Article, Otolaryngology

Liberatory vertigo: a new prognostic factor for repositioning maneuvers

a b s t r a c t

Objective: This study suggests the new concept of liberatory vertigo to facilitate emergency department treat- ment of benign paroxysmal positional vertigo.

Methods: The present prospective nonrandomized study enrolled 535 patients with typical forms of positional vertigo, who were treated following clinical practice guidelines. We observed the onset of liberatory vertigo dur- ing the maneuver as a prognostic factor, and we tested the correlation between that symptom and Therapeutic effectiveness. A subjective evaluation of vertigo was made by way of a questionnaire. Data analysis was per- formed that made use of statistical software.

Results: Complete recovery occurred in 287 patients (76.5%) with posterior semicircular canal positional vertigo and in 67 patients (80%) with horizontal semicircular canal positional vertigo; liberatory vertigo occurred in 195 (67.9%) and 59 (88%) of those cases, respectively. Differences in terms of recovery probability resulted regardless of the canal involved. Positive predictive value ranged from 93% to 97%.

Conclusions: In our sample, liberatory vertigo could predict the effectiveness of the maneuver regardless of the canal involved.

(C) 2016

Introduction

Benign paroxysmal positional vertigo (BPPV) is the most frequent form of labyrinthine vertigo (incidence, 0.6%; prevalence, 1.6%) [1]. It is caused by free-floating particles that enter an inner ear semicircular canal [2]. The particles originate in the otolith organs, which are located in the central chamber of the inner ear; each otolith organ contains otoconia, which can break free from the organ and result in symptomat- ic BPPV when they enter a semicircular canal [3]. In older people, cardio- vascular factors and degenerative metabolic processes such as modification in the metabolism of endolymphatic calcium or in homeo- stasis of endolymph pH, hyperuricemia, and matrix filament degenera- tion represent risk factors of BPPV [4,5].

According to Evidence-based guidelines published in 2008 by the American Academy of Otolaryngology-Head and Neck Surgery [6],a di- agnosis of BPPV is based essentially on the appearance of a characteristic nystagmus provoked by a Dix-Hallpike diagnostic test and a supine roll test in cases of posterior semicircular canal BPPV or horizontal semicir- cular canal BPPV, respectively. Despite strong evidence supporting the benefit of identifying BPPV and treating it with a canalith repositioning maneuver (CRM), the diagnostic test and the CRM are substantially underutilized in emergency departments (EDs) [3,7]. The reasons for

* Corresponding author at: Clinica di Otorinolaringoiatria, Ospedale di Cattinara, Strada di Fiume 447, 34149 Trieste, Italy. Tel.: +39 3402927827; fax: +39 0403994180.

E-mail address: [email protected] (M. Tofanelli).

the underuse of those diagnostic tests and treatments have not been studied systemically and are likely to be complex because several con- structs are involved [3].

In our clinical experience [8] and in performing previous studies on patients with BPPV involving the horizontal semicircular canal (HSC) [9] or the posterior semicircular canal (PSC) [10], we observed some kind of relationship between vertigo that occurred immediately after a maneu- ver as a liberatory sign and the success of the treatment. We noticed that patients with BPPV who experience vertigo at the end of the CRM are more likely to be treated effectively by the maneuver than are those who do not have vertigo. That effect has already been shown for nystag- mus evoked at the end of a CRM [11], and it is reasonable to infer that the same is true for vertigo, considering that this sign is more easily reg- istered by emergency medicine physicians [12]. Our literature search, however, failed to identify any study describing this phenomenon and identifying liberatory vertigo as a prospective prognostic predictive fac- tor. Thus, the possibility of predicting CRM success has the potential to avoid a second clinical check and to place the evaluation in the ED.

The aim of this prospective study was to assess the intuitive correlation between the therapeutic effectiveness of the maneuver and the onset of liberatory vertigo to facilitate clinical evaluation of BPPV in the ED.

Patients and methods

This prospective study involved 535 patients affected with BPPV and treated from January 2013 through December 2014 in the ear, nose, and

http://dx.doi.org/10.1016/j.ajem.2016.05.044

0735-6757/(C) 2016

Treatment outcome“>G. Tirelli et al. / American Journal of Emergency Medicine 34 (2016) 15481551 1549

throat department. Our hospital’s ethics committee on clinical investi- gation approved the study protocol. Patients were informed about the purpose of the study, and all of them gave written consent.

