Canalith Repositioning Maneuver Research Articles

"Positive to Negative" Dix-Hallpike test and Benign Paroxysmal Positional Vertigo recurrence in elderly undergoing Canalith Repositioning Maneuver and Vestibular Rehabilitation.

Introduction Benign Paroxysmal Positional Vertigo is the most common cause of dizziness in elderly people. Recent studies have shown that the elderly present higher Benign Paroxysmal Positional Vertigo recurrence and that vertiginous symptomatology remission varies according to comorbidities and the therapeutic techniques applied. Objective To assess the short-term effectiveness of Vestibular Rehabilitation in addition to Canalith Repositioning Maneuver on positive to negative Dix-Hallpike test, on recurrence and number of maneuvers to achieve a negative test in elderly patients with chronic Benign Paroxysmal Positional Vertigo. Methods In this randomized controlled trial, 7 older adults (median age: 69 years, range 65–78) underwent Canalith Repositioning Maneuver and Vestibular Rehabilitation for thirteen weeks. Seven older adults (median age: 73 years, range 65–76) in the control group received only Canalith Repositioning Maneuver. The participants were assessed at baseline (T0), one (T1), five (T5), nine (T9), and thirteen weeks (T13). We assessed the differences between the groups by Mann-Whitney and Fisher exact tests, and used the Friedman and Wilcoxon tests to determine the intragroup differences. Results No significant differences were found between groups for the positive to negative Dix-Hallpike test, recurrence, and number of maneuvers to achieve a negative test. The number of maneuvers to achieve negative Dix-Hallpike test was lower in intragroup comparisons in the experimental group. Conclusion The findings suggest that additional Vestibular Rehabilitation did not influence the positive to negative Dix-Hallpike test, recurrence, or number of maneuvers to achieve a negative test in elderly patients with chronic Benign Paroxysmal Positional Vertigo.

Diagnosis and management of posterior semicircular canal benign paroxysmal positional vertigo: A practical approach

ObjectivesTo identify variables affecting outcome in patients with unilateral and bilateral BPPV. Materials and methodsRetrospective review of 220 patients diagnosed with posterior SCC underwent treatment successfully with Canalith Repositioning Maneuver. Bilateral and severe cases received medical treatment before starting the maneuver. Scheme for management of the cases had been settled. ResultsOne hundred seventy-four patients (74.5%) as the first BPPV episode while 25.5% with recurring episodes. Significant improvement was reported in 84% of patients. Etiology is not playing a role in unilateral or bilateral BPPV. Patients presented with bilateral BPPV were classified into true or unilateral mimicking bilateral BPPV. 46.7% of the patients reported sleeping using one pillow. Daily routine Brandt–Daroff exercises after the success of CRM affect the rate of recurrence. ConclusionCanalith repositioning Maneuver provides rapid relief of symptoms of BPPV. Patients with bilateral or severe BPPV required a special protocol to reach complete relief. In addition daily routine Brandt–Daroff exercises decrease the recurrence rate.

Benign paroxysmal positional vertigo: opportunities squandered.

Benign paroxysmal positional vertigo (BPPV) presentations are unique opportunities to simultaneously improve the effectiveness and efficiency of care. The test and treatment for BPPV--the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM), respectively--are supported by two evidence-based guidelines (American Academy of Otolaryngology--Head and Neck Surgery and American Academy of Neurology). With these processes, patients can be readily identified and treated at the bedside, quickly and without expensive tests. Patients randomized to the CRM have a cure rate of 80% at 24 h, compared to only 10% of controls. Despite this large effect size, less than 10% of affected patients receive the treatment, which shows that the management of BPPV in routine care is suboptimal. Future research is necessary to disseminate and implement the DHT and the CRM into routine practice.

Effect of a hybrid maneuver in treating posterior canal benign paroxysmal positional vertigo.

