www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Is
it
important
to
repeat
the
positioning
maneuver
after
the
treatment
for
benign
paroxysmal
positional
vertigo?
夽
,
夽夽
Alexandra
Kolontai
de
Sousa
Oliveira
a,∗,
Fabio
Akira
Suzuki
b,c,
Leticia
Boari
c,daInstitutodeAssistênciaMédicaaoServidorPublicoEstadualdeSãoPaulo,SãoPaulo,SP,Brazil bUniversidadeFederaldeSãoPaulo(UNIFESP),SãoPaulo,SP,Brazil
cInstitutodeAssistênciaMédicaaoServidorPúblicoEstadualdeSãoPaulo,SãoPaulo,SP,Brazil dMedicalSciencesSchool,SantaCasadeSãoPaulo,SãoPaulo,SP,Brazil
Received8December2013;accepted20June2014 Availableonline29December2014
KEYWORDS
Vertigo;
Treatmentoutcome; Semicircularcanals
Abstract
Introduction:Benignparoxysmalpositionalvertigo(BPPV)isthemostcommoncauseof periph-eralvestibulardysfunction.
Objective: ToassesswhethertheperformanceoftheDix---HallpikemaneuveraftertheEpley positioningmaneuverhasprognosticvalueintheevolutionofunilateralductolithiasisof pos-teriorsemicircularcanal.
Methods:Aprospectivecohortstudyinmonitoredpatientsatotoneurologyambulatorywitha diagnosisofBPPV;theyweresubmittedtothetherapeuticmaneuverandthentoaretestin ordertoevaluatethetreatmenteffectiveness;allcaseswerereassessedoneweeklaterand theretestprognosticvaluewasevaluated.
Results:Asampleof64patientswhich47belongingtonegativeretestgroupand17belongingto positiveretest.Performedthemaneuverinallpatients,theretestpresented51.85%sensitivity, 91.89%specificity,82.35%positivepredictivevalueand72.34%negativepredictivevalue. Conclusion: Thestudyshowsthatdoingtheretestafterrepositioningmaneuverofparticlesin BPPViseffectual,sinceithashighspecificity.
© 2014Associac¸ãoBrasileira de Otorrinolaringologiae CirurgiaCérvico-Facial. Publishedby ElsevierEditoraLtda.Allrightsreserved.
夽 Pleasecitethisarticleas:OliveiraAK,SuzukiFA,BoariL.Isitimportanttorepeatthepositioningmaneuverafterthetreatmentfor
benignparoxysmalpositionalvertigo?BrazJOtorhinolaryngol.2015;81:197---201.
夽夽
Institution:InstitutodeAssistênciaMedicaaoServidorPúblicoEstadualdeSãoPaulo,SãoPaulo,SP,Brasil.
∗Correspondingauthor.
E-mail:[email protected](A.K.d.S.Oliveira).
http://dx.doi.org/10.1016/j.bjorl.2014.06.002
PALAVRAS-CHAVE
Vertigem; Resultadode tratamento;
Canaissemicirculares
Éimportanterealizaroretestedamanobradeposicionamentoapósotratamentoda vertigemposturalparoxísticabenigna?
Resumo
Introduc¸ão:A vertigem posicional paroxística benigna (VPPB) é a causa mais comum de disfunc¸ãovestibularperiférica.
Objetivo:Avaliarsearealizac¸ãodoretestedeDix-Hallpikeapósamanobradeposicionamento deEpleytemvalorprognósticonaevoluc¸ãodavertigemposicionaldaductolitíaseparoxística benignadecanalsemicircularposteriorunilateral.
Método: Estudoprospectivodotipocoortedepacientesemacompanhamentonoambulatório deotoneurologiacomdiagnósticodeVPPB;foramsubmetidosamanobraterapêuticae poste-riormenteaoretesteparaavaliaraeficáciadotratamento;todososcasosforamreavaliados emumasemanaeanalisadoovalorprognosticodoreteste.
