- Email: [email protected]
Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV
G Model
ANL-2421; No. of Pages 5 Auris Nasus Larynx xxx (2018) xxx–xxx Contents lists available at ScienceDirect
Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl
Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV Elshahat Ibrahem Ismail *, Ashraf Elsayed Morgan, Mohamed Moustafa Abdeltawwab Faculty of Medicine, Mansoura University, Egypt
A R T I C L E I N F O
A B S T R A C T
Article history: Received 23 November 2017 Accepted 20 February 2018 Available online xxx
Objective: To check the value of home particle repositioning maneuver in the prevention of the recurrence of posterior canal benign paroxysmal positional vertigo (pc-BPPV). Methods: In this study, patients diagnosed as unilateral posterior canal BPPV were selected following an accurate evaluation using video goggle VNG system. All patients were managed by particle repositioning maneuver (PRM). Patients were instructed to do home PRM once weekly for five years. Then, they were divided into two groups (according to choice of patient to do PRM). The first group (control group) consisted of 144 patients who did not do home PRM; whereas the second group (study group) included 165 patients who performed home PRM. All patients (control & study groups) were followed up every four months for five years. Results: The study found out that the recurrence rate of pc-BPPV in control group was 33 patients in the first year (27.2%), 11 patients in second year (9%), 5 patients in third year (4%), 3 patients in fourth year (2.5%) and 3 patients in fifth year (2.5%). The recurrence of pc-BPPV in the treated side (study group) of patients was reported as 5 patients in the first year (3.5%), 3 patients in the second year (2%), 2 patients in the third year (1.4%), 2 patients in the fourth year (1.4%), and 1 patient in the fifth year (0.7%). There was statistically significant difference between the control and the study groups regarding the recurrence rates in the first year follow up which was the highest in first four months. Conclusion: Home particle repositioning maneuver has the capacity to prevent the recurrence of pcBPPV. It proved to be more successful and functional in minimizing the recurrence of the disease in the study than in the control group. Hence, home particle repositioning maneuver is highly recommended for one year at least in pc-BPPV. © 2018 Elsevier B.V. All rights reserved.
Keywords: Particle repositioning maneuver Posterior canal benign paroxysmal positional vertigo Recurrence of benign paroxysmal positional vertigo
1. Introduction Benign paroxysmal positional vertigo (BPPV) is known to be the commonest cause of vertigo. It represents 1% of patients evaluated by neurologists and ear, nose, and throat specialists [1,2]. The most common type of BPPV is posterior canal BPPV
* Corresponding author at: Audiology Unit, ENT Department, Faculty of Medicine, El-Gomhoria St., Mansoura 35516, Egypt. E-mail addresses: [email protected], [email protected] (E.I. Ismail).
(pc-BPPV), which has a lifetime prevalence of 2.4% [2]. Posterior canal BPPV (pc-BPPV) represents 80–90% of BPPV, while lateral-canal BPPV (LC-BPPV) is reported in 10– 20% of patients [3]. However, most recent investigations stated that the horizontal–canal variant has been underestimated with an occurrence frequency of 10–30% [4,5]. A specific type of BPPV is pc-BPPV. It can be cured by the Epley maneuver and it represents the most affected canal (90.2%) [6,7]. Diagnosis of pc-BPPV is confirmed through the Dix–Hallpike (DH) test [8].
https://doi.org/10.1016/j.anl.2018.02.005 0385-8146/© 2018 Elsevier B.V. All rights reserved.
Please cite this article in press as: Ismail EI, et al. Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2018.02.005
G Model
ANL-2421; No. of Pages 5 2
E.I. Ismail et al. / Auris Nasus Larynx xxx (2018) xxx–xxx
The two main theories of BPPV pathophysiology are the Canalolithiasis and the Cupulolithiasis. According to the Canalolithiasis theory, which is now accepted as a pathophysiologic mechanism [9,10], detached otoconia from utricle comes in semicircular canals and it induces deflection of the cupula as a result of head movement which creates the endolymphatic flow. These free-floating particles result in stimulation of the hair cells and hence induce vertigo. In the Cupulolithiasis theory, otoconia becomes adherent to the cupula, so cupular specific gravity increases, thus becomes sensitive to any changes in the gravitational place of the head [9]. The Epley maneuver (EM) is a highly effective treatment supported by two evidence-based guidelines [10,11]. The maneuver is simple and can easily be performed at the bedside using a series of positions designed to move the otoconia out of the posterior canal. However, the EM is substantially underused in routine clinical care [9,12,13]. Epley recommended a canalith repositioning maneuver (CRP) to move free floating otoconia from long arm of the posterior canal into the utricle. A mastoid oscillator is used to help this process [14]. Parnes and Price-Jones described a modification of CRP and named it as the particle repositioning maneuver (PRM). Unlike Epley, Parnes and Price-Jones did not use premedication or mastoid oscillator to their patients [15]. Although PRM is very effective, BPPV often recurs. The recurrence rate was 40% within the first two years [16] and 50% in another study with long-term followup (6–17 years) [17]. In addition to PRM effectiveness, the widespread use of the PRM is a time-saving technique when compared with other techniques such as that of Semont. This is because PRM can be done immediately after a positive DH test. In general, maneuvers described for otoconia repositioning have common characteristics such as: noninvasiveness, easiness to be done in consultation without special equipment, resolving the vertigo with relative speed and possibility of being repeated several times according to the needs [18]. Posterior canal BPPV self-treatment has been used based on Epley’s and Semont’s maneuvers after BPPV diagnosis; these maneuvers are recommended and learned to patients as it can be performed with ease at homes [19,20]. Tanimoto et al. [21] compared the benefit of Epley maneuver with and without selftreatment in pc-BPPV. They argued that the symptoms and the nystagmus are better improved in Epley with self-treatment maneuver. Tanimoto et al. concluded that Epley’s maneuver, followed by self-treatment maneuver, was efficient in pc-BPPV management. Helminski et al. [22] conducted Brandt–Daroff as a daily routine exercises to be carried out for two years in pcBPPV and concluded that these exercises did not affect the recurrence of pc-BPPV. Research suggested that a daily routine of canalith repositioning procedure, carried out at home, may be more effective for preventing pc-BPPV recurrence than the Brandt–Daroff exercises. As assumed in the present paper, no studies have been conducted to evaluate the effectiveness of home PRM in the prevention of pc-BPPV recurrence. Accordingly, this study was designed mainly with an objective to check the value of home particle repositioning maneuver in the prevention of recurrence of pc-BPPV.