Patient enrollment and BPPV diagnosis

Patients underwent routinely anamnestic evaluation, vestibular clinical examination with otoscopy, balance and posture tests (Romberg test, Unterberger test, and Mingazzini test), and coordination tests (index finger to nose and heel to knee). Clinical examination included the Dix-Hallpike diagnostic maneuver to test the PSC; if a patient has a history compatible with BPPV and the Dix-Hallpike test is negative, the clinician should perform a supine roll test to assess for HSC BPPV as follows.

      • Dix-Hallpike diagnostic test is performed by bringing the patient from an upright seated position to a supine position with the head turned 45? to one side and the neck extended 20?. The patient may be slowly returned to the upright position, and a reversal of the nystagmus may be observed; the maneuver is then repeated for the other side [13].
      • Supine roll test is performed by initially positioning the patient su- pine with the head in neutral position followed by quickly rotating the head 90? to one side to examine for characteristic nystagmus. Then the head is returned to the face-up position, allowing all nys- tagmus to subside. The head is then turned rapidly to the other side to examine for nystagmus once again [6].

We looked for onset of the provoked positional nystagmus by using Fresnel lenses.

The study consisted of 192 males and 343 females, who were 54.6 +-

15.2 years old and had BPPV characterized by certain typical features [6,13-15] according to the guidelines.

Symptoms: Recurring paroxysmal rotatory vertigo attacks trig- gered by head movements, lasting for approximately 1 minute, associated with neurovegetative symptoms (nausea and/or vomiting), instability, and altered spatial perception (dizziness)
  • Examination: Occurrence of typical nystagmus during diagnostic positional tests.
  • According to the guidelines, we considered the following positional nystagmus as typical forms [15,16].

      • Dix-Hallpike diagnostic test evokes a torsional-rotatory geotropic nystagmus, which is paroxysmal, exhaustible, repeatable, and usu- ally fatigable and which presents variable latency lasting for less than 30 seconds.
      • Supine roll test evokes a paroxysmal horizontal direction- changing nystagmus, which is geotropic when the head is turned to the pathologic side while the patient is lying supine (canalolithiasis of the HSC). Nystagmus lasts approximately 1 min- ute and is called paroxysmal variant. The apogeotropic type is less common and is horizontal, persistent, and bearing toward the up- permost ear (cupulolithiasis of the HSC, also called persistent vari- ant, according to Baloh) [17].

    Sixty-five patients were excluded from the study either because a different type of nystagmus–so-called atypical nystagmus–had arisen

    [18] or because of the presence of severe cervical osteoarthritis, vertebrobasilar insufficiency, or neck pain during the maneuver [19].

    Bedside examination and BPPV treatm”>Bedside examination and BPPV treatment

    We identified 2 subgroups depending on which canal was involved: the first group consisted of 376 patients with PSC BPPV, and the second group was composed of 84 patients with HSC BPPV. Patients who expe- rienced severe neurovegetative symptoms during the diagnostic test as- sumed antiemetic prophylaxis before performing the maneuver. That

    prophylaxis consisted of a dose of metoclopramide for the short-term management of nausea or vomiting; in those specific indications, clini- cians provided counseling to inform patients that rates of cognitive dys- function, falls, Drug interactions, and driving accidents increase with use of that drug.

    According to the guidelines [6], we perform the Epley maneuver or the Lempert maneuver to treat posterior or horizontal semicircular canal BPPV, respectively.

    Assessment of reliability of liberatory vertigo prognostic potential

    During execution of the repositioning procedures, patients were questioned at the end of the CRM about the presence or absence of the following symptoms:

        • objective vertigo,
        • neurovegetative symptoms (illness, nausea, or vomiting), and
        • sensation of retropulsion or falling.

    We considered the presence of liberatory vertigo positive if the pa- tient reported objective vertigo or, alternatively, neurovegetative symp- toms (illness, nausea, or vomiting) in association with retropulsion or dizziness.