Resultados: Amostrade64pacientes,47dogruporetestenegativoe17doretestepositivo; realizada manobra de Epley em todos os pacientes. Oreteste apresentou sensibilidade de 51,85%;especificidadede91,89%;valorpreditivopositivode82,35%evalorpreditivonegativo de72,34%.
Conclusão:Oestudomostraqueéválidorealizaroretesteapósamanobradereposicionamento departículasnaVPPB,vistoquepossuialtaespecificidade.
©2014Associac¸ãoBrasileira deOtorrinolaringologiaeCirurgiaCérvico-Facial.Publicadopor ElsevierEditoraLtda.Todososdireitosreservados.
Introduction
BPPVis caused by otoconial debris coming fromutricular macula,movingtooneormoresemicircularcanalsand mis-takenlystimulatingtheampullarycrest.1
Positionalnystagmusisessentialtoestablishthe diagno-sisof BPPV.Through thecharacteristicsof thenystagmus, itispossibletoidentifytheaffectedsemicircularcanaland damagedlabyrinth,and adistinctionbetween cupulolithi-asis and canalithiasis also can be drawn. Thus, the most appropriatetreatmentcanbeimplemented.2
Performing specific maneuversfor otolith repositioning inthetreatmentofBPPVhasattractedspecialinterest,due toitseaseofapplicabilityandgoodresults.Suchmaneuvers areaimedatremovingtheotoconialdebrissituatedintothe ductsor semicircular canalcupulae toward the vestibule, followinganampulifugalmovement.3 Consideringthatthe
debrisscatteredthroughtheendolymphhasahigherdensity thanthatof thesurroundingendolymph,it canbemoved noninvasivelybymeansofasequenceoforientationsofthe headrelativetogravity.4
The literature informs us that there is variability in theresultsonthenumberofrepositioningmaneuvers nec-essary for the abolition of positional nystagmus.5 Some
studiessuggestanaverageof1.23maneuvers,6others,1.36
maneuvers,7andinamorerecentstudy,1.53maneuvers.4
Inclinicalpractice,somedoctorsperformaDix---Hallpike maneuver retest shortly after otolith repositioning, as a strategy to predict treatment success. However, there is nodatashowing whetherthis assessment is valuableasa routine.
Given the paucity of data in the literature, this study aimed to assess whether the implementation of a retest fortheDix---Hallpikemaneuver afterEpleypositioninghad prognostic value in the evolution of benign paroxysmal
positionalvertigobyunilateralposteriorsemicircularcanal canalolithiasis.
Methods
Thisisaprospectivecohortstudy,approvedbytheResearch EthicsCommittee(opinionnumber200,813),whichincluded 64 patients from the otoneurology department each with clinical picture characteristic of benign paroxysmal posi-tional vertigo (BPPV). All study participants signed an informedconsent.
Patientswithimpairmentofthelateraloranterior semi-circular canal, nystagmus lasting for more than a minute (whichcharacterizescupulolithiasis),signsorsymptomsof centralnervoussysteminvolvement,bilateralinvolvement of posterior semicircular canal, physical restrictions that preventedperformingthediagnosticortherapeutic maneu-ver,andpatientswithonlydizzinessandwithnopositional nystagmusonthediagnosticmaneuverwereexcludedfrom thestudy.Patientswhowereusinganti-vertigodrugsupto3 daysandbenzodiazepinesupto5daysbeforethestudywere alsoexcludedfromthestudy.Patientsdiagnosedwith unilat-eralposteriorcanalBPPV,whohaddizzinessandpositional nystagmuswithlatency duration<1minandfatigabilityto Dix---Hallpikemaneuverwereincluded.
Atthefirstvisit,anorientedhistory,acompletephysical otorhinolaryngologic andotoneurologic examinationand a positioningnystagmustestwereperformed.Allcaseswere evaluatedbythesameexaminer.Thediagnosticmaneuver performed was the Dix---Hallpike test: in the sitting posi-tion,thepatienthastheheadturned 45◦ toward theside whichtobetested;andthenthepatientislaiddown back-wards. At the endof the maneuver, the patient’s head is slightlyextended andturned towardthetestedside.1The
Table1 Comparisonbetweenretestgroupsregardingthenumericalvariablesofthestudy.