2. Methods and materials This study was performed after fulfilling the requirements of the ethical committee at the ENT Department and the approval of the Institutional Research Board of the Faculty of Medicine in our University. Written informed consent was also obtained from all the patients who participated in this study. The study was conducted at the Audiology Unit, ENT Department at our University Hospital. The research was conducted on dizzy patients who visited the vestibular unit from June (2010) to September (2016). Patients selected in this study were diagnosed as having unilateral posterior canal BPPV. Diagnosis of posterior canal BPPV was made based on the history of recurrent attacks of rotatory vertigo which lasted for less than one minute related to different head positions and positive Dix–Hallpike test on only one side. The patients were evaluated by using video goggle VNG system (Visual Eye, Micromedical Technologies, Spectrum, Version 6.1). The present study was restricted for unilateral pc-BPPV patients, whereas bilateral pc-BPPV and unilateral atypical BPPV were excluded. Four criteria were needed for the diagnosis of pc-BPPV canilolithiasis as follows: (1) 1–20 s latency before the onset of vertigo and nystagmus; (2) Torsional up-beating nystagmus on hyperextended head place; (3) Vertigo and nystagmus less than one minute and (4) Reversal of nystagmus directions on sitting. Patients were managed by particle repositioning maneuver in case no contraindication to such maneuver (for example, neck surgery, cervical radiculopathy, severe limitation of neck movement and vascular loop dissection) was reported. The PRM was repeated after half an hour. Then, the patients were reevaluated on the 3rd and the 7th day from the first maneuver and PRM was performed if required. Patients who accepted to perform PRM in this study were trained on how to carry out the maneuver. Home PRM training started to be given from the first session and the following two sessions. Patients’ understanding of how to perform PRM was tested and checked by the examiners until correct procedure is followed. Patients were advised to perform home PRM once weekly for five years at a fixed day and time they prefer. Those patients were followed weekly in the first month of the study to confirm guarantee a successful PRM. Then, patients were divided into two groups (according to the convenience of each patient to perform home PRM). The first control group included 144 patients who did not do home PRM. The second study group included 165 patients who performed home PRM. All patients (control & study groups) were followed up every four months for five years. Patients reported irregular practice of home PRM were excluded from study. All patients were advised to visit our unit within 24 h if any vertiginous symptoms or any problem with home PRM arose. The following procedures were carried out: history taken, positioning tests and PRM performed if required every follow-up, also study group reviewed for home PRM regularity and accuracy of performance. pc-BPPV recurrence based on history and recorded nystagmus of pc-BPPV during Dix–Hallpike test and PRM performed for recurrent cases.
Please cite this article in press as: Ismail EI, et al. Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2018.02.005
G Model
ANL-2421; No. of Pages 5 E.I. Ismail et al. / Auris Nasus Larynx xxx (2018) xxx–xxx
2.1. Statistical data analysis After carrying out the above procedure, data was qualitatively analyzed using Statistical Package for Social Science software (version 22, SPSS, Inc., Chicago, IL, USA). Qualitative data was presented as frequency (number-percent). Chi-square “x2” or Fischer’s exact tests, as indicated, were used to compare the qualitative data. P value less than 0.05 was considered statistically significant.
3
Table 1 The side (right vs left) and gender (males vs females) for the control and study groups.
Side Right side Left side Gender Females Males
Control group
Study group
P
67 (55.4%) 54 (44.6%)
78 (54%) 66 (46%)
0.8
72 (59.5%) 49 (40.5%)
85 (59%) 59 (41%)
0.93
3. Results The main result of the study is that the mean age for the control group is (55.4 years 5.5), and that of the study group is (54.4 years 6.5). In the first group (control), which consisted of 144 patients, only 121 patients completed the follow-up period: 72 females (59.5%) and 49 males (40.5%). In the second group (study) which consisted of 165 patients, 144 patients completed the follow-up period 85 females (59%) and 59 males (41%) (Fig. 1). In this study there was no statistical difference between the two groups as regards gender and age. The right side was affected more than the left side. 67 right (55.4%) & 54 left (44.6%) in the control group; while it was 78 right (54%) & 66 left (46%) in the study group (Table 1). The patients cured from BPPV in control group in first session were 94 (77.7%), 13 in the second session (10.7%) and 14 in the third session (11.6%) on the 7th day. On the other hand, the patients cured from BPPV in the study group in first session were 109 (75.7%), 17 in the second session (11.8%) in 3rd and 18 in the third session (12.5%) at the 7th day (Table 2). The recurrence rate of pc-BPPV in the control group was 33 patients (27.2%) in the first year, 11 patients (9%) in the second year, 5 patients (4%) in the third year, 3 patients (2.5%) in the fourth year and 3 patients (2.5%) in the fifth year. The recurrence of pc-BPPV in the treated side was reported 5 (3.5%) in the first year, 3 (2%) in the second year, 2 (1.4%) in the third year, 2 (1.4%) in the fourth year, and 1 (0.7%) patients in the fifth year in the study group. There was statistically significant difference between the control and the study groups regarding the recurrence rates in the first year follow up which was the highest in the first 4 months (Table 3).
