Clinical Study of BPPV and the Effectiveness of Canalolith Repositioning Manoeuvre in Subjects of BPPV

Abstract

Vertigo is an illusion of motion, either of one self or of the environment. Vertigo in BPPV is a very devastating experience for the patient who experiences it. However, it can be reversible with vestibular rehabilitation, with very good results. A study on 72 patients attending Otoneurology clinic in our hospital, diagnosed as BPPV with history and examination were subjected to DHI (Dizziness Handicap Index) questionnaire prior to and after intervention and results were analyzed. BPPV is more commonly seen in elderly individuals above 45 yrs, females and posterior semi circular canal. A significant improvement was noted in all the three components of DHI index in patients treated with CRM (Canalolith Repositioning Manoeuver) when compared to the patients who received only reassurance. CRM is a very safe and effective treatment of BPPV which has the added advantage of being noninvasive procedure, with excellent results.

Introduction

Dizziness is a very common complaint in the general population, significantly increasing with advancing age [1, 2]. BPPV is the most common peripheral vestibular disorder [3]. The hallmark of the disease is brief spells (lasting seconds) of often severe vertigo experienced after specific movements of the head. It was first described by Barany in 1921 [4]. In 1952, Dix and Hallpike [5] reported this entity in a large group of patients. Cupulolithiasis, was later proposed by Schuknecht as the mechanism of BPPV [6].The incidence increases with age [7] and is twice common in women [8]. Symptoms occur suddenly and last on the order of seconds,and they rarely last in excess of a minute. Light headedness that is worsened by head movement [9]. BPPV is most commonly idiopathic with no specific etiology identified in 50–70% of cases. The two most common causes of secondary BPPV are head injuries and VN (Vestibular Neuritis) [8, 10].

A patient with vertigo visits a physician with a lot of apprehension and grave prognosis in mind, gets misguided into numerous investigations, ends up consulting multiple physicians with no relief from prolonged medication he has been prescribed. Proper history and clinical examination at Otoneurology clinic can diagnose the condition which can be effectively treated with vestibular rehabilitation. According to certain studies, BPPV is self resolving to a certain extent. The objectives of present study are to study the demographics, symptomatology, proportion of semicircular canals affected and analyze the effectiveness, sequelae associated with Canalolith Repositioning Manoeuver, with respect to reassurance alone.

Methods

Study Setting: It is a prospective study conducted at the Otoneurology clinic at a tertiary care centre in Telangana, India, for a period of 2 years (DECEMBER 2018- NOVEMBER 2020).

Inclusion criteria:

1. Males and Females in the age group of 20–70 yrs.

2. Positive history and Dix Hallpike positive patients.

3. Patients willing to participate in the study, after informed consent.

Exclusion criteria:

1. Vertigo from causes other than BPPV.

2. Patients with comorbidities like cardiovascular pathologies and CVA.

3. Patients not willing for study.

Study Design: This study comprises of participants grouped into 2 categories, one of the groups received the Manoeuver according to the type of canal involved who were categorized as CRM( Canalolith Repositioning Manoeuver) group, while the other group which received only reassurance were categorized as NON-CRM group.

A total of 72 patients were analyzed. Participants in both the groups were matched according to age, gender, etiology, type of canal involved, severity of symptoms according to scores in the DHI (Dizziness Handicap Index).

Post intervention, the subjects were followed up every week for 4 weeks, later for every 2 weeks for a period of 6–8 weeks and efficacy of treatment was assessed using DHI scoring. Subjects who were lost to follow up at various levels were excluded proportionately and categorically prior to arriving at the current sample size.This study was a double blinded procedure both to patient and the treating doctor. Results were analyzed by a nontreating statistician. Due to less number of subjects in the horizontal canal and anterior canal BPPV,results were obtained in terms of percentage.

• Results of posterior canal BPPV were obtained using student T-test.