Benign paroxysmal positional vertigo (BPPV) is the most common disorder of the vestibular system of the inner ear, which is a vital part of maintaining balance. Although the efficacy of the Epley maneuver-also known as the canalith repositioning maneuver (CRM)-is well established, data comparing CRM versus a hybrid treatment are lacking. The purpose of this study was to determine the effect of a hybrid treatment, the Gans repositioning maneuver (GRM) either with or without postmaneuver restrictions, compared with CRM on treatment of posterior canal BPPV (PC-BPPV). Study design was a randomized controlled trial. A total of 45 patients (30 males and 15 females) with unilateral PC-BPPV were randomly allocated to one of three equal groups on the basis of the date of the first visit with matched assignment for gender: a GRMR group (GRM with postmaneuver restrictions), a GRM group, and a CRM group. Patients received weekly administration of the maneuver until resolution of symptoms. The Dix-Hallpike test was performed before treatment at every appointment, and finally after 1 mo from the last maneuver. Nystagmus duration and vertigo intensity were recorded. The supine roll test was performed in case the Dix-Hallpike test was negative to test otoconial migration. Data were analyzed with repeated-measures analysis of variance, paired t-tests with a Bonferroni correction, and the Spearman rank correlation coefficient. All patients showed improvement within the groups, and PC-BPPV symptoms were resolved by an average of 2, 1.7, and 1.6 maneuvers for GRMR, GRM, and CRM, respectively, with no statistical differences among the three groups (p > 0.05). Only two patients had recurrence, and one patient had horizontal BPPV at 1 mo follow-up. We demonstrated that the GRM as a new treatment is effective in treating PC-BPPV with no benefits to postmaneuver restrictions.

Utricular Dysfunction in Refractory Benign Paroxysmal Positional Vertigo.

To determine the prevalence of otolith dysfunction in patients with refractory benign paroxysmal positional vertigo (BPPV). Unmatched case control. Tertiary care institution. Patients included were diagnosed with BPPV, failed initial in-office canalith repositioning maneuvers (CRMs), and completed vestibular testing and vestibular rehabilitation (n = 40). Refractory BPPV (n = 19) was defined in patients whose symptoms did not resolve despite vestibular rehabilitation. These patients were compared with a control group of those with nonrefractory BPPV (n = 21) for results of a caloric test, cervical vestibular evoked myogenic potential (cVEMP), and subjective visual vertical (SVV). Forty-six of 251 patients failed initial treatment with in-office CRM. Forty patients met inclusion criteria. There was no significant difference between the cases (refractory BPPV) (n = 19) and controls (nonrefractory BPPV) (n = 21) in terms of age, duration of symptoms, laterality of BPPV, and BPPV symptoms. There was no difference in the prevalence of caloric weakness and cVEMP abnormalities (P > .05), with odds ratios (ORs [95% confidence interval (CI)]) of having abnormal results among cases vs controls of 1.1818 (0.3329-4.1954) and 4.3846 (0.7627-25.2048), for caloric and cVEMP, respectively. Abnormal eccentric SVV was more prevalent in refractory BPPV cases (58%) than in controls (14%) (P < .0072). The OR (95% CI) of having abnormal SVV was 8.25 (1.7967-37.8822) higher among patients with refractory BPPV than those with nonrefractory BPPV. Patients with refractory BPPV are more likely to have abnormal eccentric SVV and thus underlying utricular dysfunction. This finding is important to take into account when designing rehabilitation strategies for patients with BPPV who fail CRM.

Repositioning nystagmus: prognostic usefulness?

Conclusions: The presence of orthotropic nystagmus (ON), in multiple positions, appears to predict the success of canalith repositioning maneuvers (CRMs). In this sense CRMs under video-Frenzel are informative for the immediate follow-up, although not related to the degree of disability or emotional distress. Still, attention should be given to psychological assistance even in cases of clinically cured benign paroxysmal positional vertigo (BPPV). Objective: The aim of the study was to highlight the prognostic value of nystagmus in CRMs for BPPV and its relevance for emotional and patient-perceived disability. Methods: A group of 57 patients were selected from 3 balance disorders centers. CRMs were performed under video-Frenzel control. Assessment of patient disability and positional nystagmus was performed 2 months later. Emotional (Cuestionario de Impacto Emocional del Vértigo, CIEV) and quality of life (Dizziness Handicap Inventory, DHI) impact were evaluated. Results: The posterior semicircular canal (SCC) was affected in 84.2% of cases, the horizontal SCC in 10.5%, and the anterior SCC in 5.1%. Appropriate CRMs were performed. ON was present in 67% of cases. Overall resolution after the first treatment was achieved in 56% of cases. With ON present the success rate was 63% and when not observed the rate was 42%. DHI or CIEV scores were not significantly different when comparing the presence vs absence of ON. In nine patients (16%) an abnormal CIEV score was observed after treatment, even though a cured status was achieved in six of these nine patients.