4. Discussion One of the most important results of the present study is that vertigo often recurs in BPPV, with documented (15–37%) recurrence rates following first CRMs [23–26]. The recurrence rate was 50% during a mean follow-up 10 years, whereas 80% of recurrence occurs within the first year after treatment [17]. Brandt–Daroff exercises carried out for two years in pcBPPV and as a result of these exercises did not affect the recurrence of pc-BPPV [22]. Accordingly, the current study was conducted for longer time (five years) as an attempt to ascertain the effectiveness of home PRM in prevention of recurrence of pc-BPPV. A further significant implication of the study is that proper repositioning maneuvers after correct diagnosis may produce immediate and simple cure for the BPPV [27]. Accordingly, the only recommended method of curing pc-BPPV is Epley’s maneuver, with confirmed evidence level (A) according to the American Academy of Neurology [28]. It is clear now that the prevention of BPPV recurrence would improve the quality life of the patient and/or decrease the long-term cost of the medical management of BPPV. Home canalith repositioning maneuver may be effective for preventing pc-BPPV recurrence [22]. Selftreatment after Epley maneuver was proved to be efficient in pcBPPV management [21]. In this study, the mean age of the control group was 55.4 5.5 and the mean age of the study group was 54.4 6.5 years, which was correlating to literature [29,30]. Also, the sex distribution for females and males in the control group and the study group was correlating with research reports [29]. The study concluded that the right side is affected more in the control and the study group which was reported by Von Brevern et al. [31]. In the present study, it was concluded that up to 75% of patients were cured after the first session, 90% after the second session, and 100% after the third session in both the control and the study groups. A randomized study, after a single session Table 2 Number of cured cases of BPPV for control and study groups.
Fig. 1. The total no. of patients and patients completed the study for the control and study groups.
Number of cured cases of BPPV
Control group
Study group
P
Cured cases in first session Cured cases in second session Cured cases in third session Total number of BPPV
94 (77.7%) 13 (10.7%) 14 (11.6%) 121
109 (75.7%) 17 (11.8%) 18 (12.5%) 144
0.7 0.78 0.8
Please cite this article in press as: Ismail EI, et al. Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2018.02.005
G Model
ANL-2421; No. of Pages 5 E.I. Ismail et al. / Auris Nasus Larynx xxx (2018) xxx–xxx
4
Table 3 The recurrence of BPPV for control and study groups. Recurrence of BPPV
Control group (total number = 121)
Study group (total number = 144)
P-Value
First year
First follow up Second follow up Third follow up
15 (12.4%) 10 (8.3%) 8 (6.6%)
2 (1.4%) 2 (1.4%) 1 (0.7%)
<0.001* 0.01* 0.01*
Second year
First follow up Second follow up Third follow up
5 (4.1%) 3 (2.5%) 3 (2.5%)
1 (0.7%) 1 (0.7%) 1 (0.7%)
0.096 0.33 0.33
Third year
First follow up Second follow up Third follow up
3 (2.5%) 1 (0.8%) 1 (0.8%)
1 (0.7%) 0 (0%) 1 (0.7%)
0.33 0.45 1.00
Fourth year
First follow up Second follow up Third follow up
2 (1.7%) 0 (0%) 1 (0.8%)
1 (0.7%) 0 (0%) 1 (0.7%)
0.6 NA 1.00
Fifth year
First follow up Second follow up Third follow up
1 (0.8%) 2 (1.7%) 0 (0%)
1 (0.7%) 0 (0%) 0 (0%)
1.00 0.2 NA
with either Semont’s or Epley maneuvers, 90% of patients were either improved or cured [32]. Epley himself recorded more than 90% success rate following a single treatment session. In another study of 25 BPPV patients, 18 (72%) cured immediately after the Epley maneuver and 23 (92%) patients cured at the first week of follow-up. The last two patients recovered from vertigo during the second and the third followup [33]. The recurrence rate of pc-BPPV in the control group was 27% in the first year, 36% in next two years, 40% within three years, 42% within four years and 44% in first five years of the follow up. These results are in line with Hain et al. [16]. They reported that 40% of patients successfully recovered with the canalith repositioning procedure redevelop BPPV within the first two years. Also, Brandt et al. [17] recorded 50% recurrence in a mean 10 years follow-up. Epley argued that the mechanism of canalolithiasis that causes nystagmus in the posterior canal particle must produce a critical mass in the dependent part of the posterior semicircular canal [34,35]. In our study, the recorded recurrence of pc-BPPV of affected side in the study group was only 13 patients (9%) all over 60 months with highest recurrence rate occurred in first two years (8 patients). This can be speculated by repetition of PRM every week frequently remove and push the otoconia particles to utricle and prevent it from formation of large masses to reach “a critical mass” to induce recurrence of BPPV. The otoconia dissolved frequently when reaching the urticle. So, there is no critical mass formation to develop other variant of BPPV or recur in the same canal. Brandt–Daroff exercise used by Helminiski et al. [22] failed to prevent the recurrence of BPPV as this maneuver is a habituation exercise rather than a repositioning Maneuver. On the other hand, the recurrence of pc-BPPV in some cases in our study can be explained by those patients who performed particle repositioning maneuver irregularly and in an imperfect way or those who have highly recurrent cases of pc-BPPV. The study suggests and recommends a daily routine home PRM for those patients for at least two years with monthly follow up.