• Posterior semicircular canal BPPV was treated with EPLEY’s manoeuver.

• Horizontal semicircular BPPV was treated with BARBEQUE ROLL.

• Anterior semicircular canal BPPV was treated with YACOVINO manoeuver.

Dizziness Handicap Index (DHI):

The Dizziness Handicap Index (DHI) is a validated, self-report questionnaire which is widely used as an outcome measure [11]. The DHI was developed by Jacobson and Newman to assess disability grade [12]. The DHI is a 25-item questionnaire that was designed to help patients rate their self-perception of disability from dizziness [12]. A yes response gives a score of 4 points, sometimes 2 points, and no 0 points. The total score ranges from zero (no disability) to 100 (severe disability). The scale consists of:

• 7 physical aspects, question numbers: 1,4,8,11,13,17,25.

• 9 functional aspects, question numbers: 3,5,6,7,12,14,16,19,24.

• 9 emotional aspects, question numbers: 2,9,10,15,18,20,21,22,23.

Results

CRM: Canalolith Repositioning Manoeuver; DHI: Dizziness Handicap Index; PSC: Posterior Semicircular Canal; LSC: Lateral Semicircular Canal; ASC: Anterior Semicircular Canal.

The wide age group between 20 and 70 yrs were studied and the results showed that with increasing age, incidence of BPPV was increasing.Majority affected were above 45 yrs (Fig. 1).

Fig. 1.

Showing treatment flow chart

Youngest affected was 20 yr old, and eldest age was 70 yr old. Mean age group was 48.62 yrs.

Among the studied subjects, majority (75%) of them had symptoms for 1–2 weeks before presenting to the Otoneurology clinic. 19.44% of subjects presented within 1 week of symptoms, while 5.55% of subjects presented after 2 weeks of symptoms.

All subjects had vertigo as the main presenting symptom. Nausea and vomiting was the most common associated complaint among the studied subjects which accounted for 51.38%, while tinnitus was associated symptom in 27.77% of the subjects. History of fall was noted in 2.77% of the individuals, Rest of the subjects had only vertigo as a symptom.

However many of the subjects had overlapping symptoms and more than 1 associated symptom (Table 1 and Fig. 2).

Table 1.

Comparing various aspects of DHI and their scoring in CRM GROUP and NON-CRM GROUP, before and after intervention

Aspects	CRM group			Non–CRM Group
	Pre DHI	Post DHI	P value	Pre DHI	Post DHI	P value
PHYSICAL	14.96	3.03	< 0.001	14.51	13.33	0.73
EMOTIONAL	12.59	1.55	< 0.001	13.74	10.85	0.90
FUNCTIONAL	18.07	5.03	< 0.001	19.85	17.48	0.81

Fig. 2.

Showing PRE DHI SCORES in (plain) prior to intervention and POST DHI SCORES in (stripes) post intervention (CRM) with respect to various aspects of DHI, among the CRM GROUP

Post CRM, subjects in the CRM group showed a drastic improvement in all aspects of DHI, denoting its efficacy.

Management modality among NON-CRM group was reassurance, which had no impact on the relief of symptoms as depicted in the chart (Table 2).

Table 2.

Showing Success rate among CRM GROUP during follow up in Posterior canal BPPV

Success rate	CRM group
	N = 32	%
1st follow up	27	84.3
2nd follow up	30	93.75
3rd follow up	31	96.8
Residual dizziness	01	3.12
Recurrence	0	0

At the end of 1st follow up, 84% of subjects had symptomatic improvement following CRM, 93.75% subjects had improvement by 2nd follow up and 96.8% by 3rd follow up in the CRM GROUP, no recurrence of symptoms were seen in subjects treated successfully with CRM in subsequent follow up up to 6 months.

No improvement in symptoms was noted in 1/32 subjects by the end of 3rd follow up even after repeated CRM.

The rate of success in NON-CRM group, who were given reassurance was 2/32 i.e., 6.25%, by the end of 2nd follow up (Fig. 3).

