Short-Term Effect of Epley Maneuver as Treatment for Subjective Benign Paroxysmal Positional Vertigo

Abstract

Subjective Benign Paroxysmal Positional Vertigo (S-BPPV) is an atypical form of BPPV, its treatment is not well characterized and is not well known among otolaryngologists. The main aim of this study was to estimate the short-term efficacy of Epley maneuver as treatment for S-BPPV. This was a prospective study in a secondary care center. We included patients with unilateral S-BPPV demonstrated by negative nystagmus on Dix-Hallpike Maneuver (DHM) but with unilateral vestibular symptoms (dizziness or vertigo). Epley maneuver to the affected side was performed. Patients underwent Dizziness Handicap Inventory (DHI) and at 1-week follow-up, DHI and DHM were repeated. Outcome measures were resolution of symptoms during DHM and improvement of DHI scores. Patients were divided into resolved and unresolved groups according to the absence or presence of symptoms during the 1 week DHM. Wilcoxon-Mann–Whitney and Kruskal–Wallis tests were used, quantitative values were reported as mean and standard deviation. The results included thirteen participants, 12 females and 1 male, mean age 53.31 years (SD ± 15.71). Right ear was involved in 46.15% and left in 53.84%. A total of 46.15% patients (n = 6) had resolution of symptoms. DHI initial score for the resolved group was 34.66 ± 22 and for the unresolved group was 39.71 ± 19.61 (p = 0.568). At 1-week evaluation scores were 19.66 ± 25.05 for the resolved group and 30.28 ± 21.42 for the unresolved group (p = 0.252). DHI improvement was 15.00 ± 23.21 and 9.42 ± 10.17 for each group, respectively (p = 0.943). We concluded the Epley maneuver is an effective short-term treatment for S-BPPV. Half of the patients would need further diagnostic tests.

Introduction

Benign Paroxysmal Positional Vertigo (BPPV) is certainly the most common cause of vertigo in adults. It is characterized for episodes of instantaneous vertigo and nystagmus, triggered by changes in the position of the head with respect to gravity and the orientation of the semicircular canal involved [1].

A patient can experience from mild dizziness to incapacitating nausea or vomiting that can lead to daily dysfunction [2]. This occurs due to free-floating otoliths (canalithiasis) that causes the endolymphatic flow to be abnormal. Otoliths adherent to the cupula (cupulolithiasis) in any of the three semicircular canals have also been described as etiology of BPPV [3]. Diagnosis is made by targeted history and a positive positional test, being Dix-Hallpike Manuever (DHM) the most commonly used to evocate the symptoms and nystagmus.

In most patients, the diagnosis is reached with the performance of DHM and then treated satisfactory both for the patient and the physician with particle repositioning maneuvers. The Epley and Semont maneuvers are the most widely used [4].

However, some cases present a specific situation: presence of symptoms including dizziness, nausea or vomiting but not nystagmus evident during Dix-Hallpike Maneuver. This phenomenon was described in 2002 by Haynes [5], as the production of the same type of vertigo as classic BPPV on Dix-Hallpike positioning, but without the observation of nystagmus with the unaided eye. This clinical situation was called ‘Subjective’ BPPV (S-BPPV). Consequently, the classic BPPV was entitled ‘Objective’ BPPV (O-BPPV). S-BPPV has also been described as “atypical” by some authors [6]. The Bárány Society includes S-BPPV in the category of “possible BPPV” [7].

Different studies have shown that regular canal repositioning techniques used for O-BPPV also benefit patients with ‘Subjective’ BPPV. Symptoms remission among patients with BPPV without nystagmus who were treated with canalith repositioning maneuvers has been estimated on 67.64% [8]. Evidence on this subject is still scarce and few studies have been conducted, so the incidence has not been clearly estimated. Given the aforementioned, the aim of this study was to prove the efficacy of the Epley maneuver as a canalith repositioning technique in patients with S-BPPV.

Methods

This study was performed in the Department of Otolaryngology and Head and Neck Surgery of a Secondary Care Center, from October 2018 to October 2019.

Subjects

Patients selected were those ≥ 18 years old, that experienced acute compatible symptoms (dizziness, vertigo, nausea, vomiting) of BPPV but with no evidence of nystagmus when Dix-Hallpike Maneuver was performed and, therefore, diagnosed with S-BPPV. Only acute symptoms occurring during head down position were taking into consideration as S-BPPV. No Frenzel glasses were used in order to emulate the clinical situation of every day to day basis in most otolaryngology clinics. Complete neurotologic and neurology examination was performed by the senior author.

Exclusion criteria were: recent medical treatment for BPPV or any recent vestibular suppressants, previous diagnosis of BPPV, cochlear symptoms associated with vertigo, otoscopy abnormalities, other possible vestibular diseases, incomplete clinical evaluations or incomplete DHI test.

Study Design

Prospective, longitudinal study.

