Comments on Recent Papers related to BPPV

Timothy C. Hain, MD   Page last modified: August 7, 2010

These are arranged chronologically.

• Choi SJ, Lee JB, Lim HJ, Park HY, Park K, In SM, Oh JH, Choung YH.Clinical features of recurrent or persistent benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2012 Nov;147(5):919-24. doi: 10.1177/0194599812454642. Epub 2012 Jul 17. This paper discusses the case composition of BPPV in a Korean hospital. Korean BPPV seems quite different than BPPV worldwide -- they have much more persistent BPPV, and only 10% of their cases are recurrent (although 50% is the norm).
• Lin, S. Z., J. P. Fan, et al. (2010). "Efficacy of laser occlusion of posterior semicircular canal for benign paroxysmal positional vertigo: case report." J Laryngol Otol 124(5): e5. Another report of laser occlusion of the PC. Comment: This work resembles the classic paper of Dr. Phil Anthony on the same subject. Sadly, neither the author's nor the reviewers appear to be familiar with the BPPV literature.
• Helminski JO, Zee DS, Janssen I, Hain TC. (2010).  Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review.  Physical Therapy 90(5) 1-16. This paper reviews data concerning treatment trials of BPPV.
• Amor-Dorado et al. Benign paroxysmal positional vertigo and clinical test of sensory interaction and balance in systemic sclerosis. Otology and Neurotology 2008, 1155-1161. There is more BPPV in patients with scleroderma (an autoimmune disease)
• Hong SM and others. Subjective visual vertical during eccentric rotation in patients with benign paroxysmal positional Vertigo. Otology and Neurotology, 2008. 1167-1170. This paper describes a significant shift in the SV when the utricle is stimulated by eccentric rotation in BPPV patients. It suggests that there is unilateral utricular disease in persons with BPPV. One would think that ocular VEMP's would also be abnormal.
• Yang WS and others. Clinical significance of Vestibular evoked myogenc potentials in Benign Paroxysmal Positional vertigo. Otol Neurotol 29:1162-1166, 2008. This paper reports prolonged latencies of VEMP's in persons with BPPV. The amount of prolongation was small, approximately 2 ms, and of no significance.
• Hughes CA, Proctor L. Benign paroxysmal Positioanl Vertigo. Laryngoscope 1997:107(5) 607-13. In a review of 187 patients, 36 were felt to be secondary to another ear disease. In 151, 34% had a diagnosis of Meniere's disease. Comment: Most people estimate that 5% of BPPV is due to Meniere's. At this institution (John's Hopkins), they found a far higher percentage. Either we have underestimated Meniere's contribution to BPPV or the referral pattern at this institution is different than most. We think the latter is almost certainly the case.
• Brevern MV, Lempert T, Bronstein AM, Kocen R. Selective vestibular damage in neurosarcoidosis. Ann Neurol 1997:42:117-120. This paper reports a single case with apparent bilateral lateral canal vestibular paresis but preserved vertical canal function and BPPV. This article demonstrates that bilateral vestibular paresis (on ENG) is not incompatable with the diagnosis of BPPV and also that such patients may have preserved vertical canal function.
• Welling Db, Parnes LS, O'Brien B, Bakaletz LO, Brackman DE, Hinojosa R. Particulate matter in the posterior semicircular canal. Laryngoscope 107(1):90-4, 1997. Particles were found in 8/26 patients with BPPV at the time of surgery.  No particles were found in 73 patients without BPPV.
• Dunniway HM, Welling DB. Intracranial tumors mimicking benign paroxysmal positional vertigo. Otolaryngol HNS, 1998:118:429-36. These authors report 5 patients with intracranial conditions mimicking BPPV. They recommend MRI imaging in individuals who do not respond to particle repositioning done twice or who have associated auditory or neurologic symptoms. COMMENT: This is reasonable. Because BPPV is so common, it seems possible that some of these patients may have had both BPPV and unrelated intracranial lesions.
• Vannucchi P, Giannoni B, Pagnini P. Treatment of horizontal canal benign paroxysmal positional vertigo. J. Vest Res. 7(1):-6, 1997. COMMENT: These authors treated lateral canal BPPV by having them lie one one side with the "healthy" ear down for 12 hours and reported cure within 3 days in 74%. No treatment resulted in cure in only 24%.   It is difficult to understand why this procedure should work this well, as debris on the ampullary end of the lateral canal would not be seem likely to move by itself up and around the canal. However, sleeping healthy ear down overnight would seem like a reasonable procedure after a "log roll" maneuver.
• Furman JM, Cass SP, Briggs BC. Treatment of benign positional vertigo using heels-over-head rotation. Ann ORL 1998 107(12) 1046-53. A device is described that rotates subjects through 360 degrees to treat BPPV. This is both an effective procedure as well as provides additional proof for the canalithiasis hypothesis for the mechanism of classic BPPV.
