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NEUROLOGY 2007-68-manuscript.pdf
NEUROLOGY/2006/174763
Predicting a Successful Treatment in
Hui Jong Oh, MD, PhD.* Ji Soo Kim, MD, PhD1. Byung In Han, MD*.
Jeong Geun Lim, MD2
MTV (Migraine, Tinnitus and Vertigo) clinic, Oh Neurology Center,
Department of Neurology,
Department of Neurology,
Word Count for the Paper:
Character count for the title: 11
Word Count for the Abstract: 166
Number of figures: 1
Number of tables: 1
Number of video clips: 3
Acknowledgments
* Hui Jong Oh and Ji Soo Kim equally contributed to this study. The authors wish to thank Hyang Sook Kim, Bo Ra Jeon, and Min Gyeong Choi in the Neurotology Laboratory of Oh Neurology Center for their practical assistance during the patient examination. Hye Jung Son at Keimyung University School of Medicine is thanked for her assistance in the preparation of the manuscript.
Address for correspondence; Byung In Han, MD
MTV (Migraine, Tinnitus and Vertigo) clinic
Oh
200-13,
Tel; 82 - 53 - 476 - 7577
Fax; 82 - 53 - 476 - 7579
e-mail; byung_in@hotmail.com
Abstract
OBJECTIVE: To elucidate characteristics and prognostic value of positioning nystagmus during the second position of the maneuver (90O contralateral head-turn from the initial Hallpike maneuver). METHOD: The Epley maneuver was performed in126 patients with confirmed PC-BPPV. The characteristics of positioning nystagmus were investigated using video Frenzel goggles. RESULT: During the second position, 99 patients developed torsional upbeating nystagmus which was in the same direction (orthotropic nystagmus) as the one during the first position (Hallpike maneuver), while 15 patients showed a reversed pattern. In 12 patents, nystagmus was not induced during the second position. All the 99 patients with orthotropic nystagmus had resolution of BPPV after the first or second trial of the Epley maneuver. In contrast, 12 of the 15 patients with reversed nystagmus and 8 of the 12 patients without nystagmus failed to resolve. CONCLUSION: During the second position of the Epley maneuver, orthotropic pattern of nystagmus predicts a successful repositioning while the reversed nystagmus or no nystagmus is suggestive of poor response to repositioning. (Neurology. 2007 Apr 10;68(15):1219-22)
-Oh HJ, Kim JS, Han BI (Corresponding author), Lim JG. Predicting a successful treatment in posterior canal benign paroxysmal positional vertigo. Neurology. 2007 Apr 10;68(15):1219-22.
Introduction
The Epley maneuver in benign paroxysmal positional vertigo involving the posterior semicircular canal (PC-BPPV) is based on the mechanism of canalolithiasis, which holds that the otolithic debris floats freely in the endolymph of the posterior canal.1 For successful repositioning, the particles should be moved away from the ampulla to the dependent position during each step of the Epley maneuver, and the induced nystagmus would be upbeating with the torsional component beating toward the involved ear (i.e., orthotropic).2,3 It has been suggested that a reversed pattern of positioning nystagmus during the Epley maneuver indicates ampullopetal migration of the debris and repositioning failure.2,4 Furthermore, some patients with intractable BPPV are considered to have cupulolithiasis which would explain the mechanism of BPPV as resulting from otolithic debris attached to the cupula.1,3,5 It is difficult to differentiate cupulolithiasis from canalolithiasis based on the history or the patterns of nystagmus evoked during the Dix–Hallpike maneuvers since both conditions would give rise to ampullofugal displacement of the cupula in the involved canal.2 It has been postulated that the reversed pattern of nystagmus during the second position of the Epley maneuver (90O contralateral head-turn after initial Hallpike maneuver, figure) is suggestive of cupulolithiasis.1–3 Since no systematic studies have investigated the nystagmus pattern during the Epley maneuver and its correlation with the repositioning results, we evaluated the predictive value of the nystagmus for successful repositioning by studying the nystagmus pattern during the second position of the Epley maneuver.
From December 2005 to June 2006, all patients at the Oh Neurology Center,
Each patient was seated on an examination table so the neck extended over the edge of the table when he or she became supine. The basic strategy of the Epley maneuver is to rotate the involved canal slowly in the plane of gravity so that free-floating materials migrate into the utricle. The repositioning maneuver was performed in five steps involving sequential positional changes, as initially described by Epley (figure).7 Throughout the sequence, we observed the nystagmus elicited by each positional change with video Frenzel goggles. The sequence was as follows (figure). (S) Position S: in the sitting position, the head was turned horizontally 45° toward the affected ear; (1) Position 1: the patient was tilted approximately 105° backward into a slight head-hanging position, causing the particles to move in the canal away from the ampulla to the dependent position. The patient was kept in this position at least for 3 minutes; (2) Position 2: when vertigo had subsided completely, the head was turned 90° to the unaffected side. The patient was kept in this position for 3 minutes; (3) Position 3: the head and trunk were turned another 90° in the same direction until facing downward, causing the particles to move toward the exit of the canal. The patient was kept in this position for 3 minutes; (4) Position 4: while the head was kept turned toward the unaffected side, the patient was moved to the sitting position and immediately to the next position; (5) Position 5: the head was turned forward, with the chin lowered 20°.
