Persistent Vertigo Following Particle Repositioning Maneuvers an Analysis of Causes

ORIGINAL ARTICLE Persistent Vertigo Following Particle Repositioning Maneuvers An Analysis of Causes

Vedantam Rupa, MS, DLO

Objective: To analyze the causes of persistent vertigo ing at least 3 sessions of PRMs over a period of 2 weeks. following treatment with particle repositioning maneuvers (PRMs) in patients with benign paroxysmal posi- Results: Seven patients showed partial or no improve- tional vertigo. ment following treatment. The causes subsequently de- termined included coincident horizontal canal posi- Design: Prospective study of outcomes in patients with tional vertigo (2 cases), Me´nie`re’s disease (2 cases), benign paroxysmal positional vertigo. persistent posterior canal benign paroxysmal positional vertigo in association with cervical spondylosis (2 cases), Study Setting: Outpatient clinic of a tertiary care re- and a posterior fossa meningioma (1 case). ferral center. Conclusions: Patients with persistent or frequently re- Patients: A sample of 90 consecutive patients with docu- curring positional vertigo following treatment with PRMs mented benign paroxysmal positional vertigo of the pos- should undergo detailed investigation to exclude coinci- terior semicircular canal who had persistent vertigo af- dental pathology for which specific treatment is required. ter at least 3 sessions of PRMs during a period of 2 weeks. In patients in whom no coincident pathology requiring therapy is identified, treatment options other than the PRM Intervention: Particle repositioning using a modified already instituted should be considered. Epley maneuver.

Main Outcome Measure: Persistent vertigo follow- Arch Otolaryngol Head Neck Surg. 2004;130:436-439

ENIGN PAROXYSMAL POSI- vestibular system to vertigo rather than tional vertigo (BPPV) is a eliminate its cause. These exercises have clinical condition character- been performed by patients with BPPV ized by transient episodes of either as initial treatment or following non- vertigo when the affected ear response to PRMs. In recent years vari- is in the dependent position. Although first ous forms of PRMs have become popu- B 1 5-14 described by Barany in 1921, the spe- lar, all based on either of 2 theories cific characteristics of this disorder were regarding the etiology of BPPV, the theory defined in 1952 by Dix and Hallpike1 who of cupulolithiasis and the theory of cana- devised a positioning maneuver to diag- lithiasis. nose BPPV. Some maneuvers were devised on the The treatment of BPPV has ranged basis of the Schuknecht theory of cupu- from nonintervention (on the premise that lothiasis15 to disperse debris from their at- it is a self-limiting disorder) to aggressive tachment to the cupula. These include the surgical procedures such as posterior am- Semont liberatory maneuver5 and the pullary nerve section and posterior canal Brandt-Daroff exercises.3 The latter con- From the Department of Ear, occlusion. Conservative procedures such sist of a series of repetitive exercises, which Nose, and Throat/Speech and as habituation exercises or particle repo- could also produce their effect by induc- Hearing, Christian Medical sitioning maneuvers (PRMs) have been ing habituation. College and Hospital, Vellore, 2-14 India. Dr Rupa is currently at recommended by various authors. Ha- Other maneuvers based on the cana- Alice Springs Hospital, Alice bituation exercises, which were devised by lithiasis theory aim to displace particles 2 Springs, Australia. The author Cawthorne in 1944 and later described by from the semicircular canals into the has no relevant financial Brandt and Daroff3 and Norre and Beck- utricle. The maneuver proposed by Ep- interest in this article. ers,4 aimed to increase the tolerance of the ley,6 which is representative of this cat-

