Original Research
Features of Residual Dizziness after Canalith Repositioning Procedures for Benign Paroxysmal Positional Vertigo
Otolaryngology– Head and Neck Surgery 1–9 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599815627624 http://otojournal.org
Salvatore Martellucci, MD1, Giulio Pagliuca, MD, PhD1, Marco de Vincentiis, MD2, Antonio Greco, MD2, Armando De Virgilio, MD2,3, Ferdinando Maria Nobili Benedetti, MD1, Camilla Gallipoli, MD1, Chiara Rosato, MD1, Veronica Clemenzi, MD1, and Andrea Gallo, MD, PhD1
No sponsorships or competing interests have been disclosed for this article.
Abstract Objectives. To assess factors related to residual dizziness (RD) in patients who underwent successful canalith repositioning procedures (CRPs) for benign paroxysmal positional vertigo (BPPV).
Keywords benign paroxysmal positional vertigo, BPPV, residual dizziness, vertigo, imbalance, repositioning maneuver, canalith repositioning procedures, DHI, anxiety, elderly Received August 20, 2015; revised November 5, 2015; accepted December 29, 2015.
Study Design. Prospective cohort study. Setting. Academic center. Subjects and Methods. Ninety-seven consecutive patients with BPPV of the posterior semicircular canal were initially enrolled. Diagnosis was assessed according to clinical history and bedside evaluation. All patients were treated with CRPs until nystagmus disappeared. Three days after the successful treatment, presence of RD was investigated. If RD was present, patients were monitored every 3 days until the symptoms disappeared. Subjects who required 4 CRPs or who failed to meet the follow-up visit were excluded. The Dizziness Handicap Inventory (DHI) was obtained from patients at the time of diagnosis and at every subsequent visit. Results. At the end of selection, 86 patients were included; 33 (38.36%) reported RD after successful treatment. A significant difference in the incidence of RD was observed in consideration of the age of the subjects (P = .0003) and the DHI score at the time of diagnosis (P \ .001). A logistic regression analysis showed that the probability of RD occurrence increased with the increase of the emotional subdomain score of the DHI questionnaire. Conclusion. RD is a common self-limited disorder, more frequent in the elderly, which may occur after the physical treatment for BPPV. The DHI score at the time of BPPV diagnosis represents a useful tool to quantify the impact of this vestibular disorder on the quality of life and to estimate the risk of RD after CRPs.
B
enign paroxysmal positional vertigo (BPPV) is a common disorder of the inner ear characterized by repeated episodes of vertigo that are triggered by changes in head position.1,2 BPPV is the most prevalent peripheral vestibular impairment during the life span, which accounts for approximately 17% of complaints of vertigo.1-4 The suggested pathophysiology is a displacement of otoconial matter from the utricle to the semicircular canals. The movement of the otoconial matter due to gravity causes the flow of endolymph, which consequently causes vertigo and nystagmus. BPPV is usually idiopathic but can occur after head trauma or secondary to various disorders that damage the inner ear and detach the otolith from the utricular macule. The posterior semicircular canal is affected in most cases.1-5 BPPV is effectively managed via different repositioning maneuvers, which are noninvasive procedures meant to
1 Department of Surgical Biotechnologies and Science, ENT Section, Sapienza University of Rome, Rome, Italy 2 Department of Sensorial Organs, ENT Section, Sapienza University of Rome, Rome, Italy 3 Department of Surgical Science, Sapienza University of Rome, Rome, Italy
This article was presented at the 2015 AAO-HNSF Annual Meeting & OTO EXPO; September 27-30, 2015; Dallas, Texas. Corresponding Author: Salvatore Martellucci, MD, Department of Surgical Biotechnologies and Science, ENT Section, Sapienza University of Rome, Italy, Via Giulio Cesare 41\B, 04100 Latina, Italy. Email: [email protected]
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remove the otoconial debris into utricular cavity. Although many maneuvers have been described for the treatment of posterior canal BPPV (PC-BPPV), the canalith repositioning procedure (CRP) proposed by Epley is the most widely prevalent as a first-line treatment of this variant of BPPV and has been found to be safe and effective.1-8 However, in many patients, residual symptoms may remain even after disappearance of typical vertigo and nystagmus following a successful CRP. These residual symptoms, also called residual dizziness (RD), consist of nonpositional, persistent imbalance of variable duration, and its causal factors are still under debate.9-12 The goal of this study was to identify the clinical features of RD after successful CRP in patients with PC-BPPV, analyzing the factors related to the occurrence of this disorder.
