Particle Liberation Maneuvers for Benign Paroxysmal Positional Vertigo

Transcription

1 Particle Liberation Maneuvers for Benign Paroxysmal Positional Vertigo Ahmed A. El Degwi, MD* and Ayman E. El Sharabasy, MD** ENT Department * and Audiology Unit** Mansoura Faculty of Medicine

2 Abstract Sixty patients suffering from benign paroxysmal positional vertigo were randomly classified into three groups, each group was submitted to a different particles repositioning procedure. All patients were followed up for one year in order to determine the most effective approach as regards the short term as well as the long term assessment. The three procedures applied in this study were Epley s for group I, Brandt and Daroff for group II, and a new procedure for group III. The new procedure consisted of lying the patient down on his affected side, then in the prone position and finally in the upright position. Sixteen (80%), thirteen (65%), and fifteen (75%) patients of the three groups, respectively, were found to be symptoms free after the completion of the exercise courses. At the end of the follow up period, recurrence of symptoms occurred in 56%, 92%, and 73% of patients of the three groups, respectively. Despite the high recurrence of symptoms for patients of group II (92%) and group III (73%), those patients were not anxious about their symptoms as much as they were at the beginning of the exercise program. Moreover, they returned to their own exercises and this return suggested that they developed a high degree of independence. One can recommend the use of simple repositioning exercises such as those of Brandt and Daroff or the new maneuver and limit Epley s one to those patients who did not cure.

3 Introduction: Benign paroxysmal positional vertigo (BPPV) is a peripheral vertiginous disorder frequently encountered in clinical practice. This disorder was first described by Barany 1 (1921) and further defined by Dix and Hallpike 2 (1952). The natural history for BPPV is spontaneous recovery in weeks or months, however, in some patients the condition may be severely incapacitating 3. Schuknecht 4 (1962) believed that BPPV is caused by freely floating otoconia in the posterior semicircular canal (canalithiasis) because the cupula of the posterior semicircular canal (SSC) is the undermost when the head is in an upright position. He also believed that the utricle and saccule are not the origin of BPPV because their direct stimulation does not produce nystagmus. Schuknecht 5 (1969) modified his theory and proposed that BPPV is due to the deposition of otoconia on the cupula of the posterior canal causing a heavy cupula (cupulolithiasis), causing the cupula to be overly susceptible to gravity with head position change. He also reported basophilic deposits in the cupula of the posterior SSC discovered in temporal bones of cadavers who had BPPV. Canalithiasis theory is supported by many authors 3,6,7,8, and the terms cupulolithiasis and canalithiasis are perhaps the most widely used to describe such pathologic condition result in vertigo Treatment of BPPV with medication has not proven helpful and even may be detrimental. Moreover, provocative vestibular habituation therapy has not deemed helpful in BPPV and patients are usually advised to avoid the offending position 12. Brandt Daroff 9 (1980) described a specific series of movements and reported that almost all of their patients experienced complete relief of their positional vertigo within 14 days. They considered the mechanism to be a mechanical maneuver that loosen and disperse otolithic debris from the cupula. In 1992 Epley 6 described a canalith repositioning procedure (CRP) consisting of five positions head movements and he postulated that this maneuver caused free canalith to migrate by gravity out of the posterior semicircular canal to the utricle where they no longer exert a dynamic effect. High success rates were reported and many specialists accepted Epley s maneuver as the first line for management of BPPV. The aim of this study is to compare effectiveness, patient acceptance and speed of recovery of some particles repositioning maneuvers used for management of BPPV.