After a session involving the Epley maneuver, the patient was transferred to a chair and held there by someone at least for 10 minutes to prevent the patients from falling. After sitting on a chair for 1 to 2 hours in our clinic, the patient was allowed to go home with instructions to maintain an upright position until going to bed, and not to lie on the affected ear for a further 7 days.2
Follow-up visits to evaluate the repositioning result were made at intervals of 1 to 3 days. Successful repositioning was determined by complete relief of the vertigo and a conversion to a negative Dix–Hallpike test. If the positional nystagmus and symptoms persisted, the treatment was considered a failure and the Epley maneuver was repeated. Those who failed to resolve after the second trial were instructed to perform the Brandt–Daroff exercises at home until the symptoms resolved. If the symptoms and positional nystagmus persisted more than 2 weeks after the initial trial, the patients underwent MRI and MR angiography of the brain.
During the study period, 126 patients were confirmed to have PC-BPPV. The patients included 29 (23.0%) men and 97 (77.0%) women and their ages ranged from 30 to 83 years (mean ± SD: 60 ± 10.7, median 62). At initial evaluation, the reported duration of the symptoms ranged from 1 day to 8 months. The affected side was the right in 95 patients and the left in 31.
Repositioning was successful in 101 (80.2%) of the 126 patients after the initial treatment, and another five achieved resolution after the second trial. The remaining 20 patients had persistent BPPV despite repeated maneuvers, and performed the Brandt–Daroff exercises.
Of the 101 patients who showed resolution of BPPV after the initial trial, 94 (93.1%) had rotatory upbeating nystagmus in the second position of the Epley maneuver (figure), which was in the same direction as that during the first position (orthotropic nystagmus), whereas three patients exhibited a reversed pattern of nystagmus. The remaining four patients did not develop nystagmus (Table).
Twenty-five patients did not achieve resolution of BPPV after the initial trial. Of these, 12 (48.0%) developed a reversed pattern of nystagmus in the second position of the Epley maneuver (figure) and eight showed no nystagmus while only five (20.0%) patients exhibited an orthotropic nystagmus. In the 25 patients who failed to show resolution of the PC-BPPV after the initial trial, the Epley maneuver was repeated on the next visit. Of these, five patients with positional nystagmus in the orthotropic direction during the second position of the Epley maneuver (figure) showed resolution after the second trial, whereas 12 with reversed nystagmus and eight without nystagmus showed persistent BPPV despite the second trial. The 20 patients who failed to show resolution after the second trial reported marked improvement of the symptoms after 2 to 14 days of the Brandt–Daroff exercises. One patient who had orthotropic nystagmus during the second position (figure) of the initial repositioning trial showed a transition into BPPV involving the horizontal canal (HC-BPPV) of the same ear during the follow-up evaluation.
Of the 99 patients with an orthotropic pattern of nystagmus in the second position of the Epley maneuver (figure) during the initial trial, resolution occurred in 94 (94.9%) after the initial trial, and the other five (including one who showed a transition into HC-BPPV after the initial trial) achieved resolution after the second trial. In contrast, of the 15 patients with reversed nystagmus, only three (20.0%) showed resolution of BPPV after the first trial, and the other 12 failed to resolve.
Of the 12 patients with no nystagmus, resolution occurred in four (33.3%) after the initial trial and the other eight failed to resolve. Although four patients had resolution after the initial trial, BPPV recurred in three of them after 1 to 7 months (PC-BPPV on the same side after 3 months, HC-BPPV on the same side after 7 months, and PC-BPPV on the opposite side after 1 month). No recurrence of BPPV was observed in the patients with orthotropic or reversed nystagmus for the following 7 months.
For the patients with orthotropic, reversed, and absent nystagmus during the second position of the initial Epley maneuver (figure), no difference was noted in age, the affected side, or symptom duration.
The orthotropic nystagmus induced during the second position of the Epley maneuver (figure) was characterized by the followings: predominantly rotatory with the fast phase toward the affected ear, a brief latency of 1–5 s, and a usual duration less than 10 s. In contrast, the reversed nystagmus was usually rotatory toward the unaffected ear with a shorter latency of 0 to 2 s, less intensity, and variable durations. The reversed nystagmus was also observed when repositioning was repeated, but its intensity decreased on the subsequent follow-up evaluation.