The study also concluded that the effectiveness of home PRM was evident in the first year follow up in the study group where the highest recurrence pc-BPPV in the control group was reported in the first year also. From these points, home PRM is recommended once weekly for one year at least in pc-BPPV. 5. Conclusion The study concludes that home particle repositioning maneuver can effectively prevent the recurrence of pc-BPPV based on empirical data. Particle repositioning maneuver proved to be more successful in minimizing the recurrence of the disease in the study group than the control group. Accordingly, the study recommends home PRM for at least one year in pc-BPPV. Author’s contribution Elshahat Ibrahem Ismail, Ashraf Elsayed Morgan, Mohamed Moustafa Abdeltawwab: Clinical data collection, analysis and writing of the paper. Acknowledgments Several people helped me with the collection of data and providing advice for statistical analyses and they are all thanked for their contributions. My heart-felt thanks to the staff at the Audiology Unit of the ENT Department at our University Hospital. References [1] Mizukoshi K, Watanabe Y, Shojaku H, Okubo J, Watanabe I. Epidemiological studies on benign paroxysmal positional vertigo in Japan. Acta Otolaryngol Suppl 1988;447:67–72. [2] Von Brevern M, Radtke A, Lezius F, Feldmann M, Ziese T, Lempert T, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry 2007;78:710–5.
Please cite this article in press as: Ismail EI, et al. Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2018.02.005
G Model
ANL-2421; No. of Pages 5 E.I. Ismail et al. / Auris Nasus Larynx xxx (2018) xxx–xxx [3] Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Phys Ther 2010;90:663–78. [4] Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:2067–74. [5] Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med 2014;370:1138–47. [6] Chang W-C, Yang Y-R, Hsu L-C, Chern CM, Wang RY. Balance improvement in patients with benign paroxysmal positional vertigo. Clin Rehabil 2008;22(4):338–47. [7] Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003;169(7):681–93. [8] Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Proc R Soc Med 1952;45(6):341–54. [9] Marom T, Oron Y, Watad W, Levy D, Roth Y. Revisiting benign paroxysmal positional vertigo pathophysiology. Am J Otolaryngol 2009;30(4):250–5. [10] Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:2067–74. [11] Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2008;139:S47–81. [12] Polensek SH, Tusa RJ, Sterk CE. The challenges of managing vestibular disorders: a qualitative study of clinicians’ experiences associated with low referral rates for vestibular rehabilitation. Int J Clin Pract 2009;63:1604–12. [13] Polensek SH, Tusa R. Unnecessary diagnostic tests often obtained for benign paroxysmal positional vertigo. Med Sci Monit 2009;15:MT89– 94. [14] Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1980;88:599–605. [15] Parnes LS, Price-Jones RG. Particle repositioning maneuver for benign paroxysmal positional vertigo. J Otol Rhinol Laryngol 1993;102:325– 31. [16] Hain TC, Helminski JO, Reis IL, Uddin MK. Vibration does not improve results of the canalith repositioning procedure. Arch Otolaryngol Head Neck Surg 2000;126:617–22. [17] Brandt T, Huppert D, Hecht J, Karch C, Strupp M. Benign paroxysmal positional vertigo: a long-term Follow-up (6–17 years) of 125 patients. Acta Otolaryngol. 2006;126:160–3. [18] Prime-Espada MP, De Diego-Sastre JI, Perez-Fenandez Elia. Metaanalysis on the efficacy of Epley’s Maneuver in benign paroxysmal positional vertigo. Neurologı´a 2010;25(5):295–9.
5
[19] Radtke A, Neuhauser H, von Brevern M, Lempert T. A modified Epley’s procedure for self-treatment of benign paroxysmal positional vertigo. Neurology 1999;53:1358–60. [20] Radtke A, von Brevern M, Tiel-Wilck K, Mainz-Perchalla A, Neuhauser H, Lempert T. Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure. Neurology 2004;63:150–2. [21] Tanimoto H, Doi K, Katata K, Nibu KI. Self-treatment for benign paroxysmal positional vertigo of the posterior semicircular canal. Neurology 2005;65(8):1299–300. [22] Helminski JO, Janssen I, Kotaspouikis D, Kovacs K, Sheldon P, McQueen K, et al. Strategies to prevent recurrence of benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg 2005;131:344–8. [23] Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med 1999;34:1590–6. [24] Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399–404. [25] Del Rio M, Arriaga MA. Benign positional vertigo: prognostic factors. Otolaryngol Head Neck Surg 2004;130:426–9. [26] Sakaida M, Takeuchi K, Ishinaga H, Adachi M, Majima Y. Long-term outcome of benign paroxysmal positional vertigo. Neurology 2003;60:1532–4. [27] Seok JI, Lee HM, Yoo JH, Lee DK. Residual dizziness after successful repositioning treatment in patients with benign paroxysmal positional vertigo. J Clin Neurol 2008;4:107–10. [28] Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:2067–74. [29] Baloh RW, Honrubia V, Jacobson V. Benign positional vertigo: clinical and oculographic features in 240 cases. Neurology 1987;37(3):371–8. [30] Marciano E, Marcelli V. Postural restrictions in labyrintholithiasis. Eur Arch Otorhinolaryngol 2002;259(5):262–5. [31] Von Brevern M, Seelig T, Neuhauser H, Lempert T. Benign paroxysmal positional vertigo predominantly affects the right labyrinth. J Neurol Neurosurg Psychiatry 2004;75(10):1487–8. [32] 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(4):450–4. [33] Gaur S, Awasthi SK, Bhadouriya SKS, Saxena R, Pathak VR, Bisht M. Efficacy of Epley’s maneuver in treatment of BPPV patients: prospective observational study. Int J Otolaryngol 2015;1–5. [34] Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1980;88:599–605. [35] Epley JM. Human experience with canalith repositioning maneuvers. Ann N Y Acad Sci 2001;942:300–5.