4 Methodology: This study was conducted at Mansoura university hospital (Mansoura, Egypt) and a private hospital (Makkah, Saudi Arabia) between 1997 and Sixty patients with unilateral BPPV participated in the study. The diagnosis of BPPV was based on: latency of onset of vertigo with head movement into Dix Hallpike position, presence of tortional nystagmus beating towards the undermost ear, duration of nystagmus and vertigo is less than 60 seconds, and fatigability of vertigo with repeated positioning in offending position. All patients were submitted to history taking, physical and neuro otologic examination, basic audiological evaluation (including pure tone and speech audiometry and immittance testing), and electronystagmography using computerized system from Micromedical Inc. version 4.5. Patients were assigned randomly into three groups of 20 patients. Each group was treated with a different repositioning maneuver as follow: Group I: patients were treated with canalith repositioning procedure described by Epley 6 ; the maneuver begins with placement of the head into the Dix Hallpike position that evokes vertigo. After the initial nystagmus goes away, patient s head was rolled for 180º in two 90º increments with a stoppage in each position until any nystagmus resolves. Patient was then brought to a sitting position. The maneuver was repeated until the patient becomes symptom free for each session. Neither a vibrator nor a premedication was used. Patients were asked to repeat the maneuver twice weekly until symptoms disappear. Group II: patients were submitted to a customized program of vestibular exercises described by Brandt Daroff 9. The patient was instructed to sit on the side of an examining couch with his eyes closed, and then tilt to lie alternately on his affected and unaffected sides. The patient was warned that this may provoke dizziness and that he should remain in his position until symptoms subside. Then, patient was instructed to return to the upright position. After a short period to recover, the exercise was repeated up to the limit of patient tolerance and without undue distress. Patient was asked to repeat the exercise three times a day, six days a week for six weeks. Group III: patient was instructed to sit on the side of a couch and then tilt to lie on his affected side, then rotate to lie in the prone position, and then to return to the upright position. The program was continued as that of group II. Figures 1 and 2 show the maneuvers used in right and left SCC lesions respectively. The severity of vertigo at the start and at the completion of treatment was scored as severe, moderate, mild, and symptom free. Patients were asked to fill in two questionnaires, the first was on a biweekly basis for two months to score their satisfaction, and the second was on three months basis for one year to record any recurrence of symptoms.

5 Figure 1: New maneuver applied to patients of group III when the right SSC is affected: (a) patient is in upright position before maneuver is applied; (b) patient lying down on his right (affected) side; (c) patient is in prone position; and (d) patient is in upright position again. Figure 2: New maneuver applied to patients of group III when the left SSC is affected: (a) patient is in upright position before maneuver is applied; (b) patient lying down on his left (affected) side; (c) patient is in prone position; and (d) patient is in upright position again.

6 Results: The age means for the three groups included in this study were 49 years (range 28 67), 52 years (range 30 61), and 48 years (range 26 55) while the female/male ratios were 13/7, 11/9, and 14/6 for groups I, II, and III respectively. The average duration of symptoms prior to enrollment in the study was 24 months (range 9 36), 27 months (range 12 33) and 25 months (range 13 30) for group I, II and III respectively. Table 1 shows percentages of improvement of vertigo for the three groups after completion of the exercise courses (in other words, short term results). The symptom free patients were 16 (80%) for group I, 13 (65%) for group II, and 15 (75%) for group III. The table also shows those patients experienced moderate improvement, they were 3 (15%) for group I, 7 (35%) for group II, and 4 (20%) for group III. The 16 symptom free patients in group I used the assigned maneuver for an average of 14 sessions (seven weeks), while the three patients who experienced moderate improvement (in other words, they experienced occasional mild vertigo with head position change) used it for an average of 11 sessions only. The only patient experienced no improvement in group I, as well as the unimproved one in group III could not tolerate the symptoms provoked by the maneuver, and quit their programs after three weeks (nine sessions) and their results were omitted from the analysis. All patients of group II finished their six weeks exercise courses (36 sessions each). None of the patients in any of the three groups was symptom free after one session. The rate of recurrence of vertigo in the symptom free patients of all groups was determined based on the questionnaire made every three months for one year (long term follow up). At the end of the follow up period, 9 out of the 16 of group I, 12 out of the 13 of group II and 11 out of the 15 of group III who were symptom free experienced recurrence (Table II). After one year, patients of the three groups who experienced moderate improvement showed no noticeable changes of their symptoms existed prior to the application of their assigned maneuvers.. Table I: Percentage of improvement after completion of the three different maneuvers. Symptom free Moderate Mild No improvement Group I 16 (80%) 3 (15%) 0 (0%) 1 (5%) Group II 13 (65%) 7 (35%) 0 (0%) 0 (0%) Group III 15 (75%) 4 (20%) 0 (0%) 1 (5%) Table II: Recurrence of vertigo in the three groups after the follow up year. Symptom free Recurrence after follow up year Recurrence % Group I Group II Group III

