January Topic: BPPV 

Saishoji Y, Yamamoto N, Fujiwara T, Mori H, Taito S. Epley manoeuvre's efficacy for benign paroxysmal positional vertigo (BPPV) in primary-care and subspecialty settings: a systematic review and meta-analysis. BMC Prim Care. 2023;24(1):262. Published 2023 Dec 2. doi:10.1186/s12875-023-02217-z

Background: Although previous studies have reported general inexperience with the Epley manoeuvre (EM) among general physicians, no report has evaluated the effect of EM on benign paroxysmal positional vertigo (BPPV) in primary care by using point estimates or certainty of evidence. We conducted this systematic review and meta-analysis and clarified the efficacy of EM for BPPV, regardless of primary-care and subspecialty settings.

Methods: Systematic review and meta-analysis of randomised sham-controlled trials of EM for the treatment of posterior canal BPPV in primary-care and subspecialty settings. A primary-care setting was defined as a practice setting by general practitioners, primary-care doctors, or family doctors. A systematic search was conducted in January 2022 across databases, including Cochrane Central Resister of Controlled Trial, MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. Primary outcomes were the disappearance of subjective symptoms (vertigo), negative findings (Dix-Hallpike test), and all adverse events. We evaluated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach.

Results: Twenty-seven randomised controlled trials were identified. In primary-care settings, EM reduced the subjective symptoms [risk ratio (RR), 3.14; 95% confidence interval (CI), 1.96-5.02]; however, there was no applicable article for all adverse events. In the subspeciality setting, EM reduced the subjective symptoms (RR, 2.42; 95% CI, 1.64-3.56), resulting in an increase in negative findings (RR, 1.81; 95% CI, 1.40-2.34). The evidence exhibited uncertainty about the effect of EM on negative findings in primary-care settings and all adverse events in subspecialty settings.

Conclusions: Regardless of primary-care and subspecialty settings, EM for BPPV was effective. This study has shown the significance of performing EM for BPPV in primary-care settings. EM for BPPV in a primary-care setting may aid in preventing referrals to higher tertiary care facilities and hospitalisation for follow-up.

Trial registration: The study was registered in protocols.io (PROTOCOL INTEGER ID: 51,464) on July 11, 2021.

Keywords: Benign paroxysmal positional vertigo; Meta-analysis; Patient positioning; Primary care; Systematic review.

PMID: 38042776

Li J, Yu L, An P, et al. Low Bone Mineral Density and the Risk of Benign Paroxysmal Positional Vertigo. Otolaryngol Head Neck Surg. Published online December 3, 2023. doi:10.1002/ohn.600

Objective: This study aimed to comprehensively analyze the relationship between low bone mineral density (BMD) and the risk of benign paroxysmal positional vertigo (BPPV) based on the large prospective population-based UK Biobank (UKB) cohort.

Study design: Prospective population-based cohort study.

Setting: The UKB.

Methods: This prospective cohort study included UKB participants recruited between 2006 and 2010 who had information on BMD and did not have BPPV before being diagnosed with low BMD. Univariable and multivariable logistic regression models were constructed to assess the association between low BMD (overall low BMD, osteopenia, and osteoporosis) and BPPV. We further conducted sex and age subgroup analysis, respectively. Finally, the effects of antiosteoporosis and female sex hormone medications on BPPV in participants with osteoporosis were evaluated.

Results: In total, 484,303 participants were included in the final analysis, and 985 developed BPPV after a maximum follow-up period of 15 years. Osteoporosis was associated with a higher risk of BPPV (odds ratio [OR] = 1.37, P = .0094), whereas osteopenia was not. Subgroup analyses suggested that the association between osteoporosis and BPPV was significant only in elderly females (≥60 years, OR = 1.51, P = .0007). However, no association was observed between antiosteoporosis or female sex hormone medications and BPPV in the participants with osteoporosis.

Conclusion: Osteoporosis was associated with a higher risk of developing general BPPV, especially in females aged ≥ 60 years old, whereas osteopenia was not associated with BPPV.