Please cite this article in press as: Ismail EI, et al. Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2018.02.005
ANL-2421; No. of Pages 5 Auris Nasus Larynx xxx (2018) xxx–xxx Contents lists available at ScienceDirect
Auris Nasus Larynx journal homepage: www.elsevier.com/locate/anl
Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV Elshahat Ibrahem Ismail *, Ashraf Elsayed Morgan, Mohamed Moustafa Abdeltawwab Faculty of Medicine, Mansoura University, Egypt
A R T I C L E I N F O
A B S T R A C T
Article history: Received 23 November 2017 Accepted 20 February 2018 Available online xxx
Objective: To check the value of home particle repositioning maneuver in the prevention of the recurrence of posterior canal benign paroxysmal positional vertigo (pc-BPPV). Methods: In this study, patients diagnosed as unilateral posterior canal BPPV were selected following an accurate evaluation using video goggle VNG system. All patients were managed by particle repositioning maneuver (PRM). Patients were instructed to do home PRM once weekly for five years. Then, they were divided into two groups (according to choice of patient to do PRM). The first group (control group) consisted of 144 patients who did not do home PRM; whereas the second group (study group) included 165 patients who performed home PRM. All patients (control & study groups) were followed up every four months for five years. Results: The study found out that the recurrence rate of pc-BPPV in control group was 33 patients in the first year (27.2%), 11 patients in second year (9%), 5 patients in third year (4%), 3 patients in fourth year (2.5%) and 3 patients in fifth year (2.5%). The recurrence of pc-BPPV in the treated side (study group) of patients was reported as 5 patients in the first year (3.5%), 3 patients in the second year (2%), 2 patients in the third year (1.4%), 2 patients in the fourth year (1.4%), and 1 patient in the fifth year (0.7%). There was statistically significant difference between the control and the study groups regarding the recurrence rates in the first year follow up which was the highest in first four months. Conclusion: Home particle repositioning maneuver has the capacity to prevent the recurrence of pcBPPV. It proved to be more successful and functional in minimizing the recurrence of the disease in the study than in the control group. Hence, home particle repositioning maneuver is highly recommended for one year at least in pc-BPPV. © 2018 Elsevier B.V. All rights reserved.
Keywords: Particle repositioning maneuver Posterior canal benign paroxysmal positional vertigo Recurrence of benign paroxysmal positional vertigo
1. Introduction Benign paroxysmal positional vertigo (BPPV) is known to be the commonest cause of vertigo. It represents 1% of patients evaluated by neurologists and ear, nose, and throat specialists [1,2]. The most common type of BPPV is posterior canal BPPV
* Corresponding author at: Audiology Unit, ENT Department, Faculty of Medicine, El-Gomhoria St., Mansoura 35516, Egypt. E-mail addresses: [email protected], [email protected] (E.I. Ismail).
(pc-BPPV), which has a lifetime prevalence of 2.4% [2]. Posterior canal BPPV (pc-BPPV) represents 80–90% of BPPV, while lateral-canal BPPV (LC-BPPV) is reported in 10– 20% of patients [3]. However, most recent investigations stated that the horizontal–canal variant has been underestimated with an occurrence frequency of 10–30% [4,5]. A specific type of BPPV is pc-BPPV. It can be cured by the Epley maneuver and it represents the most affected canal (90.2%) [6,7]. Diagnosis of pc-BPPV is confirmed through the Dix–Hallpike (DH) test [8].
https://doi.org/10.1016/j.anl.2018.02.005 0385-8146/© 2018 Elsevier B.V. All rights reserved.
Please cite this article in press as: Ismail EI, et al. Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2018.02.005
G Model
ANL-2421; No. of Pages 5 2
E.I. Ismail et al. / Auris Nasus Larynx xxx (2018) xxx–xxx
The two main theories of BPPV pathophysiology are the Canalolithiasis and the Cupulolithiasis. According to the Canalolithiasis theory, which is now accepted as a pathophysiologic mechanism [9,10], detached otoconia from utricle comes in semicircular canals and it induces deflection of the cupula as a result of head movement which creates the endolymphatic flow. These free-floating particles result in stimulation of the hair cells and hence induce vertigo. In the Cupulolithiasis theory, otoconia becomes adherent to the cupula, so cupular specific gravity increases, thus becomes sensitive to any changes in the gravitational place of the head [9]. The Epley maneuver (EM) is a highly effective treatment supported by two evidence-based guidelines [10,11]. The maneuver is simple and can easily be performed at the bedside using a series of positions designed to move the otoconia out of the posterior canal. However, the EM is substantially underused in routine clinical care [9,12,13]. Epley recommended a canalith repositioning maneuver (CRP) to move free floating otoconia from long arm of the posterior canal into the utricle. A mastoid oscillator is used to help this process [14]. Parnes and Price-Jones described a modification of CRP and named it as the particle repositioning maneuver (PRM). Unlike Epley, Parnes and Price-Jones did not use premedication or mastoid oscillator to their patients [15]. Although PRM is very effective, BPPV often recurs. The recurrence rate was 40% within the first two years [16] and 50% in another study with long-term followup (6–17 years) [17]. In addition to PRM effectiveness, the widespread use of the PRM is a time-saving technique when compared with other techniques such as that of Semont. This is because PRM can be done immediately after a positive DH test. In general, maneuvers described for otoconia repositioning have common characteristics such as: noninvasiveness, easiness to be done in consultation without special equipment, resolving the vertigo with relative speed and possibility of being repeated several times according to the needs [18]. Posterior canal BPPV self-treatment has been used based on Epley’s and Semont’s maneuvers after BPPV diagnosis; these maneuvers are recommended and learned to patients as it can be performed with ease at homes [19,20]. Tanimoto et al. [21] compared the benefit of Epley maneuver with and without selftreatment in pc-BPPV. They argued that the symptoms and the nystagmus are better improved in Epley with self-treatment maneuver. Tanimoto et al. concluded that Epley’s maneuver, followed by self-treatment maneuver, was efficient in pc-BPPV management. Helminski et al. [22] conducted Brandt–Daroff as a daily routine exercises to be carried out for two years in pcBPPV and concluded that these exercises did not affect the recurrence of pc-BPPV. Research suggested that a daily routine of canalith repositioning procedure, carried out at home, may be more effective for preventing pc-BPPV recurrence than the Brandt–Daroff exercises. As assumed in the present paper, no studies have been conducted to evaluate the effectiveness of home PRM in the prevention of pc-BPPV recurrence. Accordingly, this study was designed mainly with an objective to check the value of home particle repositioning maneuver in the prevention of recurrence of pc-BPPV.