7 Discussion: Each of the three repositioning techniques applied in this study provides a mechanical mean that promote loosening and dispersion of otolith debris from the cupula, and each cause the nystagmus to fatigue and the vertigo to disappear after each individual session. The five positions head movement of Epley 3,6,7 applied to group I redirects the dispersed particles to the utricle. Similarly, Brandt and Daroff 9 maneuver applied to group II and the maneuver applied to group III (Figures 1 and 2) could also be considered repositioning maneuvers. Epley s description to his maneuver is accompanied by an explanation of how the five movements might result in particle migration through the membranous labyrinth from the posterior semicircular canal to the utricle. Despite the fact that the other two maneuvers applied to groups II and III look easier to administer, there results were less successful and less consistent than Epley s. Steenerson and Cronin 13 (1996) reported 82% symptom free patients by using Epley s repositioning maneuver, and these results matches those obtained in this study from group I who used the same maneuver (80%). Based on the theory of alternate reverse motion, alternate lying on each side produces more loosening of the particles than lying on the affected side alone. Banfield et al, 14 reported 96% response to their maneuver and 76% recurrence. The maneuver entitled the patient to lay on his affected side only. Brandt and Daroff 9 reported 99% success rate (66 out of 67 of the patients he studied). In this study, group II (those who applied Brandt maneuver) revealed that 65% of the patients became symptom free after the exercise course. However, if one can consider that the moderate improvement (35%) in this study is a success, then the results of this study would perfectly match those reported by Brandt and Daroff 9 It is well recognized that BPPV has a high recurrence rate even after successful repositioning. This is can be explained by the accumulation of freely floating canalith within the posterior semicircular canal over time. In this study, the 56% recurrences of symptom in those patients used Epley s maneuver after the follow up year may support the thought of particle reaccumulation. Epley s maneuver can not be taught to the patient in the manner of exercises, therefore, with recurrence it is likely that patient may represent to the physician. On the other hand, despite higher rates of recurrence in group II (92%), and group III (73%), patients were not anxious to seek further medical attention, and all of them returned to their exercise program suggesting that a build up of independence has been achieved. In the maneuver applied to group III, the shoulder acts as a fulcrum to side flex the head when lying on one side and this will make the ampulla of posterior SSC in uppermost position and the crus commune in the lower position but still not dependent in position. Therefore, the particles will move through the endolymph to lie in a nearest point to the crus commune. Rotation of the patient to lie prone with a small pillow underneath chest brings the crus

8 commune to the most dependent position and the particles slides to get through it. Sitting upright again from this position will bring the particles into the utricle. The pillow helps to maintain the head bending position. Successful management of these patients must provide short term cure as well as a long term self reliance. This long term self reliance has not been demonstrated yet with Epley s maneuver. It must be also remembered that Epley s particle repositioning maneuver can not be used with patients suffering from cervical or thoracic spine pathologies. The other exercises (those applied to groups II and III) are characterized by being simple and quickly taught and less time consuming.

9 References: 1. Barany R. Diagnose von krankheitser in Bereiche des Otolithenapparates. Acta Otolaryngol 1921; 2: Dix R, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol 1952; 6: Epley JM. Particle repositioning for benign paroxysmal positional vertigo. Otolaryngol Clin North Am 1996; 29: Schuknecht HF. Positional vertigo: clinical and experimental observations. Trans Am Acad Ophthalmol Otolaryngol 1962; 66: Schuknecht HF. Cupulolithiasis. Arch Otolaryngol 1969; 90: Epley JM. The canalith repositioning procedures for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992; 107: Epley JM. Positional vertigo related to semicircular canalithiasis. Otolaryngol Head Neck Surg 1995; 112: Beynon GJ. A review of management of benign paroxysmal positional vertigo by exercise therapy and by repositioning maneuvers. Br J Audiol 1997;31: Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol 1980; 106: Semont A, Freyss G, Vitte E. Curing BPPV with a liberatory maneuver. Adv Otorhinolaryngol 1988; 42: Brook JG, Abidin, MR. Repositioning maneuver for benign paroxysmal positional vertigo (BPPV). J Am Osteopath Assoc 1997; 97: Schuknecht HF. Positional nystagmus of benign paroxysmal type. In Naunton RF (Ed): the Vestibular System. New York, Academic Press Inc, 1975, PP Steenerson RL, Cronin GW. Compensation of the canalith repositioning procedure and vestibular habituation training in forty patients with benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1996; 114: Banfield GK, Wood C, Knight J. Does vestibular habituation still have place in the treatment of benign paroxysmal positional vertigo? J of Laryngol Otol 2000; 114: