The Clinical Response Time of Epley Maneuvers for Treatment of BPPV: A Hospital Based Study

Abstract

The Epley maneuver is one of the most effective canalith repositioning procedures for treatment of posterior canal benign paroxysmal positional vertigo. It was found that response to BPPV varies with various factors such as types, single versus multiple canals BPPV, single or repeated cycles of head maneuvers in each session and duration of follow up of patient. Furthermore, less uniform result exists after treatment of BPPV among studies. Hence, the present study was taken with aim to investigate “The clinical response time of Epley maneuvers in treatment of BPPV: A Hospital Based Study. A total of 132 patients were included in study with age ranging from 30 to 50 years These patient visited department of ENT from 2019 to 2020 with complaint of vertigo. The subjective balancing assessments along with Dix-Hallpike maneuver were done and dizziness handicap inventory were administrated for screening of BPPV. The patients, who were diagnosed as posterior canal BPPV, were treated with Canal repositioning procedure i.e. Epley’s Maneuvers during the initial visit. In addition, the same maneuvers were repeated after 1 week of sequential sessions if the patient reported no benefit or partial benefit from first session until the patient became asymptomatic and Dix-Hallpike maneuver were negative. The total number of sessions of Epley maneuver required by each patient was recorded. The findings of present study suggested that 37.69% of cases with posterior canal BPPV were asymptomatic after first CRP session of Epleys maneuver whereas repeated sessions were required in 61.52% of cases of BPPV and 0.76% of cases showed no response to repeated CRP up to 6 months. BPPV involving posterior canals may be easily detected by position test with good response to Epley maneuver. Short-term and long term control of symptoms of unilateral posterior SCC through this easy and simple procedure can be achieved. This cost effective approach requires proper trained and committed professionals. The repeated session may be required as complete recovery may not be immediate. Sometimes partial response can be due to canal switching during BPPV Hence, it is necessary to counsel the patient regarding the importance of follow-up.

Introduction

The Epley maneuver is one of the most effective canalith repositioning procedures (CRP) for treatment of posterior canal Benign paroxysmal positional vertigo (BPPV) [1]. BPPV is benign peripheral disorder of vestibular system and episodic vertigo is most common symptom with duration of vertigo of less than 30 s [1] and vertigo is self -limiting [2]. The term benign means it is not life-threatening, Paroxysmal means it comes in sudden, brief spells, Positional means it gets triggered by certain head positions or movements and vertigo means a false spinning sensation [1]. In most patients with BPPV, the otoconia are dislodged from their usual position and migrate over time into semicircular canals (Canalithiasis) in which posterior canal BPPV is most common among three semicircular canal because of it’s anatomical orientation relative to gravity [1, 2]. The free floating otoconia particles falls to the lowest part of posterior SCC under the influence of gravity thus giving false information of angular acceleration during changes in head position with respect to gravity [1, 2]. The prevalence of BPPV is 10.7–140/100,000 population and especially seen in the elderly [3], furthermore, the prevalence of BPPV is higher in females than males with ratio of 2:1 [4]. Previous studies reported that proper case history and eye-findings during positional testing i.e. Dix-Hallpike maneuver are the gold standards for diagnosing BPPV [1, 5]. It was also found that treatment response of BPPV depends on various factors such as type, single versus multiple canals BPPV. Response depends on single or multiple cycles of head maneuvers in each session and duration of follow up [6, 7]. Furthermore, less uniform results are reported after treatment of BPPV among various studies [6–10]. Hence, the present study was done to evaluate “The clinical response time of Epley maneuvers for treatment of BPPV”.