In position 3 (figure), nystagmus was occasionally induced in the patients who already showed orthotropic or reversed nystagmus in the second position. The nystagmus during position 3 replicated the previous nystagmus, lasting a few seconds. However, this nystagmus was not evident in most patients.
In position 4 (figure), when the patient returned to the upright position, downbeat nystagmus developed in 28 patients. Of these, 22 resolved after the initial trial, another two resolved after the second trial, and the remaining four failed to resolve. Of the 28 patients with downbeat nystagmus in position 4, 21 showed orthotropic nystagmus in the second position, four developed reversed nystagmus, and three had no nystagmus.
Overall, an orthotropic pattern of nystagmus in the second position of the Epley maneuver (figure) indicated successful repositioning with a positive predictive value of 94.9%. In contrast, the reversed pattern or absence of nystagmus was suggestive of a poor response to repositioning. However, occasional downbeating nystagmus on sitting was not an indicator of a poor prognosis.
In PC-BPPV, the results of particle repositioning are predicted by the characteristics of nystagmus induced during the Epley maneuver,1–3,5 and the importance of nystagmus pattern in the second position of the Epley maneuver (figure) is well recognized.1–3 In the second position, induced nystagmus continuing in the direction in which it began was thought to indicate that the otolithic debris moved in the correct direction into the common crus, which demonstrated successful repositioning of the particles (figure A).2,3
A reversed pattern of nystagmus during the second position of the Epley maneuver (figure) has two clinical implications. First, it has been postulated that the particulate matter is attached to the cupula, resulting in ampullopetal deflection of the cupula,1,3 and this may be a pathognomonic sign of cupulolithiasis (figure B).1 Second, the free-floating particles might move backward into the cupula, implying that repositioning was unsuccessful (figure C). 2,4 A recent publication also stated that positioning nystagmus with the torsional component toward the uppermost involved ear during the second position indicates that the plug has left the canal, i.e., the therapy was successful, while positioning nystagmus toward the undermost healthy ear means that the liberatory maneuver failed and must be repeated.9
We also demonstrated that the reversed pattern of nystagmus during the second position of the Epley maneuver (figure) is mostly indicative of repositioning failure. The poor outcome of repositioning in those patients with reversed nystagmus might be due to cupulolithiasis or ampullopetal migration of the otolithic debris. Cupulolithiasis should also be suspected if the torsional upbeating nystagmus persists for more than 60 s during the Dix–Hallpike maneuvers.10 The reversed nystagmus should be carefully differentiated from geotropic nystagmus of the ipsilateral HC-BPPV. If the revered nystagmus was obviously strong, Dix-Hallpike maneuver should be repeated in the contralateral side, to rule out bilateral PC-BPPV.
The patients who did not develop nystagmus in the second position tended to have intractable or recurring BPPV. We postulate that these patients might have cupulolithiasis that is intractable to repositioning or free-floating particles with low density, which are dispersed and easily recur. Four plausible mechanisms may explain the absence of nystagmus in the second position. First, in cupulolithiasis, the cupula may be parallel to the gravity vector so that the cupula is not deflected, even with the attached otolithic debris. Second, the positioning might be suboptimal so that the dispersed particles migrate in both ampullopetal and ampullofugal directions. Third, during the previous positioning, the free-floating particles became too dispersed to elicit nystagmus. Fourth, adaptation may suppress the induced nystagmus.11
Downbeating nystagmus on sitting after the Hallpike maneuver has been explained by ampullopetal migration of the otolithic debris.12 According to this postulate, the downbeating nystagmus in the fourth position of the Epley maneuver (sitting, figure) indicates a failure of repositioning. In our observations, however, most of the patients with downbeating nystagmus on sitting (Position 4, figure) showed resolution of BPPV after the repositioning maneuver. This implies that the mechanism of downbeat nystagmus in the fourth position of the Epley maneuver differs from that of the downbeating nystagmus observed on sitting after the Hallpike maneuver.13
In the patients who had typical symptoms of BPPV, but did not show positional nystagmus during the first examination, we have found that the positional nystagmus became obvious after several attempts of the Dix–Hallpike maneuvers or Brandt–Daroff exercises. This might occur when the particles adhering to the canal are freed after the liberatory exercise. We have also observed that some patients fell backwards suddenly while sitting on a bed or moving to a chair approximately 3 to 60 s after the particle-repositioning maneuver. Two of our patients fell backward abruptly while walking 10 minutes after the repositioning maneuver. This may be due to the new position of the particulate matter in the vestibule, resting against the utricle in an unfamiliar position.3 Therefore, special caution is required to protect patients from unpredicted falls by having someone hold the patient for at least 10 minutes following the repositioning.