Fig. 3.

Showing Success rate among CRM GROUP (checker board pattern) and NON-CRM GROUP (stripes) during the 1st and 2nd Follow up in Posterior Canal BPPV

Subjects in CRM group had a high rate of success following intervention with the manoeuvers compared to the subjects in NON-CRM group who received only reassurance during the 1st and the 2nd follow up.

After the 2nd follow up, subjects who had no improvement in symptoms in the NON CRM GROUP, were subjected to CRM and the results were noted.

The subjects who were relieved of symptoms in the initial 2 follow ups in the NON-CRM group were not subject to CRM during their subsequent visits.

When NON-CRM group were subjected to CRM in their subsequent follow up the rate of success was found to be high, 28/30 (93.33%) subjects had symptomatic improvement, within 2 follow ups.

Among the Posterior canal BPPV, 64 subjects were analysed of whom, 2/64 subjects had recovered without any intervention/ Reassurance. Rest of the 62 subjects, 59/62 subjects had resolution of symptoms after CRM, by the end of 3rd follow up. 3/62 subjects had no resolution of symptoms.

Among the Horizontal canal BPPV, 6 subjects were analysed, of whom 1/6 subjects had recovered with reassurance. Rest of the 5 subjects had been effectively treated with CRM.

Among the Anterior canal BPPV, 2 subjects were analysed, none had recovered with reassurance, 1/2 subjects had resolution of symptoms following CRM. There was no effect with CRM in 1/2 subjects.

Among the studied subjects, posterior semicircular canal contributed to the majority cases of BPPV, which accounted for 88.8%

Horizontal semicircular canal BPPV was noted in 8.33%

Anterior semicircular canal BPPV was noted in 2.77%

Nausea was the most common sequelae, post CRM, which accounted for 19.44%

Canal conversion from posterior canal to horizontal canal was noted in 1 case.

Discussion

BPPV is the most common peripheral vestibular disorder [3].

In the present study, most commonly affected age group was above 45 years. Mean age was 48.63 yrs, which correlates with a study conducted by R. W. Baloh [8]

In the present study it was observed that overall incidence increases with age and it correlates with a study by Bloom J. [7] Females constituted for majority 57.8%, which correlates with the study by R. W. Baloh [8].

Most of the subjects (76%) had symptoms for 1–2 weeks before presenting to the clinic and were elderly individuals. Subjects presenting within 1 week of symptoms were mostly younger individuals in 2nd and 3rd decade, majority of whom had history of trauma to head. Subjects presenting later than 2 weeks were middle aged individuals with relatively milder symptoms. Therefore severity of symptoms and etiology were 2 important factors governing the duration prior to presentation. BPPV is most commonly idiopathic with no specific etiology identified in 50–70% of cases. The two most common causes of secondary BPPVs are head injuries and VN (Vestibular Neuritis) [8, 10].

In the present study, nausea and vomiting were the most commonly associated symptoms, which is similar to the study conducted by Sushil et al. which was seen in about 51.38%, while in other studies it was seen in about 38% [13]

The Dix‐Hallpike manoeuver is the definitive test for posterior canal BPPV. When performed in the office, the sensitivity and specificity are 79 to 82% and 71 to 75%, respectively [14, 15]. The manoeuver begins with the patient seated and head turned 45 degrees to the side being tested so as to isolate and vertically orient that side's posterior canal. The patient is then laid back into a supine position with the tested ear down.