• Zucca G, Valli AS, Valli P, Perin P, Mira E. Why do benign paroxysmal positional vertigo episodes recover spontaneously ? J. Vest Res, 8, 4, 325-329, 1998. These authors suggest that otoconia dissolve in endolymph within about 20 hours, and suggest that this is the reason for spontaneous recovery of BPPV. They do not mention the "dark cell" theory of otoconial resolution. They speculate that lack of spontaneous recovery might be related to increased calcium levels in the endolymph, trapping of otoconia, or ongoing production of loose otoconia. COMMENT: this paper is a useful addition to the literature. The role of the dark cells and the explanation for lack of spontaneous recovery remain obscure.
• Quincoceres CM, Tusa RJ, Herdman SJ. Efficacy of remaining upright for 1, 2 or 3 days following canalith repositioning treatment. This abstract indicates that there is no difference between 1, 2 or 3 days. COMMENT: This paper would support use of 1 day rather than 2 or 3 days sleeping upright. It apparently is not relevant to the more common procedure of having patients sleep half-upright, and as such, it's significance is difficult to determine.
• Dornhoffer JL, Colvin GB. Benign paroxysmal positional vertigo and canalith repositioning: clinical correlations. Am J Otol 2000 Mar;21(2):230-3. In 52 patients, CRP without use of vibration resulted in 66% cure initially, and eventually 99% cure rate with multiple treatments. COMMENTS: This paper suggests vibration is not necessary for good results.
• O'Reilly RC, Elford B, Slater R. Effectiveness of the particle repositioning maneuver in subtypes of benign paroxysmal positional vertigo. Laryngoscope 110:1385-1388, 2000. In 71 patients, the canalith repositioning maneuver was very effective in both primary and secondary BPPV. COMMENT: Another paper supports CRP effectiveness.
• Ruckenstein MJ. Therapeutic efficacy of the Epley canalith repositioning maneuver. Laryngoscope 2001 Jun;111(6):940-5 . COMMENT: Another paper supports CRP effectiveness. About 100 patients. Immediate resolution in nearly all. 4% failed 4 treatments.
• Tirelli G, D'Orlando E, Giacomarra V, Russolo M. Benign positional vertigo without detectable nystagmus. Laryngoscope 2001 Jun;111(6):1053-6 . In this paper it is suggested that the CRP is effective even without a diagnosis of BPPV. COMMENT: This paper could suggest, abeit indirectly, that the CRP might be a placebo maneuver, or that improvement might be in part related to the passage of time (see Zucca et al, above) rather than the CRP procedure, per se. This is probably correct -- additional controlled studies are needed.
• Levrat and others. Efficacy of the Semont maneuver in benign paroxysmal positional vertigo. Arch Otolaryngol HNS 2003:129:629-633. COMMENT: This is an uncontrolled treatment study of 278 patients. More than 90% of patients were cured after a maximum of 4 maneuvers.
• Kaplan DM, Attal U and Kraus M (2003). "Bilateral benign paroxysmal positional vertigo following a tooth implantation." J Laryngol Otol 117(4): 312-3. COMMENT: Another paper documenting that BPPV can follow surgery, especially to the head area.
• Gacek RR (2003). "Pathology of benign paroxysmal positional vertigo revisited." Ann Otol Rhinol Laryngol 112(7): 574-82. Gacek reports results of studies of 5 temporal bones from patients with BPPV. Debris was attached to the cupula in one temporal bone. The remainder had reductions in neurons in various divisions of the vestibular nerve. COMMENT: It is difficult to see how neural damage could cause BPPV to remit after a positional maneuver.
• Vibert D, Kompis M and Hausler R (2003). "Benign paroxysmal positional vertigo in older women may be related to osteoporosis and osteopenia." Ann Otol Rhinol Laryngol 112(10): 885-9. COMMENT: This paper indicates that 75% of persons with BPPV have osteopenia or osteoporosis. Perhaps this is related to decreased activity in dizzy persons.
• Cohen, H. S., et al. (2004). "Treatment variations on the Epley maneuver for benign paroxysmal positional vertigo." Am J Otolaryngol 25(1): 33-7. COMMENT: Although this paper suggests that the all positions of the Epley maneuver are not necessary, and that an abbreviated version omiting the sidelying position is adequate, the figure within the paper suggests the opposite. We continue to recommend doing a full Epley maneuver (called an "augmented Epley" in this article).
• SIMHADRI S, Panda N, Raghunathan M. Efficacy of particle repositioning maneuver in BPPV: a prospective study. Am J Otolaryngol 2003;24:355-60. COMMENT: In 40 subjects, CRP was much better than placebo.
• Uneri A (2004). Migraine and benign paroxysmal positional vertigo: An outcome study of 476 patients. ENT journal Dec 2004, 83, 12, 814-815. This is an uncontrolled retrospective study. 54.8% of patients with BPPV had migraine headaches. COMMENT: This study is difficult to put into perspective because it lacks a control group. One wonders what percentage of, say the vestibular neuritis population in the same clinical context, have migraine headaches too. Nevertheless, it adds another connection between Migraine and BPPV.
• Salvinelli, F., M. Trivelli, et al. (2004). "Treatment of benign positional vertigo in the elderly: a randomized trial." Laryngoscope114(5): 827-31. COMMENT: This paper compares treatment with the Semont maneuver to medical treatment (flunarizine). The Semont maneuver was much more effective than flunarizine.

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