Retest Mann---Whitneytest(p) Result
0---positive 1---negative
Age
Mean 62.4 58.7
Standarddeviation 15.6 12.5 0.382 0=1
N 17 47
Numberofmaneuvers
Mean 1.88 1.46
Standarddeviation 0.60 0.89 0.003 0>1
N 17 46
positionofvertigoand/ornystagmus,accordingto informa-tionobtainedfromeachpatient.
After identifying the semicircular canal involved (by triggering nystagmus position and direction), all patients underwenttheEpleyrepositioningmaneuver.Inthis maneu-ver, the patient is placed in the Dix---Hallpike maneuver position,which triggerspositional nystagmus, maintaining thispositionfor1---2min.Next,thepatient’sheadisslowly driven, withthe aid of the handsof the examiner, up to aninclinationof 45◦ toward theoppositeside; duringthis
step,thepatientmoveshis/herbodyinthesamedirection and way,assuming a lateral decubitus position.The head movementinthesamedirectionandwaycontinuesuntilthe patient’s noseis pointing to45◦ downwards. This position
is maintainedby thepatient for another1---2min.Finally, thepatientreturnsslowlytothesittingposition,facingthe oppositesidefromthebeginningofthemaneuver.7
Afterabout10minoftheprocedure,thepatientwas sub-jectedtotheretest,whichconsistsinanotherpositioning maneuver (Dix---Hallpike). The retest was considered pos-itive only if the nystagmus was present in the triggering position.Theretestwasconsiderednegativeifthepatient wasasymptomatic,orevenifrecountingdizzinesswithout clinicalevidenceofnystagmus.
The patientsweresubdivided intotwogroups: groupI, patients withnegative retest;and group II, patients with positive retest. The patients were evaluated for age and numberofmaneuversrequired.
Oneweekaftertherepositioningmaneuver,allpatients were reassessed and submitted again to Dix---Hallpike maneuver, to evaluate whether or not an improvement of their clinical condition occurred; improvement was
consideredcomplete ifthepatientwasasymptomaticand hadnonystagmusduringthemaneuver.
Statistical analysis was performed with the program SPSSfor Windows---version 10.0;numericdata were pre-sentedasmean±standard deviation and categoricaldata aspercentages.Thecomparisonbetweenthetwogroupsof numericaldatawasperformedusingtheMann---Whitneytest and,for categorical data, the chi-squared test was used, witha significancelevel setat p<0.05. Retestsensitivity, specificity,positivepredictivevalueandnegativepredictive valueretestwerecalculated.
Results
Thestudy sample consisted of64 patientsdiagnosed with BPPV,47(73.4%)intheretest-negativegroupand17(26.5%) intheretest-positivegroup.Themeanagewas58.7years (SD±12.5)forgroupIand62.4years(SD±15.6)forgroup II.MostpatientswerefemaleinbothgroupI(55.3%)andin groupII(58.8%)(Tables1and2).
The meannumber of maneuversrequired toachieve a favorableresult withcomplete improvement in our over-allsample was1.56; group Ineeded 1.46 maneuversand groupII, 1.88 maneuvers,a statisticallysignificant differ-ence(p=0.003).
Considering all patients, the right side was the more affected (53.1% of the entire sample); there was no sta-tisticallysignificantdifferencebetweengroups.
Considering the Dix---Hallpike maneuver as the gold standard,theretestshowedasensitivityof51.85%; speci-ficity of 91.89%; positive predictive value of 82.35% and
Table2 Comparisonbetweenretestgroupsregardingtheposteriorsemicircularcanalinvolved.