In this study,it was found that posterior semicircular canal was the most commonly affected, 88.8%, horizontal semicircular BPPV accounted for 8.33%, (7–12%) correlating with the studies conducted by Steenerson RL, Fife TD, Korres S et al. [16–18]. Superior canal BPPV accounted for 2.77% in the present study, (1–3%) correlated with studies by Fife TD, Honrubia V et al. [17, 19]

BPPV is usually a self-remitting disorder and may resolve as time goes on without specific treatment. According to a report on the natural course of untreated BPPV, most HC-BPPVs resolve within 16 ± 19 days and PC-BPPVs within 39 ± 47 days from their onset [20]. However, a correct diagnosis and proper repositioning manoeuvers may allow a rapid and simple cure for the BPPV [21]

PRM (Particle Repositioning Manoeuver) has been shown to have a 70 to 85% success rate after a single treatment [22].More recently, a Cochrane review of 11 relevant studies representing 745 participants, concluded that the Epley Manoeuver and its modifications are safe and effective [23]. Thus, PRM or other variations of CRP (Canalolith Repositioning Procedure) have become mainstay in treatment of posterior canal BPPV.

In the present study, at the end of 1st follow up, 84% of subjects had symptomatic improvement following Epley’s Manoeuver for posterior canal BPPV, 93.75% subjects had improvement by 2nd follow up and 96.8% by 3rd follow up (p < 0.001). In a randomised study, 90% of patients were either improved or cured after a single session with either Semont’s or Epley Manoeuver [24].

Two main arguments exist for not immediately redoing the Dix‐Hallpike test. First, a negative test may be the result of a fatigued response and not necessarily treatment success. Second, there is a risk of (i) undoing the successful PRM by causing the canaloliths to re enter the posterior canal or (ii) inducing canal conversion when the canaloliths enter the horizontal canal. [25].When horizontal geotropic nystagmus is encountered, a manoeuver known as the Barbecue Roll or Barrel Roll can be used to reposition the canalolith in the plane of the horizontal canal [26].

With superior canal BPPV being an uncommon presentation, the data is overall sparse for effective therapeutic manoeuvers. A review by Anagnostou and colleagues found mostly case series with the commonly used technique being the reverse Epley’s Manoeuver or the Yacovino Manoeuver [27]. The mean success rate for reverse Epley’s and Yacovino was found to be 75.9 and 78.8%, respectively. In the present study, success rate with Yacovino Manoeuver was 50%. Since the sample size was extremely low, clinical significance couldn’t be evaluated.

In a study it was concluded that DHI Score is a useful tool for the prediction of benign paroxysmal positional vertigo. Correct diagnosis of BPPV is 16 times greater if the DHI Score is greater than or equal to 50. The physical, functional and emotional investigation of dizziness, through the DHI, has demonstrated to be a valuable and useful instrument in the clinical routine [28]

The DHI items composing the F3 (positional) subscale revealed the highest scoring in the BPPV group with 75% sensitivity and 92% negative predictive value (NPV) in reference to Dix–Hallpike tests [29].

Canalolith Repositioning Manoeuver has a very few associated side effects. In the present study, most frequent sequelae noted was nausea, (19.44%) which correlated with a study conducted by Hilton M et al. [23]. In less than 5% of cases, canal conversion occurs where canaloliths may be displaced from the posterior canal into the horizontal canal during repositioning [30]. In the present study, it was found to be 1.56%.

Conclusion

BPPV although common in the elderly above 4th decade is also seen in younger individuals. It has greater predilection for females. Although idiopathic for a major extent, secondary causes like trauma, vestibular neuritis can cause BPPV.

History is, very important in clenching the diagnosis, most of them presenting within 1–2 weeks of onset of symptoms. Dix Hallpike is a gold standard for diagnosing BPPV. Posterior canal is the most commonly affected semicircular canal followed by horizontal, least by anterior canal. DHI (Dizziness Handicap Inventory) is a very useful tool both for diagnosis and evaluating the course of BPPV. Canalolith Repositioning Manoeuver (CRM) is a very safe, effective, non invasive modality of treatment, with very negligible side effects.

Funding

No funding sources.

Declarations

Conflict of interest

All authors declare that they have no conflict of interest.

Ethical approval

The study was approved by the Institutional Ethics Committee.