2. Methods and materials This study was performed after fulfilling the requirements of the ethical committee at the ENT Department and the approval of the Institutional Research Board of the Faculty of Medicine in our University. Written informed consent was also obtained from all the patients who participated in this study. The study was conducted at the Audiology Unit, ENT Department at our University Hospital. The research was conducted on dizzy patients who visited the vestibular unit from June (2010) to September (2016). Patients selected in this study were diagnosed as having unilateral posterior canal BPPV. Diagnosis of posterior canal BPPV was made based on the history of recurrent attacks of rotatory vertigo which lasted for less than one minute related to different head positions and positive Dix–Hallpike test on only one side. The patients were evaluated by using video goggle VNG system (Visual Eye, Micromedical Technologies, Spectrum, Version 6.1). The present study was restricted for unilateral pc-BPPV patients, whereas bilateral pc-BPPV and unilateral atypical BPPV were excluded. Four criteria were needed for the diagnosis of pc-BPPV canilolithiasis as follows: (1) 1–20 s latency before the onset of vertigo and nystagmus; (2) Torsional up-beating nystagmus on hyperextended head place; (3) Vertigo and nystagmus less than one minute and (4) Reversal of nystagmus directions on sitting. Patients were managed by particle repositioning maneuver in case no contraindication to such maneuver (for example, neck surgery, cervical radiculopathy, severe limitation of neck movement and vascular loop dissection) was reported. The PRM was repeated after half an hour. Then, the patients were reevaluated on the 3rd and the 7th day from the first maneuver and PRM was performed if required. Patients who accepted to perform PRM in this study were trained on how to carry out the maneuver. Home PRM training started to be given from the first session and the following two sessions. Patients’ understanding of how to perform PRM was tested and checked by the examiners until correct procedure is followed. Patients were advised to perform home PRM once weekly for five years at a fixed day and time they prefer. Those patients were followed weekly in the first month of the study to confirm guarantee a successful PRM. Then, patients were divided into two groups (according to the convenience of each patient to perform home PRM). The first control group included 144 patients who did not do home PRM. The second study group included 165 patients who performed home PRM. All patients (control & study groups) were followed up every four months for five years. Patients reported irregular practice of home PRM were excluded from study. All patients were advised to visit our unit within 24 h if any vertiginous symptoms or any problem with home PRM arose. The following procedures were carried out: history taken, positioning tests and PRM performed if required every follow-up, also study group reviewed for home PRM regularity and accuracy of performance. pc-BPPV recurrence based on history and recorded nystagmus of pc-BPPV during Dix–Hallpike test and PRM performed for recurrent cases.
Please cite this article in press as: Ismail EI, et al. Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2018.02.005
G Model
ANL-2421; No. of Pages 5 E.I. Ismail et al. / Auris Nasus Larynx xxx (2018) xxx–xxx
2.1. Statistical data analysis After carrying out the above procedure, data was qualitatively analyzed using Statistical Package for Social Science software (version 22, SPSS, Inc., Chicago, IL, USA). Qualitative data was presented as frequency (number-percent). Chi-square “x2” or Fischer’s exact tests, as indicated, were used to compare the qualitative data. P value less than 0.05 was considered statistically significant.
3
Table 1 The side (right vs left) and gender (males vs females) for the control and study groups.
Side Right side Left side Gender Females Males
Control group
Study group
P
67 (55.4%) 54 (44.6%)
78 (54%) 66 (46%)
0.8
72 (59.5%) 49 (40.5%)
85 (59%) 59 (41%)
0.93
3. Results The main result of the study is that the mean age for the control group is (55.4 years 5.5), and that of the study group is (54.4 years 6.5). In the first group (control), which consisted of 144 patients, only 121 patients completed the follow-up period: 72 females (59.5%) and 49 males (40.5%). In the second group (study) which consisted of 165 patients, 144 patients completed the follow-up period 85 females (59%) and 59 males (41%) (Fig. 1). In this study there was no statistical difference between the two groups as regards gender and age. The right side was affected more than the left side. 67 right (55.4%) & 54 left (44.6%) in the control group; while it was 78 right (54%) & 66 left (46%) in the study group (Table 1). The patients cured from BPPV in control group in first session were 94 (77.7%), 13 in the second session (10.7%) and 14 in the third session (11.6%) on the 7th day. On the other hand, the patients cured from BPPV in the study group in first session were 109 (75.7%), 17 in the second session (11.8%) in 3rd and 18 in the third session (12.5%) at the 7th day (Table 2). The recurrence rate of pc-BPPV in the control group was 33 patients (27.2%) in the first year, 11 patients (9%) in the second year, 5 patients (4%) in the third year, 3 patients (2.5%) in the fourth year and 3 patients (2.5%) in the fifth year. The recurrence of pc-BPPV in the treated side was reported 5 (3.5%) in the first year, 3 (2%) in the second year, 2 (1.4%) in the third year, 2 (1.4%) in the fourth year, and 1 (0.7%) patients in the fifth year in the study group. There was statistically significant difference between the control and the study groups regarding the recurrence rates in the first year follow up which was the highest in the first 4 months (Table 3).