Method

The total of 132 patients with complaint of vertigo who visited department of ENT from 2019 to 2020 were included in this study after ruling other diseases like any neurological abnormality, ophthalmic disorder, hearing disorders like acoustic neuroma, Meniere’s diseases etc. Metabolic diseases, kidney diseases, diabetes, cerebellar disorder, cardio vascular disorders, head and neck trauma, central vestibular disorders such as vertebrobasilar insufficiency, cervical spondylosis, migraine etc. were excluded. The patients who were taking vestibular toxic drugs and alcohol were also excluded. The Patients with continuous and atypical nystagmus were also excluded. The patient who had history of transient vertigo associated with changing head position from 1 day to 2 years and controlled blood pressure were included in this study. Each patient was instructed to discontinue all anti-vertigo drugs or sedative medication 48 h before vestibular examination and CRP. The blood pressure was also tested before examination. The proper case history, otoscopic examination, audiological evaluation such as pure tone audiometry, impedance audiometry, OAE and subjective vestibular evaluation were done for differential diagnosis between peripheral versus central vestibular disorders. The behavior balancing assessment i.e. sharpened Romberg test, Fukuda stepping (Unterberger’s) test, tandem walk, dysdiadochokinesia test, past pointing (finger-to-nose) test, heel to knee test, grasp test, subjective visual vertical (SVV) and subjective visual horizontal (SVH) were done. All the patients had classical findings of BPPV based on history of episodic vertigo (< 30 s) associated with changes in the position of the head, confirmed by subjective examination i.e. Dix-Hallpike maneuver [5] for posterior canal BPPV and supine roll test for diagnosis of horizontal canal BPPV. Bilateral posterior canal BPPV were confirmed when Dix-Hallpike test was positive on the both sides. Horizontal canal BPPV were confirmed when supine roll test was positive. Dizziness handicap inventory (DHI) was administrated for screening of BPPV [11] and to check the physical, functional and/or emotional change before and after the CRP. Previous Studies reported that DHI is very useful as self assessment inventory for subjective measures of patient’s perception to handicap due to dizziness [11–13]. The patients, who were diagnosed as posterior canal BPPV were treated with CRP i.e. Epley’s maneuvers during the initial visit. In addition, the same maneuvers were repeated after 1 week of sequential sessions if the patient reported no benefit or partial benefit till Dix-Hallpike maneuver were negative. The total number of sessions of Epley maneuver required by each patient was recorded. Supine roll over test was administered for diagnosis of horizontal canal BPPV and forced prolong position maneuver were used for treatment of horizontal canal BPPV (Fig. 1).

Fig. 1.

Indicate otoconia particle distribution of posterior semi-circular canal BPPV

Result

Out of total 132 case included in study 130 cases were diagnosed as posterior canal BPPV and 02 cases were diagnosed as horizontal canal BPPV (Fig. 2). In 130 cases of posterior canal BPPV, 129 cases were found as unilateral and only 01 case had bilateral BPPV. The subjective evaluation findings of Romberg test were positive in 98% of cases, 58% of cases showed deviation (> 45°) and 42% of cases showed no deviation but were not stable in Fukuda stepping test. Tandom gait test was affected only 16% of cases, 5% cases had positive dysdiadochokinesia, 2% cases had positive past pointing and 68% of cases had positive SVV and SVH test. Heel to knee test and grasp test were appropriate for all the cases with BPPV. In this study, the dizziness handicap inventory score was 24–78 points (mean 51) before CRP and 12–26 (mean 19) after CRP. The recovery findings of present study suggested that 37.69% of cases with posterior canal BPPV responded in single session considering as complete recovery followed by 61.52% of cases which required repeated session for recovery. 41.52% of cases required two to 4 sessions from 15 days to 1 month were considered as partial recovery and 20% of cases required greater than four sessions (more than 1 month) to become asymptomatic considered as late recovery. 0.76% of cases did not recovered up to 6 months and were considered as no response (Table 1; Fig. 3).

Fig. 2.

Different types of BPPV found in this study

Table 1.

Clinical response time of Epley maneuver for treatment of posterior canal-BPPV

SN.	Stages of recovery	No. of sessions	Duration of Epley’s Maneuver	% of cases
1.	Complete response	1	1 day	37.69%
2.	Partial response	2	15 days	20.76%
		3	21 days	11.53%
		4	1 month	9.23%
3.	Late response	> 4 up to 24 sessions	> 1 months up to 6 months	20%
4.	No response	> 24 session	> 6 months	0.76%

Fig. 3.

Indicate the clinical response time after Epley Maneuver for treatment of Posterior canal BPPV

Discussion

The present study was taken with aim to investigate “the clinical response time of Epley maneuver for treatment of posterior canal BPPV. The result of current study suggested that maximum number of patient with posterior SCC BPPV were benefited within 1 month of CRP. In this study, the clinical data were used to determine the clinical response time of Epley maneuvers with negative Dix-Hallpike test considered as strict criteria for completely cure of patient with BPPV. Previous study also supported that Dix-Hallpike test should be used for diagnosing posterior canal BPPV [14] and Epley maneuver was effective for treatment of posterior SCC BPPV [15]. It was observed that Epley maneuver provided high efficacy with long lasting control of symptoms in patient with BPPV [15, 16]. Previous study suggested that conversion of Dix-Hallpike maneuver from positive to negative after Epley maneuver and efficacy of Epley maneuver is better than Sham maneuver for treatment of BPPV [17]. However time course for recovery were not studied. It also revealed that Epley maneuver is also effective in p-BPPV who was symptomatic after the first session [18]. In this study counseling regarding the post treatment instruction such as avoid sleeping on the affected side, avoid doing fast head movement were given to each patient without any postural restriction. However various studies reported that postural restrictions do not influence the efficacy and success rate of Epley maneuver for management of BPPV [19–22].