Treatment of Objective and Subjective Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo in adults and is a result of otolithic particles or debris that become free floating within a semicircular canal or adhere to the cupula. Characteristics of BPPV include brief episodes of latent onset vertigo that occur with changes in head position, transient rotary nystagmus beating toward the dependent ear, and reversed nystagmus upon sitting up. Both the vertigo and nystagmus fatigue quickly while maintaining the same head position. The BPPV may be classified as objective or subjective. Objective BPPV presents all the aforementioned symptoms whereas subjective BPPV presents all the symptoms without nystagmus. The accepted method of treatment for objective BPPV is canalith repositioning maneuvers (CRM); however, CRM are not traditionally used as the method of treatment for cases of subjective BPPV. The purpose of the study was to determine if the subjective report of dizziness using the Dizziness Handicap Inventory (DHI) was different in patients with objective and subjective BPPV and to determine if the two groups showed similar improvements in perceived dizziness handicap following CRM treatment. The present study utilized a retrospective, repeated measures design. Sixty-three adults with BPPV that were given the DHI both before and after CRM treatment. Pre and post DHI results were analyzed for participants with objective versus subjective BPPV. A five-question DHI subscale was also analyzed between the groups. A significant difference was noted between initial and posttreatment DHI scores for patients in both the subjective and objective groups when using the full-scale and subscale DHI. No significant difference was noted between groups for their initial or posttreatment DHI scores. The two groups also did not differ significantly in their initial or posttreatment DHI subscale scores. The results of the study indicated that individuals with both objective and subjective BPPV demonstrated significant improvement in DHI scores following CRM treatment. Additionally, there was no difference in DHI improvement for the subjective versus objective group suggesting CRM are effective for both subjective BPPV and objective BPPV. This improvement in DHI scores was also noted in the five-question DHI subscale with no significant difference noted between groups. These findings combined with previous studies suggest the presence or absence of nystagmus during Dix-Hallpike maneuvers is not related to the effectiveness of treatment using CRM.

Use of BPPV Processes in Emergency Department Dizziness Presentations

A common cause of dizziness, benign paroxysmal positional vertigo (BPPV), is effectively diagnosed and cured with the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM). We aimed to describe the use of these processes in emergency departments (EDs), assess for trends in use over time, and determine provider level variability in use. Prospective population-based surveillance study. Emergency departments in Nueces County, Texas, from January 15, 2008, to January 14, 2011. Adult patients discharged from EDs with dizziness, vertigo, or imbalance documented at triage. Clinical information was abstracted from source documents. A hierarchical logistic regression model adjusting for patient and provider characteristics was used to estimate trends in DHT use and provider-level variability. A total of 3522 visits for dizziness were identified. A DHT was documented in 137 visits (3.9%). A CRM was documented in 8 visits (0.2%). Among patients diagnosed with BPPV, a DHT was documented in only 21.8% (34 of 156) and a CRM in 3.9% (6 of 156). In the hierarchical model (c-statistic = 0.93), DHT was less likely to be used over time (odds ratio, 0.97; 95% confidence interval, 0.95-0.99), and the provider level explained 50% (intraclass correlation coefficient, 0.50) of the variance in the probability of DHT use. Benign paroxysmal positional vertigo is seldom examined for and, when diagnosed, infrequently treated in this ED population. Use of the DHT is decreasing over time and varies substantially by provider. Implementation research focused on BPPV care may be an opportunity to optimize management in ED dizziness presentations.

The Use of the Dix-Hallpike Test and the Canalith Repositioning Maneuver in Emergency Department Dizziness Presentations: A Population-Based Study (P02.250)

