected to the placebo treatment at the end of 6 months (Fig 2). Significant statistical difference (P ⬍ .001) was noted between the 2 groups.

Fig 2.

Recurrence of BPPV during follow-up.

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TABLE 2. Symptom Status After 1 Week and 4 Weeks

Symptom Status Complete resolution Partial resolution No resolution Recurrence Hall pike ⫹ve ⫺ve

Study (n ⫽ 20)

At 1 Week Control (n ⫽ 20)

19/20 (95%) 1 (5%) 0

3 (15%) 17 (85%) 0

0 20 (100%)

14 (70%) 6 (30%)

P Value ⬍.001 ⬍.001

⬍.001

Study (n ⫽ 20)

At 4 Weeks Control (n ⫽ 20)

19 (95%) 1 (5%) 0

3 (15%) 17 (85%) 0

⬍.001 ⬍.001

1 (5%) 19 (95%)

14 (70%) 6 (30%)

⬍.001

P Value

NOTE. ⫹ve denotes positive response and ⫺ve denotes negative response. Chi-square test was used for statistical analysis.

9 Months and 1 Year

DISCUSSION

At the end of 9 months after PRM, 17 out of 20 patients expressed complete relief from their symptoms compared with 3 out of 20 receiving the placebo treatment. Four patients of the control group reported symptomatic conversion from Grade II to Grade III (Fig 1). Only 15% of the study group was Hallpike test positive after 9 months compared with 85% of the control group. At the end of 1 year, 18 out of 20 of the study group reported complete resolution of vertigo compared with only 3 out of 20 of the control group. Thirteen out of 20 controls had partial resolution compared with 2 out of 20 in the study group. Four patients of the control group reported no resolution of symptoms. Ten percent had recurrence after PRM versus 90% after the placebo (Fig 2). Significant statistical difference was noted (P ⬍ .001) in symptomatic improvement and the recurrence rate between the 2 groups at the end of 9 and 12 months (Table 4).

Until recently, BPPV was believed to be a self-limiting condition, and hence it required no treatment. Histological demonstration of canaliths in posterior semicircular canal made many neurotologists to consider repositioning maneuvers. The addition of various types of head maneuvers particularly Epley’s maneuver7 for the treatment of BPPV has been very successful. Literature reports wide range of response rates ranging from 44% to 100%. Epley7 recorded 97.7% to 100% success rate after canalith repositioning maneuver. Parnes and Price-Jones8 had 57% to 90% success rate with PRM. Lynn et al,12 Herdman et al,13 and Barnes et al10 placed the efficacy of PRM between 84% to 96% in their respective studies. Blakely,11 in his analysis of 38 patients, reported 89% success rate. In our randomized single-blinded controlled study, success rate was between 85% to 100% at different periods of follow-up.

TABLE 3. Symptom Status After 3 Months and 6 Months

Symptom Status Complete resolution Partial resolution No resolution Recurrences Hall pike ⫹ve ⫺ve

Study (n ⫽ 20)

At 3 Months Control (n ⫽ 20)

19 (95%) 1 (5%) 0

3 (15%) 17 (85%) 0

2 (10%) 18 (90%)

14 (70%) 6 (30%)

P Value ⬍.001 ⬍.001

Study (n ⫽ 20)

At 6 Months Control (n ⫽ 20)

19 (95%) 1 (5%) 0

3 (15%) 17 (85%) 0

⬍.001 ⬍.001

1 (5%) 19 (95%)

15 (75%) 5 (25%)

⬍.001

P Value

NOTE. ⫹ve denotes positive response and ⫺ve denotes negative response. Chi-square test was used for statistical analysis.

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TABLE 4. Symptom Status After 9 Months and 12 Months

Symptom Status Complete resolution Partial resolution No resolution Recurrences Hall pike ⫹ve ⫺ve

Study (n ⫽ 20)

At 9 Months Control (n ⫽ 20)

P Value

Study (n ⫽ 20)

At 12 Months Control (n ⫽ 20)

P Value

17 (85%) 3 (15%) 0

3 (15%) 13 (65%) 4 (20%)

⬍.001 ⬍.001 ⬍.001

18 (90%) 2 (10%) 0

3 (15%) 13 (65%) 4 (20%)

⬍.001 ⬍.001 ⬍.001

3 (15%) 17 (85%)

17 (85%) 3 (15%)

⬍.001

2 (10%) 18 (90%)

18 (90%) 2 (10%)

⬍.001

NOTE. ⫹ve denotes positive response and ⫺ve denotes negative response. Chi-square test was used for statistical analysis.