Retest Total
0---positive 1---negative n %
n % n %
Affectedcanal
0---right 12 70.6% 22 46.8% 34 53.1%
1---left 5 29.4% 25 53.2% 30 46.9%
Total 17 100.0% 47 100.0% 64 100.0%
Table3 Sensitivity,specificity,positivepredictivevalueandnegativepredictivevalueoftheretest.
Sensibility Specificity Positivepredictivevalue Negativepredictivevalue
Retest 51.85% 91.89% 82.35% 72.34%
negativepredictivevalueof72.34%.Thefalse-negativerate was48.15%andthefalse-positiveratewas8.11%(Table3).
Discussion
Overtheyears,therehavebeenattemptstopredictthe suc-cessofmaneuversfortreatmentofBPPV;incasesofBPPV oftheposteriorsemicircularcanal,theresultsof reposition-ingcanbepredictedbythecharacteristics oftheinduced nystagmusduring theEpley maneuver; the importanceof thepatternofnystagmusinthesecondpositionoftheEpley maneuver (90◦ contralateral to the initial position of the head)is well recognized.In thisposition, nystagmuswith characteristicssimilartotheoriginalpositionwouldsuggest asuccessfulrepositioningofparticles.8
Repetitivetherapeuticmaneuversinasinglesessionhave beenproposed,untilnystagmuswasnolongerseenoruntil vertigo and nystagmus disappearance; some authors sug-gestthatthetreatmentofBPPVthroughrepetitionofEpley maneuversina singlesessionproved tobemore efficient thanasinglemaneuverpersession.9
The repetition of the Dix---Hallpike (retest) maneuver aftertheEpleymaneuver,inanattempttopredictthe suc-cessoftreatment,hasnotbeendescribedintheliterature. Itis assumedthat,iftheretestresultspositive,thereisa greatlikelihoodofpatientreturninginthenextweekwith noresolutionoftheproblem.
Inthisstudy,patientsweredividedintotwogroups:group Iand group II, withnegative and positive retest, respec-tively;thesegroupsshowedhomogeneityregardingsexand age. There was a predominance of females in this sam-ple,witha mean age of 59.7 years.Several studies have suggestedahigherincidenceinwomen,9---11 butinyounger
patientsandin thosecasessecondarytotrauma,the inci-dencemaybeequalbetweenmenandwomen.Theageof onsetfalls mostcommonly between thefifth and seventh decades.10---12 Theelderlyareinincreasedrisk;astudyina
populationof elderlypatients undergoinggeriatric assess-mentforcomplaintsunrelatedtoequilibriumfoundthat9% hadundiagnosedBPPV.13
Themeannumberofmaneuversofthesamplewas1.56; ingeneralliterature,onaverage 1.23maneuvers14;1.366;
1.315; and 1.3816 were observed. According to Vrabec,7
thenumber of repositioning maneuvers needed toinduce BPPVremission is variable, and multiple treatments may beneededformorethanonethirdofpatients.10 Basedon
thesedata,conductingtheretestaftertheEpleymaneuver wasnotaharmfulprocedure,sincetherewasnoincreasein theaveragenumberofmaneuversrequired.Comparingthe numberof maneuvers,withtheuse ofthe Mann---Whitney test between groups there was a statistically significant greater number of maneuvers in group II; this result was
expected, given that, theoretically, these patients would nothaveagoodresponsewithasinglemaneuver.