After meeting inclusion criteria, patients received one Epley maneuver according to the affected side. Only one conventional Epley maneuver was performed, the time between each position was 45 s to 1 min, roll test was also performed with no dizziness or nystagmus during the procedure. Additionally, no nystagmus enhanced maneuvers were performed such as mastoid vibrator. Patients were re-evaluated at the clinic at 1-week time.

Also, patients fulfilled the Dizziness Handicap Inventory (DHI) at basal (inclusion visit) and at 1-week follow-up evaluation.

Outcome Measurements

Improvement was measured by the reduction of DHI scores (1-week score minus initial DHI score) and the presence or absence of symptoms (dizziness, nausea, vomiting) during the Dix-Hallpike test at 1-week follow-up.

If no symptoms were evident at 1 week during the Dix-Hallpike testing the patient was considered as resolved case, in contrary, patients with persistence of symptoms in the DHM at 1 week were considered unresolved cases. Statistical comparison was based on these two groups.

After completion of the study, patients were followed-up at the neurotologic clinic.

Informed consent was signed by all patients and Institutional Review Board approval (Comité de Investigación, CIDOCS) at our institution was obtained.

Statistical Analysis

Levene test was used to estimate the equality of variances. The continuous variables were analysed using Wilcoxon–Mann–Whitney and Kruskal–Wallis tests, both nonparametric statistical tests. Quantitative values were reported as mean, standard deviation (σ) and qualitative variables as absolute numbers and percentages. Categorical variables were analyzed with X². Statistical significance level was set to p < 0.05.

For the statistical analysis the Statistical Package for the Social Sciences (SPSS) version 21 (IBM Corp., Armonk, NY, USA) was used.

Results

Thirteen patients were included: 92.30% (n = 12) females and 7.69% (n = 1) males. Mean age was 53.31 years (σ ± 15.71). Range from 35 to 85 years. Presence of comorbidities were 30.76% (n = 4) for hypertension, 7.69% (n = 1) diabetes mellitus, 7.69% (n = 1) dyslipidemia and 30.76% (n = 4) prolonged rest, none of the participants had hypothyroidism. The left ear was affected in 53.84% (n = 7) of participants and the remaining 46.15% (n = 6) presented affection of the right ear. In the majority of subjects (76.92%) the average of symptoms length was referred as less than 1 min. The demographic characteristics of the population are described on Table 1.

Table 1.

Demographic characteristics of the population

	Total population n = 13	Resolved n = 6 (46.15%)	Unresolved n = 7 (53.84%)	p
Age (mean, SD)	53.31 ± 15.71	54.33 ± 19.89	52.43 ± 12.73	0.504
Sex
Females	12 (92.30%)	5 (38.46%)	7 (53.84%)
Males	1 (7.69%)	1 (7.69%)	0	0.261
Affected ear
Right	6 (46.15%)	4 (30.76%)	2 (15.38%)
Left	7 (53.84%)	2 (15.38%)	5 (38.46%)
Both	0	0	0
None	0	0	0	0.170
Symptoms duration
Seconds	10 (76.92%)	4 (30.76%)	6 (46.15%)
Minutes	1 (7.69%)	0	1 (7.69%)
Hours	2 (15.38%)	2 (15.38%)	0	0.188
Comorbidities
Hypertension	4 (30.76%)	3 (23.07%)	1 (7.69%)	0.164
Diabetes	1 (7.69%)	0	1 (7.69%)	0.335
Dyslipidemia	1 (7.69%)	1 (7.69%)	0	0.261
Hypothyroidism	0	0	0	–
Prolonged rest	4 (30.76%)	3 (23.07%)	1 (7.69%)	0.164

SD standard deviation

After undergoing one Epley maneuver, 6 patients (46.15%) experienced improvement at 1-week follow-up, with absence of symptoms when Dix-Hallpike Maneuver was performed again. Seven patients persisted with symptoms (53.84%).

In the total population (n = 13) initial DHI score was of 37.38 ± 20.02, and the total 1-week follow-up DHI score was of 25.38 ± 22.83. A statistical significance was reached (p = 0.026) when total initial and 1-week DHI were compared.

In the resolved group (n = 6) initial DHI score was 34.66 ± 22 and at 1-week DHI was 19.66 ± 25.05, with improvement of 15 ± 23.21 points (p = 0.144). The unresolved group (n = 7) had an initial DHI score of 39.71 ± 19.61 and at 1-week DHI score was of 30.28 ± 21.42 with an improvement of 9.24 ± 10.17 points. Comparison between groups of initial DHI scores (p = 0.568) and at 1-week follow-up score were not significant (p = 0.252). DHI improvement scores (15.00 ± 23.21 from resolved group vs 9.42 ± 10.17 from unresolved group) did not reached statistical significance (p = 0.943). (Table 2).

Table 2.