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 egory, is simple to perform and often effective with a single treatment session.6,9,11 The 5-position cycle of Epley, for Table 1. Clinical Data and Management of 7 Patients which Epley reported a success rate of 100%, has been Who Did Not Respond to PRMs modified by various authors7-11,13,14 with success rates rang- 6 Associated Cause for PRM ing from 67% to 97%. Except for Epley’s, which claims Age, y/Sex Medical Condition Failure Treatment 100% success, most reports suggest that the response rate to a PRM is less than 100% in patients with BPPV. The 60/M Hypertension, BPPV from left PRM diabetes mellitus HSC present study evaluates the small group of patients with 48/F Unknown BPPV from left PRM BPPV who were nonresponsive to the Epley maneuver HSC in previous studies as well as this one, and suggests meth- 49/F Hypothyroidism Meńierè’s disease Betahistine ods of evaluation and management. hydrochloride 60/M Hypertension Meńierè’s disease Betahistine hydrochloride METHODS 65/M Cervical Persistent BPPV Vestibular spondylosis from PSC habituation We prospectively studied 90 patients who presented with symp- therapy toms suggestive of BPPV from 1997 to 2002. Results for 51 of 70/M Cervical Persistent BPPV Refused further these patients have been published previously.11 These pa- spondylosis from PSC treatment tients were administered the Dix-Hallpike test. A positive re- 60/M Posterior fossa Persistent BPPV Neurosurgery meningioma from PSC referral sult to the Dix-Hallpike test and an absence of positive neuro- logical signs were criteria allowing to proceed with the Epley Abbreviations: BPPV, benign paroxysmal positional vertigo; maneuver. A result was declared positive when the patient who HSC, horizontal semicircular canal; PRM, particle repositioning maneuver; was placed in the Dix-Hallpike position (with the head turned PSC, posterior semicircular canal. 45° to the affected hear in the sagittal plane and 30° below the

horizontal in a head-hanging position) exhibited a torsional nys- 2 tagmus lasting about 30 seconds after a short latency period. cises and included gazing in different directions, changing head The nystagmus was directed toward the dependent ear and was position, bending and stooping, alternatively sitting and stand- fatiguable. There was associated vertigo in all patients. ing, and walking up and down stairs. Patients were instructed Pure-tone audiometry was performed as a routine proce- to perform these exercises for 15 minutes every day for the en- dure in all affected patients to avoid missing an unsuspected mild suing 3 months. or asymmetrical sensorineural hearing loss. Brainstem-evoked • The patients’ medical history was reviewed and a posi- response audiometry was performed in all patients in whom it tional test was performed to exclude lateral semicircular canal was necessary to exclude a retrocochlear disorder, particularly BPPV. Patients who gave a positive response to the positional test were administered the lateral semicircular canal PRM as those with unilateral tinnitus or asymmetrical hearing loss. Elec- 12 tronystagmography was performed in patients in whom associ- suggested by