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Foster, †Kathleen Zaccaro, and †Darcy Strong. Departments of. H-BPPV or common crus reentry and the outcome of treatment maneuvers.
Objective To identify variables affecting outcome in patients with benign paro‐ysmal positional vertigo (BPPV) treated with canalith repositioning maneuvers. Study Design Retrospective review of patients at a tertiary vestibular rehabilitation center.
Methods Variables identified for statistical analysis included method of diagnosis, age, se‐, onset association with trauma, semicircular canal involvement, presence of bilateral disease, treatment visits, and cycles of canalith repositioning maneuvers per treatment visit. Multivariate statistical analysis using Pearson χ 2, likelihood ratio, linear‐by‐linear association, and cross‐tabulation tests were performed.
Results Two hundred fifty‐nine patients with BPPV who received treatment were identified from 1996 to 1998. Average follow‐up time was 16.9 months. 74.8% required one treatment visit, 19.0% required a second treatment visit, and 98.4% were successfully treated after three treatment visits. The remainder required up to seven treatment visits for relief of symptoms. Variables affecting the number of treatment visits included bilateral disease or location of disease other than in the posterior semicircular canal. Patient age, se‐, method of diagnosis, and onset association with trauma had no statistically significant impact.
Conclusion Patients with benign paro‐ysmal positional vertigo not located in a single posterior semicircular canal are more likely to require multiple visits for canalith repositioning. INTRODUCTION Benign paroxysmal positional vertigo (BPPV) is one of the most common diagnoses made in the otolaryngologist's office in patients presenting with complaints of vertigo. Dense free‐floating particles within the semicircular canals, cupula, or both are presumably the cause of positionally provoked abnormal vestibular stimulation resulting in nystagmus. The diagnosis of BPPV is based on a characteristic history of positionally provoked vertigo, and a physical examination or electronystagmogram showing a positive Dix‐Hallpike test. Posterior semicircular canal BPPV (PBPPV) is most common, but involvement of other canals is seen. Canalith repositioning is thought to clear the offending particles out of the semicircular canals by a series of rotational maneuvers and has demonstrated good efficacy in providing rapid and long‐lasting relief of symptoms. Treatment requires only one treatment visit in most patients.
However, there are a significant number of patients who require multiple treatment visits for relief or develop rapid recurrence of their symptoms. The goal of this study is to identify variables that may be associated with these difficult to treat cases. MATERIALS AND METHODS A retrospective review was made of patients whose BPPV was diagnosed by the senior author (J.D.M.) and treated by the co‐authors (S.M., A.E., J.A.F.) at Good Samaritan Rehabilitation Institute in Phoenix, Arizona, between 1996 and 1998. Patient information was obtained from patient records and direct patient telephone calls were made to ensure accuracy on recurrence data.
Only those patients demonstrating a positive Dix‐Hallpike test on physical examination at the time of treatment were included in this study. The Dix‐Hallpike test was considered positive if nystagmus was observed with appropriate positioning, and had characteristic latency, duration, and fatigue. Horizontal canal BPPV was identified by horizontal direction‐changing positional nystagmus and a normal magnetic resonance imaging study to rule‐out brainstem pathology. Data variables included patient age, sex, electronystagmogram performed to assist diagnosis, association with trauma, involved semicircular canal, multiple canals, bilateral disease, number of treatment visits, and number of canalith repositioning maneuver cycles performed per visit. Treatment success was judged as complete relief of the symptoms of vertigo and a conversion to a negative Dix‐Hallpike test on physical examination. Treatment consisted of canalith repositioning maneuvers appropriate for the semicircular canal involved, as described in the literature, - and performed by trained vestibular therapists (S.M., A.E., J.F.).
The maneuvers were repeated each visit (cycles) until treatment success was achieved, or patient fatigue prevented continuation. Statistical analysis using Pearson χ 2, likelihood ratio, linear‐by‐linear association, and cross‐tabulation tests was performed to determine which variables impacted treatment outcome.
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RESULTS Two hundred fifty‐nine patients (average age, 58.6 y; range, 20–93 y) for whom follow‐up information was obtainable were identified for this study. Seventy two percent were female. Validity of available variable data were high. Average follow‐up after treatment was 16.9 months (range, 0.2–39.8 mo; SD, ± 8.93). Diagnosis was made by a positive Dix‐Hallpike test on physical examination in 88.9% of patients, with the remainder having an electronystagmogram to assist in diagnosis.
Onset of symptoms was associated with head trauma in 10.1% of patients. In 93.1% of patients disease was isolated to the posterior semicircular canal; in 1.9% disease was located in the horizontal semicircular canal; and in 5.0% in multiple canals. Anterior semicircular canal BPPV could not be distinguished from PBPPV from the data. Bilateral involvement was identified in 6.9% of patients.