Methods With the approval of the Institutional Review Board of the Department of Surgical Biotechnologies and Science of the Sapienza University of Rome, 97 consecutive patients (35 male and 62 female, mean age: 58.23 6 15) affected by PC-BPPV were initially enrolled in this prospective trial from June 2013 to January 2015. Patients with the involvement of multiple semicircular canals or with clinical history of previous episodes of dizziness (including previous episodes of BPPV) were excluded from the study, as well as patients unable to understand Italian language and those who did not undergo the follow-up visits as planned. A flowchart describing the study design is illustrated in Figure 1. All patients underwent a bedside neurotologic evaluation, including examinations for ocular alignment, spontaneous and gaze-evoked nystagmus, vestibuloocular reflex, saccades, smooth pursuit, and balance. During the evaluation, patients also underwent diagnostic positional tests for BPPV assessment. Once the diagnosis of PC-BPPV was reached and other vestibular pathologies were excluded, patients were treated with CRP and asked to return for a posttreatment visit 3 days later. During the first visit, patients again underwent diagnostic positional tests. In case of negative test results (absence of positional vertigo and undetectable positional nystagmus), the last CRP performed during the previous examination was defined as ‘‘successful.’’ Conversely, in case of positive positional test results, CRP was repeated, and the patients were reevaluated every 3 days until the disappearance of positional vertigo and positional nystagmus (ie, until the achievement of a successful CRP). Patients who required 4 CRPs were excluded from the study. During the first visit after the successful CRP, the presence of RD was investigated. RD was defined as feeling of unsteadiness and/or light-headedness and/or dizziness in the absence of true vertigo and nystagmus. Then, patients reporting RD were evaluated every 3 days until the residual symptoms disappeared. The Dizziness Handicap Inventory
Figure 1. Study design. BPPV, benign paroxysmal positional vertigo; CRP, canalith repositioning procedure; DHI, Dizziness Handicap Inventory; PC-BPPV, posterior canal BPPV; RD, residual dizziness.
(DHI) was submitted to all patients at the diagnosis and at every follow-up visit.
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Diagnosis and Treatment of PC-BPPV The diagnosis of unilateral PC-BPPV, suspected by clinical history, was confirmed by positioning tests for the vertical canals (Dix-Hallpike test unilaterally positive) and horizontal canals (supine head roll test bilaterally negative). Dix-Hallpike test was considered ‘‘positive’’ for PCBPPV if able to evoke the typical paroxysmal nystagmus— upbeating and torsional (with the upper pole of the eyes beating toward the ear in a lower position)—developed with a latency of several seconds and resolved within 1 minute. In all cases, PC-BPPV was treated with Epley’s CRP.1,13 The patient was placed in the upright position with the head turned 45° toward the ear that was positive on the DixHallpike test. Then, the patient was rapidly laid back to the supine head-hanging position, which was maintained for about 30 seconds. Next, the head was turned 90° toward the unaffected side and held for about 30 seconds. Following this rotation, the patient’s head was turned 90° reaching the facedown position while the patient’s body moved from the supine position to the lateral decubitus position. After about 30 seconds, the patient was brought into the upright sitting position, completing the maneuver. Diagnostic tests and CRPs were performed 1 or more times during the same session until the disappearance of positioning nystagmus.
Dizziness Handicap Inventory The DHI evaluates the self-perceived handicapping effects of vestibular disease and its impact on quality of life.14 In this study, we used the Italian version of the DHI, validated in 2010.15 The DHI consists of 25 items divided into 3 domains believed to encompass the impact of the disease: functional (DHI-F, 9 questions), emotional (DHI-E, 9 questions), and physical (DHI-P, 7 questions; Table 1). Each item is assigned 0, 2, or 4 points; therefore, the DHI score is between 0 and 100 points. In this study, the total DHI score and the score for each domain were calculated.