    Assessment of treatment outcome

    To confirm the level of success of the treatment in this study, all pa- tients were subjected again to clinical examination 1 week later and were classified according to the following criteria:

    complete symptom resolution: asymptomatic patient and ab- sence of positional nystagmus (negative diagnostic tests)
  • incomplete resolution: diagnostic test still positive or patient with Persistent symptoms.
  • Group b represented the group of patients needed to treat who underwent a second CRM.

    Statistical analysis

    Statistical analysis was performed using dedicated software (SPSS version 15; SPSS, Inc, Chicago, IL). We tested the correlation between the occurrence of liberatory vertigo and therapeutic effectiveness of the procedure with Fisher exact test. Moreover, we applied Bayes’ theo- rem to establish the conditional probability of healing when liberatory vertigo occurred during performing of CRM.

    The level of significance for all tests was Pb .05.

    Results

    Ten patients (6 belonging to the PSC group and 4 to the HSC group) were excluded because of disabling vegetative symptoms during the maneuver, which stopped the operator from proceeding with the treat- ment despite the antiemetic protocol.

    Tables 1 and 2 report the frequency of patients’ either experiencing or not experiencing liberatory vertigo after the first CRM with regard to success of the maneuver in the posterior semicircular canal sub- groups and horizontal semicircular canal subgroups of patients, respectively.

    Table 1

    Contingency table displaying incidence of liberatory vertigo in patients with PSC BPPV in relation to success and Failure rates of the first CRM

    Success of first CRM Failure of first CRM Total Presence of liberatory vertigo 195 15 210

    Absence of liberatory vertigo 92 74 166

    Total 287 89 376

    1550 G. Tirelli et al. / American Journal of Emergency Medicine 34 (2016) 15481551

    Table 2

    Contingency table displaying incidence of liberatory vertigo in patients with HSC BPPV in relation to success and failure rates of the first CRM

    Success of first CRM

    Failure of first CRM

    Total

    Presence of liberatory vertigo

    59

    2

    61

    Absence of liberatory vertigo

    8

    15

    23

    Total

    67

    17

    84

    As already said, patients still presenting symptoms after the primary treatment underwent a second CRM within 7 days. In addition, 106 pa- tients (23%) needed further treatment at a second clinical checkup and at the end of the complete cycle of treatment. Almost all of the patients responded positively to the treatment. Only 5 patients (1%) belonging to the second group underwent additional treatment because 1 week later they were still affected by the second maneuver. In summary, 354 pa- tients (77%) were completely healed after the first CRM, 101 patients (22%) needed a second CRM before being classified as completely healed, and 5 patients (1%) underwent the third treatment.

    Of the 106 patients still affected by BPPV after the first CRM, 89 (84%) belonged to the PSC group; and 17 (16%), to the HSC group. Among those patients, the incidence rate of liberatory vertigo was significantly lower, ranging from 14.2% to 1.9% in cases of persistent PSC BPPV and HSC BPPV, respectively.

    The recovery odds in case of BPPV involving the PSC was 76.5%, and the positive predictive value was 92.8% when liberatory vertigo hap- pened. In cases of BPPV that involved the HSC, the recovery odds was 80%, and the positive predictive value was 96.7% in the presence of liber- atory vertigo. Bayesian analysis assessed the probabilities of successfully treatment–which were 76.3% and 80% in the 2 groups, respectively–and the reliability of the maneuver ranges from 70% to 90%. The statistical analysis confirmed that the occurrence of liberatory vertigo was a statis- tically significant positive predictive factor in patients’ recovery in cases of BPPV involving both the PSC (Pb .01) and the HSC (Pb .05).

    Discussion

    The CRM we used for treating enrolled patients effectively cured most of them after 1 treatment, with most of the remaining patients re- quiring only a second treatment. In accordance with the guidelines, we found the CRM to be effective in resolving most of the Clinical cases, and it was both easy to perform and well accepted by patients. Moreover, a second repositioning maneuver obtained a 98% success rate [6]. Our re- sults are in agreement with the data reported by other authors: Brandt and Daroff [20], Steenerson et al [21], and Asprella Libonati [22] report- ed success rates ranging from 94% to 100%. Other authors found lower success rates: 70% [23-26] or greater than 80% [27,28].

    Several prognostic factors.that may influence the percentage of recov- ery have already been described. The most common feature is the liberato- ry nystagmus that appears during the repositioning procedure, and several authors noticed its association with an increased therapeutic success rate [6,29,30]. In particular, it has been reported that liberatory nystagmus oc- curs on average in 75% of patients treated with a canalith repositioning procedure; in those patients, the treatment success rate ranged from 81.9% to 94.9% [27,28,31,32]. It is reasonable to infer that the same is true for liberatory vertigo. We did not evaluate the presence of liberatory nys- tagmus because reliable evaluation of nystagmus requires the use of videonystagmography, which is not available at the ED; we generally re- serve the use of that tool for in-depth analysis. In fact, our purpose was to establish an easily detectable symptom or sign that can be observed by an ED physician performing a repositioning procedure.

    In looking for new prognostic factors in patients with PSC BPPV or HSC BPPV, we observed a correlation between the therapeutic efficacy of the CRM [6] and the occurrence of vertigo during the maneuver we called liberatory vertigo. Our literature search, however, failed to identify any study describing such an event or reporting liberatory vertigo as a

    potential prognostic predictive factor regardless of the presence of liber- atory nystagmus. It is conceivable that a gravitational force attracts the otoliths through the semicircular canals and the crus commune and, fi- nally, to the utricle with an ampullifugal movement; that process might explain the benefits of the repositioning maneuver. In our experience, most patients who experienced resolution of symptoms reported that liberatory vertigo had occurred. As an explanation for the phenomenon, we support the finding that a gravitational pull attracts otoconia debris, which fall down directly in the utricle at the end of the maneuver and that the patient perceives the event like an onset of vertigo, a retropulsion, or a falling sensation.

    Recent research [33] sought to estimate the annual costs associated with ED visits for dizziness. The authors indicated that rising costs ap- peared to reflect rising prevalence of dizziness and increased rates of imaging use instead of improvements in the quality of bedside diagno- sis. In light of the present study’s findings, we suggest that the occur- rence of liberatory vertigo during a canalith repositioning procedure in an ED represents a cost-effective way to predict successful treatment of BPPV. In our experience, a bedside examination was satisfactory for diagnosing and successfully treating most cases of BPPV, applying in- depth analysis to atypical cases.

    According to guideline criteria, patients who meet clinical criteria for diagnoses of BPPV should not routinely undergo additional vestibular function tests because the information obtained does not add much more to diagnostic accuracy, whereas the tests do add significant cost and length of stay in the ED. Moreover, neuroimaging is not useful in the routine diagnosis of BPPV because no radiologic findings are charac- teristic of or diagnostic for BPPV [34] and because, according to the guidelines, radiographic imaging should be reserved for patients who present with additional neurologic symptoms atypical for BPPV, includ- ing abnormal cranial nerve findings, Visual disturbances, and Severe headache [6]. Routine neuroimaging has not been recommended for de- termining those conditions as separate from the more common case of BPPV, and the costs in cases of BPPV are not justified given that neuro- imaging does not improve diagnostic accuracy. Therefore, neuroimag- ing should not be used routinely to confirm a diagnosis of BPPV [6]. In our opinion, the diagnosis and treatment of BPPV should be priorities in clinical medicine because the disorder is common, readily identified by simple and quick tests, and easily treatable by a bedside positional maneuver that has been demonstrated as simple and highly effective [3]. Moreover, primary research, systematic reviews, and 2 guideline statements support the diagnostic tests and the CRM; despite that, the tests and the CRM are substantially underused in routine care settings [3].

    The literature finds no widely accepted time interval at which to re- assess patients for treatment failure. Therapeutic BPPV trials variably re- port follow-up assessment for Treatment outcomes at 40 hours, 2 weeks, 1 month, and up to 6 months, although the most commonly used interval is 1 month [24,35,36]. The guidelines suggest reassess- ment of patients within 1 month because 1 month is long enough to allow a spontaneous rate of resolution to happen; we chose to perform the follow-up 1 week later simply to distinguish the percentage of pa- tients who had beneficial effects after the treatment from the percent- age of patients who had spontaneous resolution of symptoms [6].

    Therefore, to disseminate and implement the optimal use of the tests and the CRM, we propose the use of a simple flowchart based on inter- national guidelines for easy treatment of one of the most frequent ves- tibular diseases.

    • Clinicians should diagnose patients as having PSC BPPV when the Dix-Hallpike test’s diagnostic maneuver provokes vertigo associat- ed with typical forms of nystagmus. Clinicians should treat such patients with a repositioning maneuver: the Epley maneuver or the Semont maneuver.
    • In the event that the patient has a typical history of BPPV and the Dix-Hallpike test is negative, the clinician should assess for HSC

    G. Tirelli et al. / American Journal of Emergency Medicine 34 (2016) 15481551 1551

    BPPV by use of a supine roll test. If the test is positive, the clinician should perform the Lampert maneuver.

      • When liberatory vertigo occurs after the first repositioning proce- dure, the probability of achieving Full recovery is high, and there- fore, follow-up is not recommended; an otorhinolaryngological evaluation by a specialist could be suggested at 1 month. In case of lack of liberatory vertigo, a 1-week follow-up is advisable to en- sure accuracy of the diagnosis of BPPV and to avoid potential pa- tient harm.

    Further prospective studies are needed to reduce selection bias and to plan thorough symptom investigation by means of a standardized questionnaire.

    Conclusion

    The study found that most patients with BPPV who obtained full re- covery after the repositioning maneuvers had experienced liberatory vertigo. In particular, in our sample, liberatory vertigo was a prognostic positive predictive factor of success regardless of which canal was involved.

    References

    1. Von Brevern M, Radtke A, Lezius F, Feldmann M, Ziese T, Lempert T, et al. Epidemi- ology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry 2007;78:710-5.
    2. Baloh RW, Honrubia V, Kerber KA. Baloh and Honrubia’s clinical neurophysiology of the vestibular system. 4th ed. Philadelphia: Oxford University Press; 2011.
    3. Kerber KA, Burke JF, Skolarus LE, Meurer WJ, Callaghan BC, Brown DL, et al. Use of BPPV processes in emergency department dizziness presentations: a population- based study. Otolaryngol Head Neck Surg 2013;148:425-30.
    4. Faralli M, Ricci G, Molini E, Bressi T, Simoncelli C, Frenguelli A. Paroxysmal positional vertigo: the role of age as a prognostic factor. Acta Otorhinolaryngol Ital 2006;26: 25-31.
    5. Jang YS, Hwang CH, Shin JY, Bae WY, Kim LS. Age-related changes on the morphol- ogy of the otoconia. Laryngoscope 2006;116:996-1001.
    6. Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical prac- tice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2008;139:47-81.
    7. Polensek SH, Tusa R. Unnecessary diagnostic tests often obtained for benign parox- ysmal positional vertigo. Med Sci Monit 2009;15:MT89-94.
    8. Tirelli G, D’Orlando E, Giacomarra V, Russolo M. Benign positional vertigo without detectable nystagmus. Laryngoscope 2001;111:1053-6.
    9. Tirelli G, Russolo M. 360-degree canalith repositioning procedure for the horizontal canal. Otolaryngol Head Neck Surg 2004;131:740-6.
    10. Tirelli G, D’Orlando E, Zarcone O, Giacomarra V, Russolo M. Modified particle reposi- tioning procedure. Laryngoscope 2000;110:462-8.
    11. Nuti D, Nati C, Passali D. Treatment of benign paroxysmal positional vertigo: no need for postmaneuver restrictions. Otolaryngol Head Neck Surg 2000;122:440-4.
    12. Uneri A. Falling sensation in patients who undergo the Epley maneuver: a retrospec- tive study. Ear Nose Throat J 2005;84:82,84-5.
    13. Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med 1999;341: 1590-6.
    14. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal po- sitional vertigo (BPPV). CMAJ 2003;169:681-93.
    15. Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, et al. Practice param- eter: therapies for benign paroxysmal positional vertigo (an evidence-based re- view): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:2067-74.
    16. Casani AP, Vannucci G, Fattori B, Berrettini S. Positional vertigo and ageotropic bidi- rectional nystagmus. Laryngoscope 1997;107:807-13.
    17. Baloh RW, Honrubia V, Jacobson KM. Benign positional vertigo: clinical and oculographic features in 240 cases. Neurology 1987;37:371-8.
    18. Viirre E, Purcell I, Baloh RW. The Dix-Hallpike test and the canalith repositioning ma-

      neuver. Laryngoscope 2005;115:184-7.