Lempert and Tiel-Wilck. ated labyrinthine dysfunction due to conditions such as • Nonpositional vertigo, if present, was treated with ap- Meńie`re’s disease or vestibular ototoxicity was suspected and propriate medications. who were willing to undergo the procedure. A complete clini- If not already done, contrast-enhanced computed tomog- cal neuro-otological examination was also performed. Radio- raphy or magnetic resonance imaging was performed to ex- graphs of the cervical spine were performed in patients in whom clude the possibility of an intracranial lesion. cervical spine disease such asspondylosis was suspected. The Epley maneuver was performed in the conventional fashion,6 with the modification that a low-frequency vibrator RESULTS (such as an electrolarynx or body massager) was used only if Of 90 patients who underwent the Epley maneuver, the patient demonstrated partial or no response initially. Ten patients required the use of a vibrator. No premedication was 7 (8%) did not achieve complete relief of symptoms af- given. Responses to the Epley maneuver were evaluated after ter 2 weeks (Table 1). These 7 patients were adminis- 2 weeks as follows: tered a PRM with the vibrator. Two patients were dis- covered to have horizontal semicircular canal BPPV and • The response was complete if the patient responded with underwent a specific PRM to which they responded. Of complete relief of BPPV after 1 to 3 sessions. • It was partial if the patient had about 75% or more (but the 5 remaining patients, 2 developed persistent nonpo- less than 100%) relief of BPPV. This was largely a subjective sitional episodic vertigo with associated aural fullness and response. Occasionally, the patient could quantify a decrease tinnitus, which suggested a diagnosis of Meńie`re’s dis- in number of episodes of vertigo. Nonpositional vertigo, if pres- ease. Pure-tone audiometry showed a mild, bilateral, low- ent, was noted. frequency sensorineural hearing loss. In both these pa- • It was absent if the patient had minimal (less than 75%) tients BPPV preceded the first attack of Meńie`re’s disease, or no relief of BPPV. Nonpositional vertigo, if present, was noted. which appeared about 2 weeks after PRMs were initi- Only responses pertaining to symptomatic relief were elicited, ated. After detailed investigation to exclude other causes, and no routine evaluation for the presence or absence of nys- the patient was given 16 mg of betahistine hydrochlo- tagmus was performed. ride 3 times daily and experienced relief. Two other pa- Patients who failed to obtain complete relief following the tients had persistent BPPV of the posterior semicircular Epley maneuver were managed as follows: canal with no associated condition except for cervical • The Hallpike test was repeated to note if there was per- spondylosis. Of these patients, 1 responded to 3 months sistent posterior canal BPPV. If present, vestibular habituation of home-based vestibular habituation therapy as de- exercises were initiated if the patient was willing. The exer- tailed above while the other refused further treatment. cises were modified from the Cawthorne habituation exer- The remaining patient, who presented 3 times to the out-