Statistical Analysis Continuously distributed variables were described by the mean and SD; categorical variables were described by frequencies and percentages. Comparisons of qualitative and quantitative variables (after the normal distribution was verified) were performed with the chi-square test and Student’s t test, respectively. P \ .05 was considered statistically significant. A binary logistic regression model was fitted to examine the statistical relationship between RD and a set of selected factors, enabling predictions about RD based on covariates such as sex, age, duration of BPPV before diagnosis, number of CRPs performed, and the DHI score at the time of diagnosis (considering both the total score and that of each of the 3 domains). All variables that were associated with the dependent variable at significance level of .05 were candidates to be included in the model as potential covariates.
All data were analyzed with SPSS 15.0 for Windows.
Results Eleven patients who initially met the inclusion criteria were later excluded from the study. Five of them (5.15%) failed to attend the follow-up visits, while 6 (6.18%) required .3 CRPs to treat their BPPV. Then, 86 patients (88.65%) were finally included. The demographics of patients included in this study are summarized in Table 2. A statistically significant difference between the DHI score at the time of diagnosis and the DHI score after successful CRP was observed both in patients who developed RD and in those free from residual symptoms. Thirty-three subjects (38.36%) reported RD after the third day from the successful CRP. In 18 patients (54.54%), this disorder resolved within 6 days after CRP, while 4 subjects (12.12%) recovered within 9 days. Only in 11 patients (33.33%) did RD last for .10 days but not exceed 15 days. Statistical analysis did not show differences in the incidence of RD according to sex, side of involved canal, number of repositioning maneuvers, and duration of BPPV before diagnosis. Conversely, we observed a significant difference in the incidence of RD taking into account the age of the subjects (P = .0003) and the DHI score at the diagnosis (P \ .001; Figure 2). Taking into account the age, we considered all subjects ‘‘elderly’’ who were .65 years old. According to this cutoff, the incidence of RD was significantly greater in the elderly (P = .002; Figure 2). The relative risk of RD in this group of patients was 2.29 with a 95% confidence interval ranging from 1.34 to 3.91. The scores derived from the 3 subdomains of DHI were also compared. We observed a significant difference between patients who experienced RD and those who did not develop this disorder accounting for the DHI-F and DHI-E scores at the time of diagnosis (P \ .001). There were no differences in the incidence of RD based on the DHI-P (P = .25; Figure 3). Similar results were observed by analyzing the DHI scores obtained at the time of first visit. Results are summarized in Table 3. With respect to the binary logistic regression model, a stepwise selection method filtered predictors to include in the model only essential parameters, in observance of parsimony and interpretability principles. The resulting model consists of 2 significant parameters: the intercept and the DHI-E score at the time of diagnosis. The value beyond the significance threshold of Hosmer-Lemeshow goodness-of-fit statistic (.256) meant that the model reasonably approximated the behavior of data. Nagelkerke’s R2 (.535) showed that a limited amount of variation is explained by the model. Table 4 summarizes the effect of each predictor. The resulting odds ratio (1.385) meant that the probability of RD occurrence increases with an increasing DHI-E score at the time of diagnosis. The classification table (Table 5) shows practical results of using the binary logistic regression model; overall, the fitted model had a high predictive
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Table 1. Dizziness Handicap Inventory.a No.