The right posterior semicircular canal was the most affectedinthispopulation;severalstudieshaveshownthat the right ear is predominantly affected by BPPV. It was demonstratedthatthesideaffectedbyBPPVcorrelateswith thepreferredpositiononthebed.Intherightlateral decubi-tusposition,theopeningsofbothposteriorandlateralright channelsareinalowerposition,whichfacilitatestheentry of heavy particles fromthe utricle.Thus,one can specu-latethatBPPVpredominantlyinvolvestherightear,because manypeopleprefertosleepontherightside,possiblydue toanaggingfeelingof heartbeatswhenlyingontheleft side.11
Proceduretolerancewasconsideredgoodinbothgroups; only onepatienthad nauseaandvomitswhile performing the retest. Anotherstudy, which conductedseveral Epley maneuvers in the same session, also demonstrated good tolerability;transientnauseaandimbalanceweretheonly symptomsimmediatelyreported.17
Inall64patientsinthepresentstudy,nocaseof conver-sionfromposteriortoanteriorhorizontalsemicircularcanal wasobserved, evenwhen theDix---Hallpike maneuver had beenrepeatedinthesameday;onestudyobserved approx-imately15.9%conversiontoanotherchannel,andallcases occurred in patients who underwent a new Dix---Hallpike maneuver.Theseauthorssuggestthataperiodoftimeinthe verticalpositionwouldberequiredtoallowthatthosenot fullyrepositionedparticlestomoveoutofthecommoncrus area,reducingtheriskofre-entry;thus,fortheseauthors, a15-minintervalwouldreducesubstantiallytheincidence of subsequent reentry.12 In ourstudy, arange of
approxi-mately 10min between theEpley maneuverand retesting wasallowed,withnocaseofconversiontootherchannels. Inourstudy,theretestshowedlowsensitivity(51.85%) andhighspecificity(91.89%),apositivepredictivevalueof 82.35% and a negative predictive value of 72.34%. Thus, if the retest has a positive result, one can assume that theparticlesofcalciumcarbonatewerenotproperly repo-sitioned. This finding demonstrates the importance of a positive retest,sinceit willhelp todifferentiate patients who areunlikely to have a quick resolution of BPPV, and thus willdepend ona largernumberof maneuvers.Thus, in cases of positive retest,a newrepositioning maneuver canbeperformedinthesamevisit.Ontheotherhand,ifa negativeresultoftheretestwasobtained,onecannotinfer thatthepatientwillreturnwithorwithoutimprovementof his/hercondition.
Thefindingthat anegativeretest doesnot completely accurately predict the success of BPPV treatment can be explainedbyseveralreasons.
Another hypothesis would be theincomplete returnof otoconialdebrisintothevestibule,leavingsomeparticlesin theposteriorcanal,whichcouldnotbesufficienttoreach thethresholdandtriggernystagmusand/orvertigo (nega-tiveretest).Inthefollowingweek,thesefragmentswould form new clusters, again achieving the required thresh-oldtogeneratevertigowithnystagmus.Otoconialparticles werestudiedintraoperatively,showingthatitisthebinding of those smallfragments that will forma large conglom-erate. Thus, this conglomerate may break up during the Epleymaneuver.Someoftheparticleswouldflowintothe utricle, and the others would flow back into the poste-rior canal ampulla.15 The remaining debris would not be
sufficienttodivertthecupuleandreachtheneeded thresh-old level to stimulate the vestibular-ocular route.16 The
calciumcarbonate particles can beclustered into various sizes,ordispersedthroughthesemicircularcanal. Presum-ably, patients requiring additional maneuvers have more dispersedparticles intosmaller masses.These massesare removedmoreslowlythroughrepeatedmaneuvers;and,at eachmaneuver,thesemassesprobablybecomeevenmore widespreadintheutricle.Thus,theymaynotbesufficient totriggerthenystagmus.
Arateof8.1%false-positives,i.e.,patientswhoshowed apositiveretestbutwerefoundasymptomaticthe follow-ingweek,wasfound.Thesepatientsmayhavepresenteda spontaneousremissioninthistimeinterval,resultingmainly fromtheabilityoftheendolymphtodissolveotoconia dis-placedbyitslowionizedcalciumcontent(20mM),resulting inthedisappearanceofBPPVsymptoms.18Thus,duringthe
Epleymaneuver,therewouldbeafragmentationofotoconia andalargerportionwouldhavestayed intheduct, trigg-ering nystagmus anddizziness while the retest wasbeing conducted;inthefollowingweek,thismaterialwouldhave beenreabsorbedbyendolymph.