Previous studies have recommended pauses of varying duration, from 1 to 2 minutes or until the nystagmus and vertigo stopped, at each position during the particle-repositioning maneuver.2-4,7,14 Some authors rolled the patient’s head 180° all the way from position 1 to position 3 without stopping at position 2.2,3,14 Thus far, no standardized duration at each repositioning position exists, and no evidence has indicated whether stopping longer at each position is superior. In this study, however, the authors sought to eliminate confounding factors other than the direction of nystagmus induced at position 2 (figure), and permitted sufficient time (3 minutes) for the particles to settle down to the dependent position at each position (from positions 1 to 3, figure). Maintaining the upright posture for 48 h and not lying on the affected side for 7 days was once suggested.2 However, maintaining an upright posture for 48 h after repositioning turned out to be bothersome and ineffective.15 Not lying on the affected side was based on a study suggesting that sleeping on one side is a causative mechanism of BPPV.16 The optimal length of time at each position during the particle repositioning maneuver and the effectiveness of the post-maneuver instructions should be validated further.
References
1, Parnes LS, McClure JA. Free-floating endolymph particles: a new operative finding during posterior semicircular canal occlusion. Laryngoscope 1992;102:988-992.
2, Parnes LS, Price-Jones RG. Particle repositioning maneuver for benign paroxysmal positional vertigo. Ann Otol Rhinol Laryngol 1993;102:325-331.
3, Welling DB,
4, Beynon GJ. A review of management of benign paroxysmal positional vertigo by exercise therapy and by repositioning manoeuvres. Br J Audiol. 1997;31:11-26.
5, Brandt T. Arguments for canalolithiais. In: Brandt T. Vertigo. 2nd ed.
6, Dix MR, Hallpike CS, Pathology, symptomatology and diagnosis of certain disorders of the vestibular system. Proc R Soc Med 1952;45:341-354.
7, Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399-404.
8, Han BI, Oh HJ, Kim JS. Nystagmus while recumbant in horizontal canal benign paroxysmal positional vertigo. Neurology 2006;66:706-710.
9, Brandt T, Dieterich M, Strupp M. Physical liberatory maneuvers. In: Brandt T, Dieterich M, Strupp M. Vertigo and dizziness. Springer 2005;47-50.
10, Herdman SJ, Tusa RJ. Schematic for assessment leading to treatment (Flowchart for the diagnosis of BPPV). In: Herdman SJ. Vestibular rehabilitation. 2nd ed. F.A. Davis Company.
11, Furman JMR, Hain TC, Paige GD. Central adaptation models of the vestibuloocular and optokinetic systems. Biol Cybern 1989;61:255-264.
12, Brandt T, Dieterich M, Strupp M. Reversal of nystagmus. In: Brandt T, Dieterich M, Strupp M. Vertigo and dizziness. Springer 2005;46.
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14, Brandt T, Dieterich M, Strupp M. Figure 2.2, Schematic drawing of modified Epley liberatory maneuver. In: Brandt T, Dieterich M, Strupp M. Vertigo and Dizziness. Springer 2005;48.
15, Gordon CR, Gadoth N. Repeated vs single physical maneuver in benign paroxysmal positional vertigo. Acta Neurol Scand. 2004 Sep;110:166-169.
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Figure Legend
Figure. Schematic drawing of each position during the Epley maneuver (left ear) and mechanism of each type of nystagmus in position 2. A clump of particulated matters move in the correct direction into the common crus resulting in a successful repositioning and induces an orthotropic nystagmus (A). Heavy cupula with an otolith deposit deflects ampullopetally and induces a reversed nystagmus (B). The particles move back towards the cupula and induce a reversed nystagmus, implying that repositioning is unsuccessful (C). S = start. Each number indicates the corresponding position. N = nystagmus.
Video Legends
Video 1. Orthotropic nystagmus is rotatory upbeating in the second position of the Epley maneuver (the same direction as that during the first position). This nystagmus is predominantly rotatory, usually lasting less than 10 s, with the fast phase toward the affected ear and a brief latency of 1 to 5 s. Orthotropic nystagmus predicts a successful repositioning.
Video 2. Reversed nystagmus in the second position of the Epley maneuver develops in the opposite direction that is observed during the first position. This nystagmus has a latency of several seconds and weak intensity, and usually lasts for several seconds. Reversed nystagmus predicts a repositioning failure.
Video 3. No nystagmus. If nystagmus does not occur during the second position of the Epley maneuver, the result of repositioning is unpredictable.