Objective: To describe the use of the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM) in a population-based emergency department (ED) dizziness study. Background A common cause of dizziness, benign paroxysmal positional vertigo (BPPV), is effectively diagnosed with the DHT and treated with the CRM. No prior studies have assessed the use of these processes in ED dizziness presentations. Design/Methods: From January 15, 2008 to January 14, 2011, adult patients presenting to the ED in Nueces County, Texas, with dizziness, vertigo, or imbalance documented at triage were identified by review of ED logs, excluding those admitted to the hospital. Clinical information was abstracted from source documents. A hierarchical logistic regression model was fitted to estimate trends in DHT use and evaluate provider variability in DHT use. Results: 3,525 dizziness patients were identified. A DHT was documented in 137 visits (3.9%). The side tested was reported in 51 (37%). The DHT results were positive in 94 visits, negative in 37, and not documented in 6. Results were based on symptoms in 23, nystagmus in 21, and unknown in 93. None of the positive DHTs documented the characteristic pattern of BPPV nystagmus and only 47.9% (45 of 94) documented the affected side. A CRM was performed in only 8 visits. In the hierarchical model, every increase in month was associated with a 2% decrease in the use of the DHT (p=0.04), and the provider level explained more than 50% (ICC, 0.54) of the variance in DHT use. Conclusions: The DHT and CRM are used infrequently in this population. When documented, details about the technique and results are sparse. DHT use is decreasing over time, and varies substantially by provider. Implementation research focused on BPPV care may be an opportunity to optimize the efficiency and effectiveness of care in ED dizziness presentations. Supported by: NIHK23RR024009. Disclosure: Dr. Kerber has received personal compensation for activities with Munson Medical Center, Weinberg Group, Estes, Ingram, Foels & Gibbs as a speaker and/or consultant. Dr. Meurer has nothing to disclose. Dr. Brown has received compensation and/or their research work has been funded, entirely or in part, by a grant to their university. The grant agreement requires that the name of the funding entity and the purpose of the grant may not be disclosed. The funding entity is a governmental organization. Dr. Lisabeth has nothing to disclose. Dr. Callaghan has nothing to disclose. Dr. Fendrick has received personal compensation for activities with Abbott Laboratories, Inc., ActiveHealth Management, GlaxoSmithKline, Inc., Hewitt Associates, MedImpact HealthCare Systems Inc., Merck & Co., Inc., Novartis, and Perrigo as a consultant. Dr. Fendrick has received personal compensation in an editorial capacity for The American Journal of Managed Care. Dr. Fendrick has received research support from AstraZeneca Pharmaceuticals, Pfizer Inc, and Sanofi-Aventis Pharmaceuticals, Inc. Dr. Morgenstern has nothing to disclose.

Are Postural Restrictions Necessary for Management of Posterior Canal Benign Paroxysmal Positional Vertigo?

An important component of management of benign paroxysmal positional vertigo (BPPV) has been the application of postural restrictions after use of a canalith repositioning maneuver (CRM) to prevent the return of otolithic debris into the posterior semicircular canal (PSC). This study was designed to explore the effectiveness of postural restrictions in patients with BPPV caused by otolithic debris in the PSC. Seventy-four adult patients with unilateral PSC BPPV were enrolled into this study. All patients were managed with a CRM--either the modified Epley maneuver or the Semont maneuver. The patients were divided randomly into 2 groups: group A, with postural restrictions, and group B, without postural restrictions. The statistical analysis was performed with X2 tests and t-tests. No patients in either group showed positional nystagmus in the posttreatment evaluation under infrared videonystagmoscopy. No patients had symptoms of vertigo after the therapy. The results of follow-up vestibular tests were normal in both groups. In our experience, postural restrictions do not enhance the beneficial effect of the CRMs. They do not seem to have any protective role and therefore should not be recommended as an adjunct to the treatment of PSC BPPV.

Disconnect Between Charted Vestibular Diagnoses and Emergency Department Management Decisions: A Cross‐sectional Analysis From a Nationally Representative Sample