Differences in success rates of various repositioning maneuvers are in part because of various grading levels used to assess symptomatic response. Although we partially relied on patients self-report of symptom resolution, we eliminated the bias regarding spontaneous resolution as factor of recovery by using the Hallpike maneuver. Resolution of symptoms, whether partial or complete, may not imply cure of BPPV as evidenced in our study. Cases might still turnout to be Hallpike maneuver positive, thus indicating persistence of disease. We considered Hallpike maneuver as a gold standard for assessment of recurrence rate. Success rate after 1 week and 4 weeks after of PRM was at 100% and 95%, respectively, compared with 30% after the placebo treatment. Of the 20 who underwent PRM, there was only 1 recurrence versus 14 recurrences out of 20 in the control group at the end of 4 weeks. It definitely excludes the concept of spontaneous resolution as a prime factor for immediate recovery. Results recorded after 3 months of follow-up put the success rate of PRM at 90%. Ten percent of patients after PRM showed Hallpike maneuver positive compared with 70% of controls. Two patients in the study group who reported recurrence were subjected to repeat PRM. None of them had recurrence of symptoms in their further follow-ups. This establishes the fact that PRM is an easy, simple procedure, which can be repeated as and when required. After 6 months of followup, recurrences were found to be least with PRM (5%). At the end of 1 year, 90% of the study group patients had complete resolution in symp-

toms compared with a meager 15% in the control group. Recurrence rate after PRM was at 10% compared with 90% after placebo. This establishes the long-term efficacy of PRM in the treatment of BPPV. Interestingly, there were no dropouts at the end of 1 year. All patients subjectively reported their symptomatic status. No telephonic communication was used in assessment of symptoms.14 Blakley11 in his study found no difference between the canalith repositioning maneuver and doing nothing. His findings emphasize the role of spontaneous resolution in BPPV. The basic idea of including the placebo treatment in our study was to exclude the role of spontaneous resolution in BPPV. Although 10% to 30% showed no recurrence of BPPV, the results were not so consistent. At the end of 1 year, only 15% of the controls had complete symptomatic relief with 90% showing a recurrence in BPPV. Only 3 patients had complete relief of symptoms throughout the study. This signifies the insignificant role of spontaneous resolution in the long-term management of BPPV. Epley7 in his study used mastoid vibrators for increasing the effectiveness of the repositioning maneuver. Tirelli et al15 introduced head shaking to mastoid vibrator to achieve a high success rate. Controversy still lingers around the usage of vibrators.14 In our study, all patients underwent PRM without the usage of any additional equipment. The efficacy rates obtained questions the usage of vibrators, although a controlled study is required to confirm it. To conclude, PRM is a very easy and effective procedure in the management of benign paroxysmal positional vertigo. Patients expe-

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riencing later recurrences can be subjected to a repeat maneuver. This study also emphasizes the importance and validity of Hallpike maneuver in the diagnosis of disease and its recurrence. This study also rules out spontaneous resolution as a major theory in the resolution of BPPV. It reestablishes the shortterm and long-term efficacy of PRM in the management of BPPV. REFERENCES 1. Adler A: Uter less “unsuitigen drehschwindel.” Dtsch Ztschr Nevenheilk 11:358-375, 1897 2. Barany R: Diagnose Von Krankheitserbcheinungen im Berciche Dis Otolithenapparates. Acta Otolaryngol (Stockh) 2:334-337, 1921 3. Dix MR, Hallpike CS: The pathology, symptomatology and diagnosis of certain common disorders of vestibular system. Ann Otol Rhinol Laryngol 6:987-1016, 1952 4. Schuknecht HF, Ruby PRF: Cupulolithiasis. Adv Otorhinolaryngol 20:434-443, 1973 5. Brandt T, Daroff RB: Physical therapy for benign paroxysmal positional virtigo. Arch Otolaryngol 106:484485, 1980

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6. Hall SF, Ruby RRF, McClure JA: The mechanics of benign paroxysmal vertigo. J Otolaryngol 8:151-158, 1979 7. Epley JM: The canalith repositioning procedure: For treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 107:399-404, 1992 8. Parnes LS, Price-Jones RG: Particle repositioning maneuver for benign paroxysmal positional vertigo. Ann Otol Rhinol Laryngol 102:325-331, 1993 9. Harvey SA, Hain TC, Adamiec TC: Modified liberatory maneuver: effective treatment for BPPV. Laryngoscope 104:1206-1212, 1994 10. Welling DB, Barnes DE: Particle repositioning maneuver for BPPV. Laryngoscope 104:946-949, 1994 11. Blakely BW: A randomized, controlled assessment of the canalith repositioning maneuver. Otolaryngol Head Neck Surgery 110:391-396, 1994 12. Lynn S, Poole A, Rose D, et al: Randomized trial of canalith repositioning11 procedure. Otolaryngol Head Neck Surg 113:714-719, 1995 13. Herdman SJ, Tusa RJ, Zee DS, et al: Single treatment approaches to benign paroxysmal positional. Arch Otolaryngol Head Neck Surg 119:450-454, 1993 14. Nunez RA, Cass SP, Furman JM: Short and long term outcomes of canalith repositioning for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 122:647-652, 2000 15. Tirelli G, D Orlando E, Giaconmarra V, et al: Modified particle repositioning procedure. Laryngoscope 100: 462-468, 2000