Items
Yes
Sometimes
No
P1 E2 F3 P4 F5 F6
Does looking up increase your problem? Because of your problem, do you feel frustrated? Because of your problem, do you restrict your travel for business or recreation? Does walking down the aisle of a supermarket increase your problems? Because of your problem, do you have difficulty getting into or out of bed? Does your problem significantly restrict your participation in social activities, such as going out to dinner, going to the movies, dancing, or going to parties? Because of your problem, do you have difficulty reading? Does performing more ambitious activities such as sports, dancing, household chores (sweeping or putting dishes away) increase your problems? Because of your problem, are you afraid to leave your home without having without having someone accompany you? Because of your problem have you been embarrassed in front of others? Do quick movements of your head increase your problem? Because of your problem, do you avoid heights? Does turning over in bed increase your problem? Because of your problem, is it difficult for you to do strenuous homework or yard work? Because of your problem, are you afraid people may think you are intoxicated? Because of your problem, is it difficult for you to go for a walk by yourself? Does walking down a sidewalk increase your problem? Because of your problem, is it difficult for you to concentrate Because of your problem, is it difficult for you to walk around your house in the dark? Because of your problem, are you afraid to stay home alone? Because of your problem, do you feel handicapped? Has the problem placed stress on your relationships with members of your family or friends? Because of your problem, are you depressed? Does your problem interfere with your job or household responsibilities? Does bending over increase your problem?
4 4 4 4 4 4
2 2 2 2 2 2
0 0 0 0 0 0
4 4
2 2
0 0
4
2
0
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
F7 P8 E9 E10 P11 F12 P13 F14 E15 F16 P17 E18 F19 E20 E21 E22 E23 F24 P25
a A progressive number and a letter mark each item. The letter indicates the domain of the inventory: E, emotional; F, functional; P, physical. (Reproduced with permission from Archives of Otolaryngology–Head & Neck Surgery. 1990;116(4):424-427. Copyright Ó 1990 American Medical Association. All rights reserved.)
Table 2. Demographic Data. Characteristics Subjectsa Sex Male Female Canal involved Right Left Duration of BPPV \4 h 2-7 d 1-4 wk . 4 wk No. of CRPs performed 1 2 3
Values, n(%) 86 33 (38.36) 53 (61.64) 44 (51.16) 42 (48.84) 41 (47.67) 24 (27.9) 9 (10.46) 12 (13.97) 60 (69.76) 22 (25.58) 4 (4.66)
Abbreviations: BPPV, benign paroxysmal positional vertigo; CRP, canalith repositioning procedure. a Age mean 6 SD, 58.59 6 14.98 years.
capability, with 79.1% of cases that were correctly classified. The median of the DHI-E score at the time of diagnosis was 10 (range, 0-36). Performing a chi-square test, we compared the incidence of RD in patients with a DHI-E score less or equal to the median value or greater than the median. The difference was statistically significant (P = .0001). Then, adopting the median as cutoff value, we calculated the relative risk of RD occurrence for patients with a DHI-E score .10 at the time of diagnosis. Relative risk was equal to 7.60 with a 95% confidence interval ranging from 2.92 to 19.76.
Discussion Finding of residual symptoms after the resolution of BPPV, often defined as ‘‘nonspecific’’ dizziness, is a common occurrence.9-12,16,17 RD, however, has never been considered a disease entity with its own features but rather the short and unpleasant side effects of the earlier BPPV. This consideration, partly justified by the benignity and
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Figure 2. Patients at diagnosis: (A) age and (B) Dizziness Handicap Inventory (DHI) score. RD1, patients reporting residual dizziness; RD–, patients free from residual dizziness.