The most common vestibular disorders seen in the emergency department (ED) are benign paroxysmal positional vertigo (BPPV) and acute peripheral vestibulopathy (APV; i.e., vestibular neuritis or labyrinthitis). BPPV and APV are two very distinct disorders that have different clinical presentations that require different diagnostic and treatment strategies. BPPV can be diagnosed without imaging and is treated with canalith-repositioning maneuvers. APV sometimes requires neuroimaging by magnetic resonance imaging (MRI) to exclude posterior fossa stroke mimics and should be treated with vestibular sedatives and corticosteroids. We sought to determine if emergency physicians (EPs) apply best practices to diagnose and treat these common vestibular disorders. This was a cross-sectional study of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS). A weighted sample of U.S. ED visits (1993-2005) was used. Patients at least 16 years of age who were given a final ED diagnosis of BPPV (International Classification of Diseases, 9th Revision [ICD-9], 386.11) or APV (ICD-9 386.12 or 386.3x) comprised the study population. The frequency of imaging and drug therapy in those diagnosed as BPPV or APV versus controls was the main outcome measure. A total of 9,472 dizzy patient visits were sampled over 13 years (weighted estimate 33.6 million U.S. ED visits over that period). A weighted estimate of 2.5 million patients (7.4%) were given a vestibular diagnosis, mostly BPPV (weighted 0.2 million) or APV (weighted 1.9 million). Patients given BPPV (19%) and APV (19%) diagnoses were more likely to undergo imaging (all by computed tomography [CT]) than controls (7%; p < 0.001). Patients given BPPV (58%) and APV (70%) diagnoses were more likely to receive meclizine than controls (0.1%; p < 0.001). Corticosteroid administration was rarely documented (2% BPPV, 1% APV). Patients given a vestibular diagnosis in the ED may not be managed optimally. Patients given BPPV and APV diagnoses undergo imaging (predominantly CT) with equal frequency, suggesting overuse of CT (BPPV) and probably underuse of MRI (APV). Most patients diagnosed with BPPV are given meclizine, which is not indicated. Specific therapy for APV (corticosteroids) is probably underutilized. Educational initiatives and clinical guidelines merit consideration.

Benign paroxysmal positional vertigo recurrence and persistence

Benign paroxysmal positional vertigo (BPPV) is one of the most common vestibular disorders. AIM: To study the recurrence and persistence of BPPV in patients treated with canalith repositioning maneuvers (CRM) during the period of one year. STUDY DESIGN: longitudinal contemporary cohort series. MATERIALS AND METHODS: One hundred patients with BPPV were followed up during 12 months after a treatment with CRM. Patients were classified according to disease evolution. Aquatic physiotherapy for vestibular rehabilitation (APVR) protocol was applied in cases of persistent BPPV. RESULTS: After CRM, 96% of the patients were free from BPPV's typical nystagmus and dizziness. During the follow up period of 1 year, 26 patients returned with typical BPPV nystagmus and vertigo. Nystagmus and vertigo were persistent in 4% of the patients. Persistent BPPV presented improvement when submitted to APVR. Conclusion: During the period of one year, BPPV was not recurrent in 70% of the patients, recurrent in 26% and persistent in 4%.

Benign paroxysmal positional vertigo recurrence and persistence

SummaryBenign paroxysmal positional vertigo (BPPV) is one of the most common vestibular disorders.AimTo study the recurrence and persistence of BPPV in patients treated with canalith repositioning maneuvers (CRM) during the period of one year.Study designlongitudinal contemporary cohort series.Materials and MethodsOne hundred patients with BPPV were followed up during 12 months after a treatment with CRM. Patients were classified according to disease evolution. Aquatic physiotherapy for vestibular rehabilitation (APVR) protocol was applied in cases of persistent BPPV.ResultsAfter CRM, 96% of the patients were free from BPPV's typical nystagmus and dizziness. During the follow up period of 1 year, 26 patients returned with typical BPPV nystagmus and vertigo. Nystagmus and vertigo were persistent in 4% of the patients. Persistent BPPV presented improvement when submitted to APVR. Conclusion: During the period of one year, BPPV was not recurrent in 70% of the patients, recurrent in 26% and persistent in 4%.

Are postural restrictions after an Epley maneuver unnecessary? First results of a controlled study and review of the literature

Objective Postural restrictions after canalith repositioning maneuvers (CRM) for benign paroxysmal positional vertigo of the posterior semicircular canal (p-BPPV) have no proven value and therefore most physicians regard them as unnecessary. The aim of this study was to assess the short-term efficacy of head and body movement limitations after a single Epley maneuver. A review of the literature was performed to assess the current level of evidence for the efficacy of postural restrictions. Materials and methods Sixty-four patients, median age 59 years (range 37–82 years), with p-BPPV, were allocated either to instructions for movement restrictions or free movements for 48 h after a single Epley maneuver. The minimization method was used for allocation to treatment. This procedure ‘minimizes’ the differences in the distribution of pre-specified prognostic factors (e.g. sex and age) between the two groups of treatment. Minimization was preferred over randomization which is not as effective in balancing baseline characteristics when the number of participants is small. Outcome was assessed by physician and patient reported measures (Dix-Hallpike test, subjective vertigo intensity in a 10-point scale, patient's assessment of improvement) within 1 week after treatment by an independent investigator. The level of statistical significance was 0.05. Results More patients with movement restrictions reported a subjective improvement after treatment ( p = 0.007). Ninety percent of patients with movement restrictions and 74.2% of patients with free movements had a negative follow up Dix-Hallpike test but the difference was not significant ( p = 0.108). The mean pre-treatment vertigo intensity was reduced from 6.07 and 5.97 to 1.18 and 2.86, respectively but the difference was not significant ( p = 0.122). Conclusions Postural restrictions do not increase the efficacy of the canal-repositioning maneuver despite the fact that patients report a subjective improvement after post-procedural instructions. In the review of the literature, all studies except one conclude that postural restrictions are unnecessary. However, a number of methodological issues such as inadequate sample size are not addressed and more conclusive evidence is required. Based on current evidence, the use of postural restrictions after the canal-repositioning maneuver is unjustified.

