Comments on Recent Papers related to BPPV
C. Hain, MD •
Page last modified:
July 21, 2020
These are arranged chronologically.
- Scarpa, A., et al. (2019). "Lateralization of horizontal semicircular canal benign paroxysmal positional vertigo (HSC-BPPV) with the latency test: a pilot study." Acta Otolaryngol 139(10): 854-859. "LT is a novel technique involving a 180 degrees movement of the head and the analysis of the time required to reverse the nystagmus. Results: LT achieved a correct side diagnosis in 86%. " Comment: It is difficult to understand the physics of this test. It also would seem prone to create severe nausea.
- Iglebekk, W., et al. (2019). "Can the bending forward test be used to detect a diseased anterior semi-circular canal in patients with chronic vestibular multi-canalicular canalithiasis (BPPV)?" Acta Otolaryngol 139(12): 1067-1076. "The sensitivity of the Bending forward-test is 81%; the specificity 91%. " We think thi is just wrong because the frequency of nystagmus with head prone is very high (i.e. specificity is likely about 0%).
- Dispenza, F., et al. (2019). "Observational study on risk factors determining residual dizziness after successful benign paroxysmal positional vertigo treatment: the role of subclinical BPPV." Acta Otorhinolaryngol Ital 39(5): 347-352. " We conclude that residual otoliths may play a role in determining post-maneuver residual dizziness that is often linked to subclinical BPPV;" This makes sense to us.
- Uz, U., et al. (2019). "Efficacy of Epley Maneuver on Quality of Life of Elderly Patients with Subjective BPPV." J Int Adv Otol 15(3): 420-424. This paper suggests that even when the clinician doesn't see nystagmus, PT may help. This reflects ordinary care. Most of the time, it is because the clinician doesn't have the right tools to see nystagmus (i.e. video frenzel goggles).
- Luryi et al, Traumatic versus Idiopathic Benign Positional Vertigo: Analysis of Disease, Treatment, and Outcome Characteristics. Otolaryngol Head Neck Surg. 2019 Jan;160(1):131-136This was a study of traumatic BPPV.2019 They stated "The overall resolution rate was 76%, and the recurrence rate was 38%. Patients with traumatic BPPV were younger (mean age: 61 vs 65 years, P = .007) and more likely to be male (40% vs 27%, P = .004) than patients with idiopathic BPPV. Traumatic BPPV was more likely to affect both ears (32% vs 19%, P = .009). No significant association was detected between trauma history and resolution rate, recurrence rate, number of treatment visits, or affected semicircular canals." So in other words, BPPV is mostly the same, whether truamatic or not.
- Kitahara, T., et al. (2019). "Idiopathic benign paroxysmal positional vertigo with persistent vertigo/dizziness sensation is associated with latent canal paresis, endolymphatic hydrops, and osteoporosis." Auris Nasus Larynx 46(1): 27-33. Out of 611 patients with BPPV, 201 were intractable (32.9%).
- Dsilva et al. (2017) Postural sway in individuals with type 2 diabetes and concurrent BPPV. Int J. Neuroscience, 2017. [Unsurprisingly, patients with BPPV and diabetes sway more than patients with control and diabetes groups.]
- Obrist, D., et al. (2016). "Determinants for a Successful Semont Maneuver: An In vitro Study with a Semicircular Canal Model." Front Neurol 7: 150. This study was done on a mechanical model. The angular velocity of the head did not affect the performance of the simulated maneuver. Thus this mechanical model confirms common sense.
- Imai T, Higashi-Shingai K, Takimoto Y, Masumura C, Hattori K, Inohara H.New scoring system of an interview for the diagnosis of benign paroxysmal positional vertigo.. Acta Otolaryngol. 2016;136(3):283-8. doi: 10.3109/00016489.2015.1121547. Epub 2016 Jan 12. [These authors studied 4 questions to diagnose BPPV. ]
- Sari K, Yildirim T, Borekci H, Akin I, Aydin R, Ozkiris M.The relationship between benign paroxysmal positional vertigo and thyroid autoimmunity. Acta Otolaryngol. 2015 Aug;135(8):754-7. doi: 10.3109/00016489.2015.1021932. Epub 2015 Mar 11. They found no relationship in a small study of 50 patients.
- He JW1, Gong Q, Wang XF, Xiao Z. High stimulus rate brainstem auditory evoked potential in benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol. 2015 Sep;272(9):2095-100. doi: 10.1007/s00405-014-3172-6. Epub 2014 Jul 9. This paper suggests that ABR can be used to "assess the ischemic degree in subjects over the 20 years old. We are dubious about this conclusion.
- Talaat HS1, Abuhadied G, Talaat AS, Abdelaal MS.Low bone mineral density and vitamin D deficiency in patients with benign positional paroxysmal vertigo. Eur Arch Otorhinolaryngol. 2015 Sep;272(9):2249-53. doi: 10.1007/s00405-014-3175-3. Epub 2014 Jun 29. This paper suggets that vit-D less than 30 is more likely in BPPV than controls. This study was just too small to draw any firm conclusions. However, we would certainly advise vit-D supplementation in most persons who get little sunlight in any case.
- Ogun OA, Janky KL, Cohn ES, Büki B, Lundberg YW.PLoS One. Gender-based comorbidity in benign paroxysmal positional vertigo. 2014 Sep 4;9(9):e105546. doi: 10.1371/journal.pone.0105546. eCollection 2014. These authors reported that in 1360 cases from Boystown, that "The following comorbidities were found to be significantly more prevalent in the BPPV population when compared to the age- and gender-matched general population: ear/hearing problems, head injury, thyroid problems, allergies, high cholesterol, headaches, and numbness/paralysis. There were gender differences in the comorbidities. In addition, familial predisposition was fairly common among the participants." We don't find this data very illuminating.
- 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).
- Guneri, E. A. and O. Kustutan (2012). "The effects of betahistine in addition to epley maneuver in posterior canal benign paroxysmal positional vertigo." Otolaryngol Head Neck Surg 146(1): 104-108. This paper suggested a small advantage for treating with betahistine after Epley.
- 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
- 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.
- Uz, U., et al. (2019). "Efficacy of Epley Maneuver on Quality of Life of Elderly Patients with Subjective BPPV." J Int Adv Otol 15(3): 420-424.
- 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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