Repositioning for the Patient with Benign Positional Vertigo

abstract & commentary

Source: Froehling DA, et al. The canalith repositioning
procedure for the treatment of benign paroxysmal positional vertigo: A randomized controlled trial. Mayo Clinic Proc 2000; 75:695-700.

In this prospective, randomized, double-blind, controlled trial, 50 patients with a history suggestive of benign positional vertigo (BPV) and unilateral positional nystagmus on physical exam were treated with the canalith repositioning procedure (CRP) or a sham maneuver. Major outcomes included resolution of vertigo and positional nystagmus at a follow-up visit.

Patients were recruited from an outpatient Urgent Care Center and internal medicine practices at the Mayo Clinic. Inclusion criteria were simply positional vertigo and positional nystagmus in either the right or left Dix-Hallpike head-hanging position. Exclusion criteria included gaze-evoked nystagmus, positive result of the Dix-Hallpike maneuver in both right and left head hanging positions, evidence of ongoing central nervous system disease, otitis media, otosclerosis, and inability to tolerate a diagnostic Dix-Hallpike head-hanging maneuver because of restricted head movement or severe positional vertigo with nausea or vomiting.

In the CRP, each patient was put through a series of five brief maneuvers that are a modification of the Dix-Hallpike maneuver itself. The procedure was repeated until no positional nystagmus was elicited or until five cycles had been performed. All patients were sent home with instructions to sleep the first two nights in a sitting position wearing a cervical collar.

A nurse, blinded to the type of maneuver, performed follow-up evaluations at a mean of 10 days. Twelve of the 24 patients in the CRP group had resolution of symptoms (50%; 95% CI, 30-70%) compared to five of the 26 patients in the sham group (19%; 95% CI, 4-57%; P = 0.02). The results of the Dix-Hallpike maneuver were negative for positional nystagmus in 16 of the CRP group (67%; 95% CI, 48-86%) and in 10 of the sham group (38%; 95% CI, 20-57%; P = 0.046). A number of clinical characteristics obtained at the time of the initial examinations were assessed, and none were found to be associated with the resolution of vertigo.

Comment by Stephanie B. Abbuhl, MD,FACEP

Although a larger sample size and narrower confidence intervals would be even more convincing, this study is fairly persuasive in showing the benefit of the CRP in many BPV patients. In a recent review, at least three other trials noted benefit from the CRP in BPV patients.1 This study is the most relevant to the emergency department (ED) setting in that diagnosis was based entirely on history and physical exam without any laboratory tests or vestibular/audiologic testing. In addition, the study was conducted by general internists rather than otorhinolaryngologists.

The rationale for the CRP is anatomic and straight-forward. The theory is that free-moving particles in the endolymph of the posterior semicircular canals cause positional vertigo with head movement. The five-step CRP maneuver is thought to transfer the debris from the posterior semicircular canal into the utricle, where it presumably adheres and no longer causes symptoms. The maneuver is not thought to be of any benefit to patients with other causes of vertigo. It is appealing that a simple bedside procedure might treat some of the BPV we see in the ED. It has been noted that the procedure can be difficult in the elderly and in very obese patients, which may limit its use. It also would be interesting to see if there is measurable improvement immediately after the maneuver (as some literature suggests), and if this predicts resolution of symptoms at a later follow-up. In summary, BPV is common, CRP seems simple and brief enough to be practical, and the literature is suggestive of its utility—now we need someone to assess its feasibility and outcome in the ED.

References

1. Furman JM, Cass SP. Benign paraoxysmal positional vertigo. N Engl J Med 1999;341:1590-1596.