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Patients, Failures, Source No. No. (%) Diagnosis Management Parnes and Price-Jones,8 1993 38 4 (10.5) BPPV from PSC PSC occlusion Herdman et al,9 1993 30 3 (10) BPPV from PSC Retreatment BPPV from HSC Brandt-Daroff exercises3 Harvey et al,13 1994 25 8 (32) BPPV from PSC Brandt-Daroff exercises,3 singular neurectomy Welling and Barnes,7 1994 27 4 (22.2) PLF following stapedectomy, Fistula closure, neurosurgery referral, vestibular cerebral glioma, BPPV from PSC habituation exercises and posterior canal occlusion Weider et al,10 1994 44 2 (4.5) BPPV possibly from PSC Further treatment refused Steenerson and Cronin,14 1996 20 3 (15) BPPV possibly from PSC Complete relief with vestibular habituation therapy

Abbreviations: BPPV, benign paroxysmal positional vertigo; HSC, horizontal semicircular canal; PLF, perilymph fistula; PRM, particle repositioning maneuver; PSC, posterior semicircular canal.

patient services with acute positional vertigo and expe- ease in the present series had their first attack 2 weeks rienced partial relief with PRM at each visit, was found after starting PRM. The vertigo that appeared was found on computed tomographic scanning to have a 2ϫ3-cm to be historically different from the characteristic posi- mass in the right posterior fossa, which was later found tional vertigo that occurred initially. The appearance of to be a meningioma. concomitant tinnitus and aural fullness was diagnostic. Analyzing the results of previous studies (Table 2), Perez et al18 describe patients with Meńie`re’s disease in we found that the failure rate of PMRs varied from 4.5% whom attacks of BPPV may precede, accompany, or fol- to 32%. In one report7 a definite cause, perilymph fis- low the attacks of Meńie`re’s disease. Careful monitoring tula and cerebral glioma, was present in the 2 nonre- of patients who have had PRMs is therefore essential. sponders, for whom definitive treatment was initiated. Once it is clear that BPPV is not improved by a par- In others, after other possible causes were excluded, ves- ticular PRM and no other treatable cause for posterior tibular habituation therapy13,14 was administered and canal BPPV has been identified, an attempt should be made found to be beneficial. Patients who were subsequently to try an alternative PRM or habituation procedure. It may found to have horizontal canal BPPV were treated suc- be that cupulolithiasis, and not canalithiasis, is causing cessfully with the appropriate exercises.9 Interestingly, BPPV; hence, the appropriate PRM is required. Some au- in one report,10 2 patients tagged “failed cases” sought thors describe differentiating between cupulolithiasis and no further treatment, preferring to live with their BPPV. canalithiasis by means of the Dix-Hallpike maneuver.19 In cupulolithiasis, when the head is placed in the Dix- COMMENT Hallpike position, there is no latency in the onset of vertigo and nystagmus. Further, nystagmus and vertigo last Most cases of BPPV are idiopathic and respond well to as long as the head is maintained in the provoking po- PRMs. Some resolve without specific treatment, prov- sition. In canalithiasis, however, there is usually a la- ing the self-limiting nature of the disease. A lack of re- tency period of about 1 to 40 seconds before the onset sponse to at least 3 consecutive sessions of PRM within of vertigo and nystagmus when the head is placed in the 2 weeks, or frequent recurrence of symptoms despite par- Dix-Hallpike position, and vertigo and nystagmus dis- tial or total response to PRM, should prompt the physi- appear within 60 seconds if the head’s position is main- cian to investigate the possibility of other conditions— tained. When the patients of Harvey and colleagues13 re- for instance, an intracranial space-occupying lesion. Thus, sponded neither to the PRM nor to a modified liberatory of the 2 patients who did not respond to PRMs in Well- maneuver, the authors prescribed the Brandt-Daroff ex- ing and Barnes’s series of 27 patients, 1 was found to have ercises. Occasionally, vestibular habituation therapy is a glioma.7 Similarly, in the present series, 1 patient had more effective than PRMs. Steenerson and Cronin14 found 3 episodes of severe positional vertigo within 3 months, that the 3 patients who had persistent BPPV following each episode resolving partially with PRMs. On com- PRMs had complete relief of symptoms following insti- puted tomographic scanning, this patient was found to tution of vestibular habituation exercises. have a moderate-sized meningioma of the posterior fossa. Some patients with BPPV have either horizontal ca- Rarely, patients with tumors of the fourth ventricle or nal canalithiasis or a combination of horizontal canal and with vestibular schwannomas present with persistent po- posterior canal canalithiasis. Such patients do not attain sitional vertigo.16 The exact causal relationship between complete relief with PRMs such as the Epley or Semont episodic BPPV and an intracranial space-occupying le- maneuver alone. Indeed, Herdman and Tusa20 suggest that sion is debated. One of the mechanisms suggested is that a few patients who have been treated for posterior semi- there is vascular compromise of the affected labyrinth as circular canal BPPV may be found to have horizontal ca- the tumor causes ischemia of the anterior vestibular ar- nal BPPV after treatment. The conversion of posterior tery, which leads to posterior canal BPPV.17 Other treat- semicircular canal BPPV to lateral semicircular canal BPPV able conditions that should be excluded include local au- is believed to be due to the shift of otoconial debris from ral conditions like chronic otitis media, Meńie`re’s disease, the posterior canal to the horizontal canal via the utricle. or perilymph fistula.7 The 2 patients with Meńie`re’s dis- This appeared to be the case in 2 patients in the present