4. Discussion One of the most important results of the present study is that vertigo often recurs in BPPV, with documented (15–37%) recurrence rates following first CRMs [23–26]. The recurrence rate was 50% during a mean follow-up 10 years, whereas 80% of recurrence occurs within the first year after treatment [17]. Brandt–Daroff exercises carried out for two years in pcBPPV and as a result of these exercises did not affect the recurrence of pc-BPPV [22]. Accordingly, the current study was conducted for longer time (five years) as an attempt to ascertain the effectiveness of home PRM in prevention of recurrence of pc-BPPV. A further significant implication of the study is that proper repositioning maneuvers after correct diagnosis may produce immediate and simple cure for the BPPV [27]. Accordingly, the only recommended method of curing pc-BPPV is Epley’s maneuver, with confirmed evidence level (A) according to the American Academy of Neurology [28]. It is clear now that the prevention of BPPV recurrence would improve the quality life of the patient and/or decrease the long-term cost of the medical management of BPPV. Home canalith repositioning maneuver may be effective for preventing pc-BPPV recurrence [22]. Selftreatment after Epley maneuver was proved to be efficient in pcBPPV management [21]. In this study, the mean age of the control group was 55.4 5.5 and the mean age of the study group was 54.4 6.5 years, which was correlating to literature [29,30]. Also, the sex distribution for females and males in the control group and the study group was correlating with research reports [29]. The study concluded that the right side is affected more in the control and the study group which was reported by Von Brevern et al. [31]. In the present study, it was concluded that up to 75% of patients were cured after the first session, 90% after the second session, and 100% after the third session in both the control and the study groups. A randomized study, after a single session Table 2 Number of cured cases of BPPV for control and study groups.
Fig. 1. The total no. of patients and patients completed the study for the control and study groups.
Number of cured cases of BPPV
Control group
Study group
P
Cured cases in first session Cured cases in second session Cured cases in third session Total number of BPPV
94 (77.7%) 13 (10.7%) 14 (11.6%) 121
109 (75.7%) 17 (11.8%) 18 (12.5%) 144
0.7 0.78 0.8
Please cite this article in press as: Ismail EI, et al. Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2018.02.005
G Model
ANL-2421; No. of Pages 5 E.I. Ismail et al. / Auris Nasus Larynx xxx (2018) xxx–xxx
4
Table 3 The recurrence of BPPV for control and study groups. Recurrence of BPPV
Control group (total number = 121)
Study group (total number = 144)
P-Value
First year
First follow up Second follow up Third follow up
15 (12.4%) 10 (8.3%) 8 (6.6%)
2 (1.4%) 2 (1.4%) 1 (0.7%)
<0.001* 0.01* 0.01*
Second year
First follow up Second follow up Third follow up
5 (4.1%) 3 (2.5%) 3 (2.5%)
1 (0.7%) 1 (0.7%) 1 (0.7%)
0.096 0.33 0.33
Third year
First follow up Second follow up Third follow up
3 (2.5%) 1 (0.8%) 1 (0.8%)
1 (0.7%) 0 (0%) 1 (0.7%)
0.33 0.45 1.00
Fourth year
First follow up Second follow up Third follow up
2 (1.7%) 0 (0%) 1 (0.8%)
1 (0.7%) 0 (0%) 1 (0.7%)
0.6 NA 1.00
Fifth year
First follow up Second follow up Third follow up
1 (0.8%) 2 (1.7%) 0 (0%)
1 (0.7%) 0 (0%) 0 (0%)
1.00 0.2 NA
with either Semont’s or Epley maneuvers, 90% of patients were either improved or cured [32]. Epley himself recorded more than 90% success rate following a single treatment session. In another study of 25 BPPV patients, 18 (72%) cured immediately after the Epley maneuver and 23 (92%) patients cured at the first week of follow-up. The last two patients recovered from vertigo during the second and the third followup [33]. The recurrence rate of pc-BPPV in the control group was 27% in the first year, 36% in next two years, 40% within three years, 42% within four years and 44% in first five years of the follow up. These results are in line with Hain et al. [16]. They reported that 40% of patients successfully recovered with the canalith repositioning procedure redevelop BPPV within the first two years. Also, Brandt et al. [17] recorded 50% recurrence in a mean 10 years follow-up. Epley argued that the mechanism of canalolithiasis that causes nystagmus in the posterior canal particle must produce a critical mass in the dependent part of the posterior semicircular canal [34,35]. In our study, the recorded recurrence of pc-BPPV of affected side in the study group was only 13 patients (9%) all over 60 months with highest recurrence rate occurred in first two years (8 patients). This can be speculated by repetition of PRM every week frequently remove and push the otoconia particles to utricle and prevent it from formation of large masses to reach “a critical mass” to induce recurrence of BPPV. The otoconia dissolved frequently when reaching the urticle. So, there is no critical mass formation to develop other variant of BPPV or recur in the same canal. Brandt–Daroff exercise used by Helminiski et al. [22] failed to prevent the recurrence of BPPV as this maneuver is a habituation exercise rather than a repositioning Maneuver. On the other hand, the recurrence of pc-BPPV in some cases in our study can be explained by those patients who performed particle repositioning maneuver irregularly and in an imperfect way or those who have highly recurrent cases of pc-BPPV. The study suggests and recommends a daily routine home PRM for those patients for at least two years with monthly follow up.