Initial and 1-week DHI scores by groups

	Total population n = 13 (mean, SD)	Resolved n = 6 (mean, SD)	Unresolved n = 7 (mean, SD)	p*	pϕ
Initial DHI	37.38 ± 20.02	34.66 ± 22.00	39.714 ± 19.61	0.568	0.524
1 week DHI	25.38 ± 22.83	19.66 ± 25.05	30.286 ± 21.42	0.252	0.707
p†	0.026	0.144	0.075	–	–
Improvement	12.00 ±16.87	15.00 ± 23.21	9.42 ± 10.17	0.943	0.020

SD standard deviation, DHI dizziness handicap inventory

p* Kruskal–Wallis test

p^ϕ Levene test

p^† Wilcoxon-Mann–Whitney test

Discussion

Subjective Benign Paroxysmal Positional Vertigo is a alternative clinical manifestation of BPPV in which the nystagmus elicited by a Dix-Hallpike Maneuver is not readily present to the naked eye. Nonetheless, other clinical symptoms (nausea, vomiting, dizziness) are present. Haynes [5] described this phenomenon and treated this disease with Semont maneuver, obtaining total resolution in 63% of the patients. Our study shows that almost 50% of S-BPPV patients can benefit from an Epley maneuver.

In the literature, it has also been described during DHM the presence of unilateral sitting-up vertigo or body sway, felt by the patients at the moment of sitting up (last phase of the Dix-Hallpike position). Typically, the patients feel it on one side, but not on the other, and it has been considered an atypical BPPV [9].

Many authors have tried to explain the absence of nystagmus on S-BPPV: eye fixation, nystagmus fatigue prior to the Dix-Hallpike Maneuver or the presence of a weak and short nystagmus not perceived by the clinician are some of the postulated theories [8, 10]. The most accepted proposition is that the otoconia attached to the cupula or floating in the semicircular canals are minimum and as result, the nervous signal is capable of stimulate vertigo but not strong enough to produce nystagmus through the vestibular-ocular via [7, 10, 11]. For the purpose of treating BPPV via canal repositioning maneuvers it is established that the presence of symptoms of vertigo associated to positioning tests are sufficient [11]. In a review conducted by Jung and Kim [12] the complete recovery rate was 58% after treating 43 patients with the modified PSCC (posterior semicircular canal) repositioning maneuver. Total recovery rate in our study was 46.15%. A study made by Balatsouras [13] evaluating 45 patients with S-BPPV treated with canal repositioning maneuvers concluded with a success rate of 87.5%. Other authors agree that the S-BPPV should be treated with the corresponding maneuver depending on which semicircular-canal is affected [14].

In the study made by González-Aguado et al. [15] comparing O-BPPV and S-BPPV it was demonstrated that the patients with S-BPPV have similar response to the Epley maneuver as treatment, with comparable remission of symptoms of 48.4% of patients versus 50.8% of those with O-BPPV (p = 0.75).

Additionally, when the side involved cannot be correctly identified, there is a clinical trial that studied bilateral Epley treatment versus control group for S-BPPV. Interestingly, this last study has reported positive outcomes with decrement of post-treatment DHI scores (p < 0.001); as well as improvement of visual analog scale against the control group (p < 0.001) [16].

In our study, we treated the S-BPPV with the Epley maneuver based on previous evidence of efficacy, nonetheless our recovery rates were lower than those reported on other studies [5, 13].

Other causes of subjective vertigo can add bias to the inclusion of patients in this study, particularly those that cannot be totally excluded by regular otolaryngology examination, provoking an overlap in diagnosis. The Persistent Postural-Perceptual Dizziness (PPPD), is an entity recently defined in which the most common trigger events are acute peripheral or central vestibular disorders (25%) with clinical characteristic of dizziness and vertigo similar to BPPV that nonetheless it is not accompanied with nystagmus [17].

Another possible drawback is the intentional lack of frenzel googles during examination, we wanted to provide a common scenario were patients are actually seen, with the inclusion of primary care centers or any health care unit. We believe that atypical BPPV or S-BBPV should be in the mind any primary care practitioner.

Due to the fact that nystagmus is not present, we also applied the Dizziness Handicap Inventory to correlate the effectiveness of the Epley maneuver as treatment of S-BPPV. Huebner et al. [18] and Tirell et al. [11] demonstrated previously that DHI scores improves either if the vertigo is subjective or objective. In addition, we have considered symptoms remission as a positive response, similar to other authors in their respective studies [18, 19].

Our study shows an overall DHI reduction at the 1-week vs the initial DHI, proving that the Epley maneuver is helpful, easy to perform and may help at the clinic to treat those patients that have a BPPV but no evident nystagmus. At least 50% of patients may have their symptoms resolved. Unfortunately, in our study, there was no difference between groups on the DHI, this is probably because of the sample size. New studies with more subjects and longer follow up are needed.

Nevertheless, S-BPPV exists and is more common than expected. The primary care practitioner, otolaryngologist and neurotologist need to be aware of the different types of BPPV.

Conclusion

Epley maneuver is an effective short-term treatment for S-BPPV. Half of the patients would need further diagnostic tests.

Funding

None.

Compliance with Ethical Standards

Conflict of interest

There are no conflicts of interest.