Clinical Practice Update Part I: Diagnosis and Treatment for Benign Paroxysmal Positional Vertigo

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•• Jeong SS, Simpson KN, Johnson JM, Rizk HG. Assessment of the cost burden of episodic recurrent vestibular vertigo in the US. Arch otolaryngol Head Neck Surg. 2022;148(12). https://doi.org/10.1001/jamaoto.2022.3247 . Although BPPV can be diagnosed and treated at bedside, BPPV continues to have extraneous medical costs related to imaging and vestibular testing. Additional resources are needed to promote more efficient use of healthcare resources.

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• Se To PL, Singh DKA, Whitney SL. Effects of customized vestibular rehabilitation plus canalith repositioning maneuver on gait and balance in adults with benign paroxysmal positional vertigo: a randomized controlled trial. VES. 2022;32(1):79. https://doi.org/10.3233/ves-190731. Balance and gait interventions combined with canalith repositioning maneuvers may be more beneficial compared to canalith repositioning maneuvers alone for addressing balance dysfunction in individuals with BPPV.

Carrillo Muñoz R, Ballve Moreno JL, Villar Balboa I, et al. Disability perceived by primary care patients with posterior canal benign paroxysmal positional vertigo. BMC Fam Pract. 2019;20(1). https://doi.org/10.1186/s12875-019-1035-3.

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Choi S-Y, Cho JW, Choi J-H, Oh EH and Choi K-D. Effect of the Epley maneuver and Brandt-Daroff exercise on benign paroxysmal positional vertigo involving the posterior semicircular canal cupulolithiasis: a randomized clinical trial. Front Neurol. 2020;11. https://doi.org/10.3389/fneur.2020.603541.

Gupta AK, Sharma KG, Sharma P. Effect of Epley, Semont maneuvers and Brandt-Daroff exercise on quality of life in patients with posterior semicircular canal benign paroxysmal positional vertigo (PSCBPPV). Indian J Otolaryngol Head Neck Surg. 2019;71(1):99–103. https://doi.org/10.1007/s12070-018-1322-7.

Imai T, Uno A, Yamato A, Takimoto Y, Sato G, Matsuda K, Takeda N, Nishiike S, Kawashima K, Iga T, Ueno Y, Ohta Y, Sato T, Kamakura T, Shingai-Higashi K, Mikami S, Kimura N, Nakajima T, Tanaka A and Inohara H. Comparison of the efficacy of the Epley maneuver and repeated Dix–Hallpike tests for eliminating positional nystagmus: a multicenter randomized study. Front Neurol. 2023;14. https://doi.org/10.3389/fneur.2023.1095041.

• Isaradisaikul S, Chowsilpa S, Hanprasertpong C, Rithirangsriroj T. Single cycle versus multiple cycles of canalith repositioning procedure for treatment of posterior canal benign paroxysmal positional vertigo: a randomized controlled trial. Otol Neurotol. 2021;42(1):121–8. https://doi.org/10.1097/mao.0000000000002894. A single cycle of canalith repositioning manuever is as effective as multiple maeuvers with a lower incidence of complication.

Jaffar M, Ghous M, Ayaz M, Khan AA, Akbar A, Haleem F. Effects of half-somersault and Brandt-Daroff exercise on dizziness, fear of fall and quality of life in patients with posterior canal benign paroxysmal positional vertigo: a randomized control trial. J Pak Med Assoc. 2023;73(1):139–142. https://doi.org/10.47391/jpma.3333.

Lee JD, Shim DB, Park HJ, et al. A multicenter randomized double-blind study: comparison of the Epley, Semont, and sham maneuvers for the treatment of posterior canal benign paroxysmal positional vertigo. Audiol Neurotol. 2014;19(5):336–41. https://doi.org/10.1159/000365438.

• Lee HJ, Jeon E, Lee D, Seo J. Therapeutic efficacy of the modified epley maneuver with a pillow under the shoulders. Clin Exp Otorhinolaryngol. 2020;13(4):376–380. https://doi.org/10.21053/ceo.2019.01830. Using a pillow underneath the shoulders during an Epley maneuver may be a way to facilitate a repositioning maneuver if a patient cannot tolerate cervical extension or has anxiety of being within a head-hanging position.