Balance in posterior and horizontal canal type benign paroxysmal positional vertigo before and after canalith repositioning maneuvers

Benign paroxysmal positional vertigo (BPPV) is characterized by acute, brief and rotatory vertigo attacks provoked by changes in head position. Most patients complain of a loss of equilibrium and unstable gait during and between the vertigo attacks. Canalith repositioning maneuvers (CRM) relieve attacks and improve postural stability. In this study balance ability of 32 patients with PC BPPV and 12 patients with HC BPPV before and after treatment with CRM was investigated. 50 healthy volunteers served as the control group. Static balance was measured as mean center of gravity sway velocity recorded in four different conditions: on a static platform and on foam with eyes open and closed. Dynamic balance was measured in tandem walk test. PC BPPV patients demonstrated greater sway velocity in stance on foam with eyes closed. After CRM the velocity decreased significantly. The results of the HC BPPV patients were not different from the healthy volunteers all through the four test conditions. Walking speed of the patients both with PC BPPV and HC BPPV was significantly low. It increased after treatment in both groups. In conclusion, patients with PC BPPV had impaired static balance ability due to a clot in the affected canal. Dynamic balance ability measured by walking speed was impaired both in PC and HC BPPV patients. Static and dynamic deficits improved significantly after CRM.

Relationship Between Bone Mineral Density and Clinical Features in Women With Idiopathic Benign Paroxysmal Positional Vertigo

To evaluate the relationship between bone mineral density (BMD) and clinical features in women with idiopathic benign paroxysmal positional vertigo (IBPPV). Prospective study. Tertiary referral center. Patients with BMD measurements made after a diagnosis of IBPPV were included. The IBPPV (n = 78) and control groups (n = 177) were divided into ordinal age categories of similar size. Group A (n = 20) patients were aged 20 to 39 years, Group B (n = 21) patients were aged 40 to 49 years, Group C (n = 18) patients were aged 50 to 59 years, and Group D (n = 19) patients were aged 60 to 69 years. In each age range, the BMD values were compared according to the number of canalith repositioning maneuvers (CRMs) or the presence of recurrence. We divided all patients into 2 groups with the normal and abnormal BMD values and compared both groups based on the number of CRMs or the frequency of recurrence. The BMD value, the number of CRMs, and the presence of recurrence. In Groups A, B, and C, there was a significant difference in the BMD values between the control, 1-visit, and 2-or-more-visits subgroups. In Group D, the 2-or-more-visits subgroup had a lower BMD value than other subgroups. The difference in the number of CRMs between the normal and abnormal BMD groups was significant. In Groups A and B, there was a significant difference in the BMD values between the control, first-attack, and recurrent-attacks subgroups. In Groups C and D, the recurrent-attacks subgroup had lower BMD values than other subgroups. The difference in the frequency of recurrence between the normal and abnormal BMD groups was significant. Patients with IBPPV had lower BMD values compared with control subjects, and patients with low BMD values showed a significant increase in the number of CRMs required and the recurrence rate.