In Romberg test, all the cases with BPPV were not able to maintain balance during closed eye condition suggestive of peripheral vestibular disorder. The Romberg test were positive in all cases with BPPV, it is suggested that testing should be done on foam in close eye position for avoiding vision and proprioception sensory cues for maintain balance. Previous studies also reported that Romberg test in compliant surface is more sensitive than fixed surface [23]. In Fukuda stepping test, 58% of cases with BPPV showed deviation greater than 45° and remaining cases had no deviation but were not stable showing displacement greater than 1 m and could not complete the task indicativing of suspected peripheral vestibular disorder. Tandem walk test were affected only in 20% cases of BPPV and 80% cases of BPPV were able to maintain static balance, since testing were done on fixed surface with eyes open position. 5% cases had positive dysdiadochokinesia test Fast pointing (finger-to-nose) test, heel to knee test and, grasp test were found as negative for all cases with BPPV, suggested intact cerebellar functioning. Subjective visual vertical and subjective visual horizontal test were positive in 88% of BPPV revealing otolith dysfunction and 11% cases with BPPV were negative. It was observed that patient with acute BPPV have a tendency to set the bar toward the side of the lesion in SVH and SVV tests.

In this study, the findings of dizziness handicap inventory score indicated that BPPV is associated with considerable dizziness handicap and after CRP, the dizziness handicap score was improved. In recent study by [12] also found the improved dizziness handicap score after CRP.

In the present study, two cases (0.76%) in which one case have bilateral posterior canal BPPV and another one case with horizontal canal BPPV were not benefitted with CRP within 6 months considered as no recovery this can be explained by difficulty in observation of provoked nystagmus, during the diagnostic positional maneuvers as it is the most significant factor in diagnosis of the type of BPPV resulting, erroneous diagnosis of pseudo-bilateral posterior SCC BPPV. Hence, Brandt-Daroff Exercises were recommended in this case for further treatment. Previous study also reported that Brandt-Daroff Exercises were also effective in the treatment of BPPV [24].One case the recovery of horizontal canal BPPV was delayed. For this delayed recovery; explanation could be that small amount of residual debris might be present in the canal after performing CRP. In this case forced prolong position (FPP) were recommended first as the patient was complaining of neck pain and difficulty in observing the geotropic and apogeotropic types of nystagmus. Previous study also reported that geotropic is more common than apogeotropic in horizontal canal BPPV [13]. Hence, in this condition FPP was considered as first choice for treatment. In addition, in the same case horizontal canal BPPV converted to posterior semicircular canal BPPV. It may be considered that displaced free floating otoconia particles may falls downwards from horizontal SCC to posterior canal due to influence of gravity. In previous published literatures, it was mentioned regarding possibility of canal switching or canal re-entry of otoconia particles from one SCC to another SCC after CRP [25].Vestibular rehabilitation should also recommend in presence of residual symptoms after CRP. Previous study also reported that it may possible for otoconia to switch canal from horizontal to posterior canal BPPV [25]. Hence, this clinical evidence suggests that multiple sessions may be required for therapeutic improvement in BPPV. In certain cases, central vestibular adaptation may also play major role in cure of persistant residual symptoms of BPPV.

Conclusion

BPPV involving posterior canals may be easily detected and cured. Short-term treatment by canal reposition maneuver and long term follow up protocol is required for the management of unilateral posterior SCC which is easy and simple procedure can be done on opd basis. Epley maneuver can be used as evaluation tool in treatment outcomes assessment as used in this study. Repeated session may be required as complete recovery may not be immediate. Audiologist and otolaryngologist should be aware of canal switching phenomena during BPPV. Vestibular rehabilitation may be included along with CRP treatment for improving the quality of life. Hence, it is necessary to counsel the patient regarding the importance of follow-up. This study was done with limited sample size. A study with large sample size can be done with different types of BPPV to measure clinical response time of BPPV.

Author contributions

KS was involved in study design, data collection and interpretation. TS was involved in study design, analysis of the data, interpretation and writing the manuscript. The manuscript has been read and approved by all the authors, that the requirements for authorship as stated earlier in this document have been met, and that each author believes that the manuscript represents honest work.

Funding

There is no funding by any agency for the manuscript.

Compliance with ethical standards

Conflict of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Informed consent

Informed consent was obtained from each participant for the participants of the study.

Ethical considerations

In the current study, all testing procedures were carried out using non-invasive techniques and all the procedures were explained to the participants for the participants of the study.