Lee C, Lee C, Wu P, Wang C, Chen H, Shih C. Efficacy of combined canalith-repositioning procedure and supine to prolonged lateral position in treating posterior canal benign paroxysmal positional vertigo. Auris Nasus Larynx. 2021;48(5):834–40. https://doi.org/10.1016/j.anl.2021.01.009.

Lovato A, Marioni G, Monzani D, Rossettini G, Genovese E, de Filippis C. Physical therapy for benign positional vertigo of posterior canal: the role of alternated epley and semont maneuvers. Ear Nose Throat J. 2023;102(2):NP60–NP64. https://doi.org/10.1177/0145561320980183.

Mishra P, Sindhu KLS, Chethana R, Kaushik M. Epleys versus semonts manoeuvre in posterior canal benign paroxysmal positional vertigo. Indian J Otolaryngol Head Neck Surg. 2023. https://doi.org/10.1007/s12070-023-03624-5.

Oh S, Kim J, Choi K, et al. Switch to Semont maneuver is no better than repetition of Epley maneuver in treating refractory BPPV. J Neurol. 2017;264(9):1892–8. https://doi.org/10.1007/s00415-017-8580-2.

Piromchai P, Eamudomkarn N, Srirompotong S, Ratanaanekchai T, Yimtae K. The efficacy of a home treatment program combined with office-based canalith repositioning procedure for benign paroxysmal positional vertigo—a randomized controlled trial. Otol Neurotol. 2019;40(7):951–6. https://doi.org/10.1097/mao.0000000000002310.

Saberi A, Nemati S, Sabnan S, Mollahoseini F, Kazemnejad E. A safe-repositioning maneuver for the management of benign paroxysmal positional vertigo: Gans vs. Epley maneuver; a randomized comparative clinical trial. Eur Arch Otorhinolaryngol. 2017;274(8):2973–2979. https://doi.org/10.1007/s00405-016-4235-7.

Sinsamutpadung C, Kulthaveesup A. Comparison of outcomes of the Epley and Semont maneuvers in posterior canal BPPV: a randomized controlled trial. Laryngoscope Investig Otolaryngol. 2021;6(4):866–71. https://doi.org/10.1002/lio2.619.

Strupp M, Goldschagg N, Vinck A, et al. BPPV: comparison of the SémontPLUS with the sémont maneuver: a prospective randomized trial. Front Neurol. 2021;12. https://doi.org/10.3389/fneur.2021.652573.

Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, Holmberg JM, Mahoney K, Hollingsworth DB, Roberts R, Seidman MD, Steiner RW, Do BT, Voelker CC, Waguespack RW, Corrigan MD. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017;156:S1–47. https://doi.org/10.1177/0194599816689667.

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Ping L, Yi-fei Z, Shu-zhi W, Yan-yan Z, Xiao-kai Y. Diagnosis and treatment of the short-arm type posterior semicircular canal BPPV. Braz J Otorhinolaryngol. 2022;88(5):733–9. https://doi.org/10.1016/j.bjorl.2020.10.012.

Vannucchi P, Pecci R, Giannoni B., Posterior semicircular canal benign paroxysmal positional vertigo presenting with torsional downbeating nystagmus: an apogeotropic variant, Int. J. Otolaryngol. 2012. https://doi.org/10.1155/2012/413603.

Helminski JO. Peripheral downbeat positional nystagmus: apogeotropicposterior canal or anterior canal BPPV. J Neurol Phys Ther. 2019;43:S8–13. https://doi.org/10.1097/NPT.0000000000000267.

Kim J, Lee S, Kim H, Kim J. Less talked variants of benign paroxysmal positional vertigo. J Neurol Sci. 2022;442:120440. https://doi.org/10.1016/j.jns.2022.120440.

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•• Scocco DH, Barreiro MA, García IE. Sitting-up vertigo as an expression of posterior semicircular canal heavy cupula and posterior semicircular canal short arm canalolithiasis. J Otol. 2022;17(2):101–106. https://doi.org/10.1016/j.joto.2022.02.001. The short-arm PC-BPPV has recently been described in the literature and can be identified with up-beating torsional nystagmus when returning to sit from the Dix-Hallpike or straight-head hanging maneuver. Correctly identifying the type of BPPV and location of debris within the SCC is critical, so the patient can be treated with the most appropriate maneuver.

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Yu J, Gu Y, Meng G, et al. Nystagmus parameters of supine roll test correlates with prognosis after repositioning maneuver in horizontal semicircular canal benign paroxysmal positional vertigo. Front Neurol. 2021;12:790430. https://doi.org/10.3389/fneur.2021.790430.

• Kinne BL, Breuer RE, Fitkin OM, Kelly RL. Interventions for apogeotropic horizontal canal benign paroxysmal positional vertigo: a systematic review. Phys Ther Rev. 2022:1–9. https://doi.org/10.1080/10833196.2022.2163082. Review of recent randomized control trials for treatment maneuvers for apogeotropic horizontal BPPV.

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• Alvarez de Linera-Alperi M, Garaycochea O, Calavia D, Terrasa D, Pérez-Fernández N, Manrique-Huarte R. Apogeotropic horizontal canal benign paroxysmal positional vertigo: Zuma e maia maneuver versus appiani variant of gufoni. Audiol Res. 2022;12(3):337–346. https://doi.org/10.3390/audiolres12030035. The Zuma manever is proposed as an alternate treatment for apogeotropic horizontal canal BPPV and may be more effective for individuals who have a history of previous BPPV episodes.

Han K, Lee J, Shin JE, Kim C. Treatment efficacy of forced prolonged position after cupulolith repositioning maneuver in apogeotropic HSCC BPPV. Ear Nose Throat J. 2022. https://doi.org/10.1177/01455613211038274.

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Kim HA, Park S, Kim J, et al. Efficacy of mastoid oscillation and the gufoni maneuver for treating apogeotropic horizontal benign positional vertigo: a randomized controlled study. J Neurol. 2017;264(5):848–55. https://doi.org/10.1007/s00415-017-8422-2.

Kong TH, Song MH, Kang JW, Shim DB. Double-blind randomized controlled trial on efficacy of cupulolith repositioning maneuver for treatment of apogeotropic horizontal canal benign paroxysmal positional vertigo. Acta Otolaryngol. 2020;140(6):473–8. https://doi.org/10.1080/00016489.2020.1736339.

Lee J, Lee D, Noh H, Shin JE, Kim C. Immediate and short-term effects of gufoni and appiani liberatory maneuver for treatment of ageotropic horizontal canal benign paroxysmal positional vertigo: a prospective randomized trial. Laryngoscope Investig Otolaryngol. 2021;6(4):832–8. https://doi.org/10.1002/lio2.600.

Li J, Zou S, Tian S. A prospective randomized controlled study of li quick repositioning maneuver for geotropic horizontal canal BPPV. Acta Otolaryngol. 2018;138(9):779–84. https://doi.org/10.1080/00016489.2018.1476778.

• Mandala M, Califano L, Casani AP, et al. Double-blind randomized trial on the efficacy of the forced prolonged position for treatment of lateral canal benign paroxysmal positional vertigo. Laryngoscope. 2021;131:E1296-E1300. https://doi.org/10.1002/lary.28981. Forced-prolonged positioning is highly effective compared to a sham maneuver, and can be recommended for treating HC-BPPV.

Martens C, Goplen FK, Aasen T, Gjestad R, Nordfalk KF, Nordahl SHG. Treatment of horizontal canal BPPV — a randomized sham‐controlled trial comparing two therapeutic maneuvers of different speeds. Laryngoscope Investig Otolaryngol. 2020;5(4). https://doi.org/10.1002/lio2.420.

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Kim SK, Li SW, Hong SM. Differences in the head roll test, bow and lean test, and null plane between persistent and transient geotropic direction-changing positional nystagmus. J Clin Med. 2019;9(1):73. https://doi.org/10.3390/jcm9010073.

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•• Ramos BF, Cal R, Brock CM, Mangabeira Albernaz PL, Zuma E Maia F. Zuma modified maneuver as a treatment to geotropic lateral semicircular canal benign paroxysmal positional vertigo. Int Arch Otorhinolaryngol. 2021;25(02):e255. https://doi.org/10.1055/s-0040-1712935. The modified Zuma maneuver may be effective for geotropic horizontal BPPV. The use of the modified Zuma may simplify treatments for patients with horizontal canal BPPV.

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