      De la Meilleure G, Dehaene I, Depondt M, Damman W, Crevits L, Vanhooren G. Be- nign paroxysmal positional vertigo of the horizontal canal. J Neurol Neurosurg Psy- chiatry 1996;60:68-71.

    19. Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol 1980;106:484-5.
    20. Steenerson RL, Cronin GW, Marbach PM. Effectiveness of treatment techniques in 923 cases of benign paroxysmal positional vertigo. Laryngoscope 2005;115:226-31.
    21. Asprella Libonati G. Diagnostic and treatment strategy of lateral semicircular canal canalolithiasis. Acta Otorhinolaryngol Ital 2005;25:277-83.
    22. Prokopakis EP, Chimona T, Tsagournisakis M, Christodoulou P, Hirsch BE, Lachanas VA, et al. Benign paroxysmal positional vertigo: 10-year experience in treating 592 patients with canalith repositioning procedure. Laryngoscope 2005;115:1667-71.
    23. Woodworth BA, Gillespie MB, Lambert PR. The canalith repositioning procedure for benign positional vertigo: a meta-analysis. Laryngoscope 2004;114:1143-6.
    24. Froehling DA, Bowen JM, Mohr DN, Brey RH, Beatty CW, Wollan PC, et al. The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc 2000;75:695-700.
    25. Lempert T, Gresty MA, Bronstein AM. Benign positional vertigo: recognition and treatment. BMJ 1995;19:489-91.
    26. Moon SY, Kim JS, Kim BK, Kim JI, Lee H, Son SI, et al. Clinical characteristics of benign paroxysmal positional vertigo in Korea: a multicenter study. J Korean Med Sci 2006; 21:539-43.
    27. Oh HJ, Kim JS, Han BI, Lim JG. Predicting a successful treatment in posterior canal be- nign paroxysmal positional vertigo. Neurology 2007;68:1219-22.
    28. Del Rio M, Arriaga A. Benign positional vertigo: prognostic factors. Otolaryngol Head

      Neck Surg 2004;130:426-9.

      Dix MR, Hallpike CS. The pathology, symptomatology and diagnosis of certain com- mon disorders of the vestibular system. Proc R Soc Med 1952;45:341-54.

    29. Califano L, Capparuccia PG, Di Maria D, Melillo MG, Villari D. Treatment of benign paroxysmal positional vertigo of posterior semicircular canal by “quick liberatory ro- tation manoeuvre”. Acta Otorhinolaryngol Ital 2003;23:161-7.
    30. Mandala M, Santoro GP, Asprella Libonati G, Casani AP, Faralli M, Giannoni B, et al. Double-blind randomized trial on short-term efficacy of the Semont maneuver for the treatment of posterior canal benign paroxysmal positional vertigo. J Neurol 2012;259:882-5.
    31. Saber Tehrani AS, Coughlan D, Hsieh YH, Mantokoudis G, Korley FK, Kerber KA, et al. Rising annual costs of dizziness presentations to U.S. emergency departments. Acad Emerg Med 2013;20:689-96.
    32. Hasso AN, Drayer BP, Anderson RE, Braffman B, Davis PC, Deck MD, et al. Vertigo and hearing loss. American College of Radiology. ACR appropriateness criteria. Radiology 2000;215:471-8 [Suppl].
    33. Hilton M, Pinder D. The Epley (canalith repositioning) manoeuvre for benign parox- ysmal positional vertigo. Cochrane Database Syst Rev 2004:CD003162.
    34. Teixeira LJ, Machado JN. Maneuvers for the treatment of benign positional paroxys- mal vertigo: a systematic review. Braz J Otorhinolaryngol 2006;72:130-9.