Clinical Features of Benign Paroxysmal Positional Vertigo in Western Turkey

Background: It was the aim of this study to analyze the clinical manifestations, the incidence of each variant and the comorbid conditions of benign paroxysmal positional vertigo (BPPV) as well as the response to treatment. Methods: One hundred and fifty-seven patients with BPPV were reviewed prospectively. An extensive neurotologic examination was performed. All patients were treated with an appropriate canalith repositioning maneuver (CRM). Results: In 138 patients, the posterior canal (PC) was involved, in 14 patients, the horizontal canal (HC), in 2 patients, the anterior canal (AC), and in 3 patients, both the PC and HC. A history of head trauma was identified in 17 patients. In 1 patient sensorineural hearing loss on the affected side and in another bilateral peripheral vestibular loss was present. A history of migraine was reported in 21 cases. A resolution attributable to the first CRM was achieved in 132 patients. Conclusions: PC involvement was the most frequent type constituting 87.9% of all BPPV cases. HC, AC and mixed canal types were relatively rare constituting 8.9, 1.3 and 1.9% of the cases, respectively. Response to the first CRM was recorded in 84.1%. Association with migraine was recorded in 13.4% of the patients.

Anterior Canal Benign Paroxysmal Positional Vertigo

Evaluate the frequency and characteristics of benign paroxysmal positional vertigo (BPPV) arising from involvement of the anterior semicircular canal (AC) as compared with the posterior canal (PC) and horizontal canal (HC). Prospective review of patients with BPPV. Tertiary referral center. A total of 260 patients who were evaluated for vertigo were identified as experiencing BPPV. Standard vestibular assessment including the use of electrooculography (EOG) or video-oculography (VOG) was completed on all patients. Based on EOG/VOG findings, the BPPV origin was attributed to AC, PC, or HC involvement secondary to canalithiasis versus cupulolithiasis. Treatment was performed with canalith repositioning maneuvers (CRMs) appropriate for type of canal involvement. For the 260 patients, the positionally induced nystagmus patterns suggested the canal of origin to be AC in 21.2%, PC in 66.9%, and HC in 11.9%. Cupulolithiasis was observed in 27.3% of the AC, 6.3% of the PC, and 41.9% of the HC patients. Head trauma was confirmed in the history preceding the onset of vertigo in 36.4% of the AC, versus 9.2% of the PC and 9.7% of the HC patients (p < 0.001). The number of CRMs completed to treat the BPPV did not differ between canals involved (1.32 for AC, 1.49 for PC, and 1.34 for HC). The direction of subtle vertical-beating nystagmus underlying the torsional component is critical in differentiating AC versus PC origin; EOG/VOG aids in accurate assessment of the vertical component for the diagnosis of canal involvement. AC involvement may be more prevalent than previously appreciated, particularly if the examiner does not appreciate the vertical component of the nystagmus or the diagnosis is made without the assistance of EOG/VOG. Head trauma history is significantly more frequent in AC versus other forms of BPPV, and patients with a history of head trauma should be examined closely for AC involvement. CRM is as successful for treatment of AC BPPV as for other types of BPPV.

Efficacy of a New Treatment Maneuver for Posterior Canal Benign Paroxysmal Positional Vertigo

Existing treatment maneuvers for posterior canal benign paroxysmal positional vertigo (PC-BPPV) include the Semont liberatory maneuver (SLM) and canalith repositioning maneuver (CRM). Independent investigations reveal that these maneuvers provide an excellent outcome for most patients. However, certain aspects of these maneuvers, such as hyperextension of the neck for CRM and brisk lateral motion for the SLM, are contraindicated for patients with vertebrobasilar insufficiency, cervical spondylosis, back problems, and so forth. A hybrid approach, the Gans repositioning maneuver (GRM) was developed for use with these patients. The purpose of this project was to assess efficacy of the GRM for treatment of PC-BPPV. Two-hundred seven participants were enrolled in this prospective study. All participants were treated with the GRM. Six different clinicians performed the treatments. Participants returned for follow-up at one-week intervals until it was determined that the PC-BPPV was clear. On average, 1.25 GRM treatments were required to resolve the PC-BPPV. The majority of the participants (80.2%) were cleared with one GRM treatment, and 95.6% were clear after two treatments. Recurrence rate was 5%. There was no difference in outcome based on clinician. The GRM is an efficacious treatment maneuver for PC-BPPV and may be preferential for use in patients with neck, back, hip, and/or mobility issues that contraindicate the use of SLM or CRM.

The 57th Annual Meeting of the American Academy of Neurology, Miami, Florida, April 9-16, 2005

The 57th Annual Meeting of the American Academy of Neurology, Miami, Florida, April 9-16, 2005