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Asymptotic significance: Pearson χ 2: 0.000; likelihood ratio: 0.014; linear‐by‐linear association: 0.001. Our patients required an average of 1.36 visits for treatment success (range, 1–7 visits). In 74.8% of patients one visit was required, in 19.0% a second visit was required, and in 4.7% a third visit was required. There was a 98.4% success rate in patients who had three visits or fewer. There were no treatment failures and no cases of brainstem pathology.
The average number of canalith repositioning maneuver cycles per treatment visit was 3.32 (range, 1–18). Asymptotic significance: Pearson χ 2: 0.056; likelihood ratio: 0.041. Three variables had a statistically significant impact on the number of treatments required for the relief of symptoms. Atypical location of disease , the presence of disease in multiple ipsilateral semicircular canals , and bilateral disease all had P values of less than.05. Patient age , sex , method of diagnosis , and trauma association had no significant association. Cross‐tabulation between variables failed to reveal any other significant findings.
For instance, the relation between bilateral BPPV and traumatic origin failed to reach statistical significance, with a Pearson χ 2 P value of.076. DISCUSSION Canalith repositioning maneuvers have become the standard treatment of BPPV, usually providing rapid relief of symptoms with one treatment visit. However, a significant subgroup of patients require multiple treatments either because of persistent symptoms or from the recurrence of symptoms after successful treatment. One patient required seven treatment visits for successful relief of symptoms. Our single treatment failure rate of 25.2% falls within reported rates of 12% to 56%. Our study group's demographics compare similarly with other studies in the literature, with an average patient age of 58.6 years and symptom onset associated with trauma in 10.1%.
Treatment success and recurrence rates (13.5% at 6 mo) were similar to previously published data. Our average follow‐up of 16.9 months is adequate to make meaningful conclusions. Our goal in this study was to identify variables that could help identify patients most likely to require multiple treatment visits. This would be useful in counseling patients and insurance companies with respect to treatment expectations and in identifying patients who will be difficult to treat. Identifying such variables might also modify our therapeutic approaches for better treatment success rates. Benign paroxysmal positional vertigo involving any location other than a single posterior semicircular canal also tended to require more treatment visits. In 93.1% of our study group BPPV was isolated to one posterior semicircular canal, and 93.8% of our patients responded after one to two treatment visits.
Bilateral BPPV was typically treated unilaterally per one treatment visit, proceeding to the contralateral ear once a negative Dix‐Hallpike test in the treated ear was obtained. Horizontal semicircular canal BPPV (HBPPV) also tended to require more treatment visits, because this canalith repositioning maneuver was less effective. Several patients experienced HBPPV during treatment for PBPPV, presumably from migrating debris, requiring additional therapy. Of equal interest are those factors that did not affect treatment visits. Although all patients receiving more than three treatment visits were over the age of 50 years, the difference did not reach statistical significance, with a Pearson χ 2 P value of.063.
Sixty‐nine patients in our study were 70 years of age or older (26.7%); 8% were 79 years or older. Many of these patients were more difficult to treat because of fatigue, significant spinal arthritis, or other illnesses that required some modification of our standard canalith repositioning routine. Most often, neck mobility was limited, making neck extension during canalith repositioning suboptimal. Soft cervical collars and other methods of support were used to assist in the procedure for safety reasons, but this apparently did not affect debris migration within the semicircular canals. Sex also had no effect on treatment. Our study included patients in a large inpatient rehabilitation center with severe traumatic head injuries, yet head trauma associated with the onset of symptoms did not relate to difficulty in treatment.
The association of trauma and bilateral disease also did not reach statistical significance. Patients with atypical symptoms who required an electronystagmogram to assist in diagnosis tended to respond quickly to treatment. This included patients who had a negative Dix‐Hallpike test in the office or at bedside and patients with atypical complaints in whom a Dix‐Hallpike test was not initially performed. There were no cases of brainstem disease mimicking BPPV.
CONCLUSION Canalith repositioning maneuvers provide rapid and long‐lasting relief of symptoms of BPPV in most patients. However, patients requiring more than one treatment visit can become disillusioned and disappointed if expectations for rapid relief are not achieved. Patients who have BPPV that is not located in a single posterior semicircular canal are more likely to require multiple treatment visits and should be counseled appropriately. In this era of managed health care, prior authorization for vestibular therapy is often required before treatment. Based on the results of this study, we recommend insurance authorization for three treatment visits, which would have accounted for 98.3% of the patients being relieved of symptoms. In those patients requiring more than two therapy visits, evaluation for HBPPV, bilateral BPPV, and brainstem disease should be considered.