The study also concluded that the effectiveness of home PRM was evident in the first year follow up in the study group where the highest recurrence pc-BPPV in the control group was reported in the first year also. From these points, home PRM is recommended once weekly for one year at least in pc-BPPV. 5. Conclusion The study concludes that home particle repositioning maneuver can effectively prevent the recurrence of pc-BPPV based on empirical data. Particle repositioning maneuver proved to be more successful in minimizing the recurrence of the disease in the study group than the control group. Accordingly, the study recommends home PRM for at least one year in pc-BPPV. Author’s contribution Elshahat Ibrahem Ismail, Ashraf Elsayed Morgan, Mohamed Moustafa Abdeltawwab: Clinical data collection, analysis and writing of the paper. Acknowledgments Several people helped me with the collection of data and providing advice for statistical analyses and they are all thanked for their contributions. My heart-felt thanks to the staff at the Audiology Unit of the ENT Department at our University Hospital. References [1] Mizukoshi K, Watanabe Y, Shojaku H, Okubo J, Watanabe I. Epidemiological studies on benign paroxysmal positional vertigo in Japan. Acta Otolaryngol Suppl 1988;447:67–72. [2] Von Brevern M, Radtke A, Lezius F, Feldmann M, Ziese T, Lempert T, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry 2007;78:710–5.
Please cite this article in press as: Ismail EI, et al. Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2018.02.005
G Model
ANL-2421; No. of Pages 5 E.I. Ismail et al. / Auris Nasus Larynx xxx (2018) xxx–xxx [3] Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Phys Ther 2010;90:663–78. [4] Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:2067–74. [5] Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med 2014;370:1138–47. [6] Chang W-C, Yang Y-R, Hsu L-C, Chern CM, Wang RY. Balance improvement in patients with benign paroxysmal positional vertigo. Clin Rehabil 2008;22(4):338–47. [7] Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003;169(7):681–93. [8] Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Proc R Soc Med 1952;45(6):341–54. [9] Marom T, Oron Y, Watad W, Levy D, Roth Y. Revisiting benign paroxysmal positional vertigo pathophysiology. Am J Otolaryngol 2009;30(4):250–5. [10] Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:2067–74. [11] Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2008;139:S47–81. [12] Polensek SH, Tusa RJ, Sterk CE. The challenges of managing vestibular disorders: a qualitative study of clinicians’ experiences associated with low referral rates for vestibular rehabilitation. Int J Clin Pract 2009;63:1604–12. [13] Polensek SH, Tusa R. Unnecessary diagnostic tests often obtained for benign paroxysmal positional vertigo. Med Sci Monit 2009;15:MT89– 94. [14] Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1980;88:599–605. [15] Parnes LS, Price-Jones RG. Particle repositioning maneuver for benign paroxysmal positional vertigo. J Otol Rhinol Laryngol 1993;102:325– 31. [16] Hain TC, Helminski JO, Reis IL, Uddin MK. Vibration does not improve results of the canalith repositioning procedure. Arch Otolaryngol Head Neck Surg 2000;126:617–22. [17] Brandt T, Huppert D, Hecht J, Karch C, Strupp M. Benign paroxysmal positional vertigo: a long-term Follow-up (6–17 years) of 125 patients. Acta Otolaryngol. 2006;126:160–3. [18] Prime-Espada MP, De Diego-Sastre JI, Perez-Fenandez Elia. Metaanalysis on the efficacy of Epley’s Maneuver in benign paroxysmal positional vertigo. Neurologı´a 2010;25(5):295–9.
5
[19] Radtke A, Neuhauser H, von Brevern M, Lempert T. A modified Epley’s procedure for self-treatment of benign paroxysmal positional vertigo. Neurology 1999;53:1358–60. [20] Radtke A, von Brevern M, Tiel-Wilck K, Mainz-Perchalla A, Neuhauser H, Lempert T. Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure. Neurology 2004;63:150–2. [21] Tanimoto H, Doi K, Katata K, Nibu KI. Self-treatment for benign paroxysmal positional vertigo of the posterior semicircular canal. Neurology 2005;65(8):1299–300. [22] Helminski JO, Janssen I, Kotaspouikis D, Kovacs K, Sheldon P, McQueen K, et al. Strategies to prevent recurrence of benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg 2005;131:344–8. [23] Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med 1999;34:1590–6. [24] Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399–404. [25] Del Rio M, Arriaga MA. Benign positional vertigo: prognostic factors. Otolaryngol Head Neck Surg 2004;130:426–9. [26] Sakaida M, Takeuchi K, Ishinaga H, Adachi M, Majima Y. Long-term outcome of benign paroxysmal positional vertigo. Neurology 2003;60:1532–4. [27] Seok JI, Lee HM, Yoo JH, Lee DK. Residual dizziness after successful repositioning treatment in patients with benign paroxysmal positional vertigo. J Clin Neurol 2008;4:107–10. [28] Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:2067–74. [29] Baloh RW, Honrubia V, Jacobson V. Benign positional vertigo: clinical and oculographic features in 240 cases. Neurology 1987;37(3):371–8. [30] Marciano E, Marcelli V. Postural restrictions in labyrintholithiasis. Eur Arch Otorhinolaryngol 2002;259(5):262–5. [31] Von Brevern M, Seelig T, Neuhauser H, Lempert T. Benign paroxysmal positional vertigo predominantly affects the right labyrinth. J Neurol Neurosurg Psychiatry 2004;75(10):1487–8. [32] 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(4):450–4. [33] Gaur S, Awasthi SK, Bhadouriya SKS, Saxena R, Pathak VR, Bisht M. Efficacy of Epley’s maneuver in treatment of BPPV patients: prospective observational study. Int J Otolaryngol 2015;1–5. [34] Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1980;88:599–605. [35] Epley JM. Human experience with canalith repositioning maneuvers. Ann N Y Acad Sci 2001;942:300–5.
Please cite this article in press as: Ismail EI, et al. Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV. Auris Nasus Larynx (2018), https://doi.org/10.1016/j.anl.2018.02.005