Conclusion
Thestudyshowstheimportanceofconductingaretestafter amaneuverofparticlerepositioninginpatientswithBPPV, sincethisprocedurehashighspecificity.Thus,whenfaced withapatientwithapositiveretest,onecaninferthatthere isagreatlikelihoodofthepatientreturninginthenextweek withnoimprovement;andonecanalsosuggestperforming moreEpleymaneuversinthesamesession,whentheretest comespositive.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
References
1.EpleyJM.Thecanalithrepositioningprocedurefor treatment ofbenignparoxysmalpositionalvertigo.OtolaryngolHeadNeck Surg.1992;107:399---404.
2.KesslerN,LuragoVM,RasqueJR,BorgesLR,Gananc¸aCF, Cam-posCAH.Vertigemposicionalparoxísticabenignaempacientes submetidosàcirurgiaotológica.ActaORL.2006;24:6---9.
3.SemontA,FreyssG,VitteE.CuringtheBPPVwithaliberatory maneuver.AdvOtorhinolaryngol.1988;106:290---3.
4.DoriguetoRS,Gananc¸aMM,Gananc¸aFF.Quantasmanobrassão necessáriasparaabolironistagmonavertigemposicional parox-ísticabenigna.BrazJOtorhinolaryngol.2005;71:769---75.
5.WolfJS,BoyevKP,KestutisP,ManokeyBJ,MattoxDE.Success ofmodifiedEpleymaneuverintreatingbenignparoxysmal posi-tionalvertigo.Laryngoscope.1999;109:900---3.
6.MaciasJD,EllensohnA,MassingaleS,GerkinR.Vibrationwith canalith repositioning maneuver: a prospective randomized studytodetermineefficacy.Laryngoscope.2004;114:1011---4.
7.VrabecJT.Benignparoxysmalvertigoandotolithrepositioning. ArchOtolaryngolHeadNeckSurg.1998;124:223---5.
8.OhHJ,KimJS,HanBI,LimJG.Predictingasuccessful treat-mentinposteriorcanalbenignparoxysmalpositionalvertigo. Neurology.2007;68:1219---22.
9.Korn GP, Dorigueto RS, Gananc¸a MM, Caovilla HH. Epley’s maneuverinthesamesessioninbenignpositionalparoxysmal vertigo.BrazJOtorhinolaryngol.2007;73:533---9.
10.Dorigueto RS, Gananc¸a MM, Gananc¸a FF. The number of procedures required to eliminate positioning nystagmus in benignparoxysmalpositionalvertigo.BrazJOtorhinolaryngol. 2005;71:769---75.
11.Von Brevern M, Seelig T, Neuhauser H, Lempert T. Benign paroxysmalpositionalvertigopredominantlyaffectstheright labyrinth.JNeurolNeurosurgPsychiatry.2004;75:1487---8.
12.FosterCA,ZaccaroK,StrongD.Canalconversionandreentry: ariskofDix---Hallpikeduringcanalithrepositioningprocedures. OtolNeurotol.2012;33:199---203.
13.Parnes LS, Agrawal SK, Atlas J. Diagnosis and manage-mentof benignparoxysmal positional vertigo(BPPV). CMAJ. 2003;169:681---93.
14.Haynes DS, Resser JR, Labadie RF, Girasole CR, Kovach BT, SchekerLE,etal.Treatmentofbenignpositionalvertigousing theSemontmaneuver:efficacyinpatientspresentingwithout nystagmus.Laryngoscope.2002;112:796---801.
15.ParnesLS,RobichaudJ.Furtherobservations duringthe par-ticlerepositioningmaneuverforbenignparoxysmalpositional vertigo.OtolaryngolHeadNeckSurg.1997;116:238---43.
16.Pollak L, Davies RA, LuxonLL. Effectiveness of theparticle repositioningmaneuverinbenignparoxysmalpositionalvertigo withandwithoutadditionalvestibularpathology.OtolNeurotol. 2002;23:79---83.
17.GordonCR, GadothN.Repeatedvssinglephysicalmaneuver inbenignparoxysmalpositional vertigo.ActaNeurolSacand. 2004;110:166---9.