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©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/24/2021 series. Testing for horizontal canal involvement fol- based upon the habituation effect. Otolaryngol Head Neck Surg. 1989;101:14-19. lowed by administration of the specific PRM12 is re- 5. Semont A, Freyss G, Vitte E. Curing the BPPV with a liberatory maneuver. Adv Otorhinolaryngol. 1988;42:290-293. quired in these cases. 6. Epley JM. The canalith repositioning procedure: for treatment of benign parox- Finally, a certain proportion of patients who have ysmal positional vertigo. Otolaryngol Head Neck Surg. 1992;107:399-404. persistent BPPV may benefit from surgical procedures like 7. Welling DB, Barnes DE. Particle repositioning maneuver for benign paroxysmal posterior ampullary nerve section or posterior semicir- positional vertigo. Laryngoscope. 1994;104:946-949. cular canal occlusion. Included in this group are those 8. Parnes LS, Price-Jones RG. Particle repositioning maneuver for benign paroxysmal positional vertigo. Ann Otol Rhinol Laryngol. 1993;102:325-331. with vestibular atelectasis. This entity was first de- 9. Herdman SJ, Tusa RJ, Zee DS, Proctor LR, Mattox DE. Single treatment ap- 21 scribed by Merchant and Shucknecht in a postmortem proaches to benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck diagnosis made in individuals whose temporal bones had Surg. 1993;119:450-454. collapsed walls of the ampullae of the semicircular ca- 10. Weider DJ, Ryder LJ, Stram JR. Benign paroxysmal positional vertigo: analysis nal and utricle, causing restriction of movement of the of 44 cases treated by the canalith repositioning procedure of Epley. Am J Otol. 1994;15:321-326. cupula and otolithic membrane. These patients had ex- 11. Jose P, Rupa V, Job A. Successful management of benign paroxysmal posi- perienced positional vertigo and persistent unsteadi- tional vertigo by Epley maneuver. Indian J Otolaryngol Head Neck Surg. 2000; ness. In such patients PRMs are unlikely to be effective. 52:50-53. The surgical procedures for BPPV are associated with a 12. Lempert T, Tiel-Wilck K. A positional maneuver for treatment of horizontal-canal small but significant risk of hearing loss, which may be benign positional vertigo. Laryngoscope. 1996;106:476-478. 13. Harvey SA, Hain TC, Adamiec LG. Modified liberatory maneuver: effective treat- acceptable to patients with severe symptoms. ment for benign paroxysmal positional vertigo. Laryngoscope. 1994;104:1206- 1212. Submitted for publication February 6, 2003; final revision 14. Steenerson RL, Cronin GW. Comparison of the canalith repositioning procedure received August 25, 2003; accepted September 3, 2003. and vestibular habituation training in forty patients with benign paroxysmal po- Corresponding author: Vedantam Rupa, MS, DLO, sitional vertigo. Otolaryngol Head Neck Surg. 1996;114:61-64. 15. Shuknecht HF. Cupulolithiasis. Arch Otolaryngol. 1969;90:113-126. Christian Medical Hospital, Vellore 632004, India (e-mail: 16. Fetter M. Vestibular system disorders. In: Herdman SJ, ed. Vestibular Rehabili- [email protected]). tation. 2nd ed. Philadelphia, Pa: FA Davis Co; 2000:93. 17. Baloh RW, Honrubia V, Jacobson K. Benign positional vertigo: clinical and ocu- lographic features in 240 cases. Neurology. 1987;37:371-378. REFERENCES 18. Perez N, Martin E, Zubieta JL, Romero MD, Garcia-Tapia R. Benign paroxysmal positional vertigo in patients with Meniere’s disease treated with intratympanic 1. Dix R, Hallpike CS. The pathology, symptomatology and diagnosis of certain com- gentamycin. Laryngoscope. 2002;112:1104-1109. mon disorders of the vestibular system. Proc R Soc Med. 1952;54:341-354. 19. Herdman SJ, Tusa RJ. Benign paroxysmal positional vertigo. In: Herdman SJ, ed. 2. Cawthorne T. The physiological basis for head exercises. J Chart Soc Physio- Vestibular Rehabilitation. 2nd ed. Philadelphia, Pa: FA Davis Co; 2000:245-246. ther. 1944;30:106-107. 20. Herdman SJ, Tusa RJ. Complications of the canalith repositioning procedure. 3. Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg. 1996;122:281-286. Arch Otolaryngol. 1980;106:484-485. 21. Merchant SN, Schuknecht HF. Vestibular atelectasis. Ann Otol Rhinol Laryngol. 4. Norre ME, Beckers A. Vestibular habituation training exercise treatment for vertigo 1988;97:565-576.

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