Keywords: benign paroxysmal positional vertigo; large-scale prospective cohort study; low bone mineral density; osteoporosis; sex difference.

PMID: 38044484

Martin-Sanz E, Chaure-Cordero M, Riestra-Ayora J, González-Marquez R, Mármol-Szombathy I, Esteban-Sanchez J. Bow and Lean Test for Rare Variants of Vertical Semicircular Canal BPPV. Laryngoscope. 2023 Dec 12. doi: 10.1002/lary.31218. Epub ahead of print. PMID: 38087849.

Objective: The objective of this study was to assess the clinical significance of the Bow and Lean Test (BLT) for the diagnosis of different variants of vertical canal Benign Paroxysmal Positional Vertigo (BPPV). BLT is commonly used for diagnoses of lateral semicircular canal (LSC) BPPV. However, vertical nystagmus in the BLT may indicate the presence of other variants such as PSC-BPPV.

Methods: 567 patients with vertical canal BPPV were recruited. Patients with anterior semicircular canal (ASC) or PSC-BPPV were weekly examined until the negativization of BPPV. Nystagmus characteristics during BLT were analyzed.

Results: Of 567 patients with vertical canal BPPV, 1.4% had ASC-BPPV. BLT was positive in 155 patients, showing patterns like down-beating nystagmus in bowing and no nystagmus in leaning (15.52% of patients), and down-beating in bowing and up-beating in leaning (6.17%), which was predominantly present in PSC-canalolithiasis. Statistically significant differences were observed in the direction of nystagmus provoked by BLT in PSC-BPPV subtypes. No significant differences were found in nystagmus latency or duration during BLT positions. Among BPPV subtypes, there was a significant difference in nystagmus duration and latency, especially between cupulolithiasis and other variants. BLT's sensitivity was 0.93 in bowing and 1 in a leaning position, while specificity was 0.93 and 0.82 respectively.

Conclusion: Beyond the LSC, the BLT has expanded to other variants. However, study results differ likely due to variations in patient characteristics and test execution. Currently, no specific features for ASC have been found to differentiate it from PSC-BPPV limiting the test's use for this variant.

Level of evidence: Level 3, according to Oxford Center for Evidence-Based Medicine Laryngoscope, 2023.

Keywords: Benign Paroxysmal Positional Vertigo; Bow and Lean test; cupulolithiasis; vertical semicircular canal.

PMID: 38087849

Zhou C, Ma C, Li Y, Zhou X, Shui L, Han C. Risk Factors and a Nomogram Model for Residual Symptoms of Cured Benign Paroxysmal Positional Vertigo. J Int Adv Otol. 2023;19(6):523-528. doi:10.5152/iao.2023.231127

Background: We aimed to analyze the independent risk factors that affect the treatment outcomes of residual symptoms of cured benign paroxysmal positional vertigo and to construct a nomogram model.

Methods: A total of 186 benign paroxysmal positional vertigo patients who were treated in our hospital from June 2019 to August 2021 were selected. According to whether there were residual symptoms, they were divided into a group with residual symptoms (n=82) and a group without residual symptoms (n = 104). The logistic regression model was used to analyze the independent risk factors affecting the treatment outcomes, and the results were incorporated into R software to establish a nomogram model for verification.

Results: The incidence rate of residual symptoms in the 186 patients was 44.09% (82/186). Logistic regression analysis showed that age, course of disease, number of maneuvers, anxiety state, diabetes mellitus, and hypertension were independent risk factors affecting the treatment outcomes of residual symptoms after cured benign paroxysmal positional vertigo. The area under the receiver operating characteristic curve of the nomogram model was 0.938. The calibration curve was fitted well (χ2 = 8.165, P = .417).

Conclusion: The nomogram model constructed based on age, course of disease, number of maneuvers, anxiety state, diabetes mellitus, and hypertension had a high predictive value for the treatment outcomes of residual symptoms in benign paroxysmal positional vertigo patients.

PMID: 38088327

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