transience of RD, probably explains the lack of epidemiologic studies about this disorder. In this series, 38.36% of patients affected by PC-BPPV and managed by CRP reported RD. In literature, the incidence of RD after physical therapy for BPPV ranges between 36.6% and 61%.9-12,16-20 This variability could be due, for the most part, to the lack of a shared definition for RD and, second, to the different inclusion criteria in the trials. To avoid selection bias, we included in this study only patients with involvement of the posterior canal alone and treated by the same procedure. We considered patients affected by RD as all those who reported instability, light-headedness, or other balance disorders in absence of true vertigo and nystagmus at time of the first control after the successful CRP. The symptoms reported by patients with RD usually consist of subjective imbalance and are often difficult to describe, suggesting features of a complex vestibular disorder. Several theories have been proposed to explain the occurrence of residual symptoms after a successful treatment for PC-BPPV. A possible explanation may be the persistence of debris in the canal insufficient to provoke noticeable positional nystagmus,21 a utricular dysfunction,22,23 a coexisting vestibular disease, or an incomplete central adaptation.24-26 These hypotheses, although theoretically valid, have not yet been supported by definitive data. To limit the role of comorbid vestibular disorders as a confounding factor for development of RD, we excluded patients with a prior history of dizziness from our study. As mentioned above, some theories about the pathogenesis of RD postulated that a longer time needed for central adaptation after particle repositioning might have a role in the occurrence of the residual symptoms.24-26 A delayed
central adaptation might be related to several factors, including the duration of BPPV,26 age of subjects,9,10,12,18 and anxiety.11,12,17,18,27 Nevertheless, unlike what has been reported by other authors, our study found no statistically significant correlation between RD and duration of BPPV. This difference may be due to differences in patient selection and distribution among the different studies. Our study observed a significant correlation between the age of patients and the occurrence of RD. Older patients are commonly affected by deterioration of the visual and proprioceptive systems but also a global impairment of vestibular function.28,29 The age-related decline of the vestibular system can explain the decreased balance compensation ability in case of peripheral vestibular deficit in the elderly and may be related to the greater incidence of RD in this group of patients. It is well known that anxiety plays a contributory role in dizziness, which may represent a somatoform disorder in some patients who experienced stressor events.30-35 The intense episodes of paroxysmal vertigo, which characterize BPPV, can themselves represent a stressor event due to the severity of the symptoms and the unpredictability of vertigo attacks.36,37 Several studies correlate anxiety, fear of vertigo recurrence, and residual symptoms after BPPV,12,17,18 which point to RD as the expression of psychogenic disorders.27 The DHI is a survey that includes functional, emotional, and physical effects of dizziness on an individual.14,15 It can be used for many pathologies dealing with dizziness, and it fits well with BPPV.38 Moreover, in the literature, this questionnaire was already used to assess the residual symptoms after Epley maneuver,10 although some authors suggested that the residual symptoms could not be effectively evaluated by the DHI score.20
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Table 3. Incidence of RD according to Sex, Canal, Number of CRPs, Duration of BPPV, and DHI Score.a
Subjects Age Sex Male Female Canal involved Right Left Duration of symptoms \24 h 2-7 d 1-4 wk .4 wk No. of CRPs performed 1 2 3 DHI score: diagnosis Total DHI-F DHI-E DHI-P DHI score: first visit Total DHI-F DHI-E DHI-P
RD1
RD–
P Value
33 (38.36) 65.85 6 13.10
53 (61.64) 54.08 6 14.54
14 (42.42) 19 (35.84)
19 (57.58) 34 (64.16)
.649
18 (40.90) 15 (35.71)
26 (59.1) 27 (64.29)
.662
17 (41.43) 9 (37.5) 1 (11.11) 6 (50)
24 (58.57) 15 (62.5) 8 (88.89) 6 (50)
.297
22 (36.66) 10 (45.45) 1 (25)
38 (63.34) 12 (54.55) 3 (75)
.656
60.67 6 10.96 24.85 6 4.12 17.09 6 5.39 19.15 6 4.09
45.55 6 10.59 18.75 6 5.69 8.79 6 4.39 18.04 6 4.60
\.0001 \.0001 \.0001 .258
24.73 6 8.42 10.12 6 4.09 7.76 6 3.60 6.42 6 3.70
11.70 6 3.87 5.21 6 2.58 1.81 6 1.58 4.70 6 2.05
\.0001 \.0001 \.0001 .006
.0003
Abbreviations: BPPV, benign paroxysmal positional vertigo; CRP, canalith repositioning procedure; DHI, Dizziness Handicap Inventory; DHI-E, emotional subdomain; DHI-F, functional subdomain; DHI-P, physical subdomain; RD, residual dizziness; RD1, patients reporting RD; RD–, patients without RD. a Values presented in n (%) or mean 6 SD.
Figure 3. Scores derived from the subdomains of DHI. DHI, Dizziness Handicap Inventory; DHI-E, emotional subdomain; DHI-F, functional subdomain; DHI-P, physical subdomain; RD1, patients reporting residual dizziness; RD– patients without residual dizziness.
In this study, according to literature, we verified the effectiveness of physical therapy for BPPV using the DHI, assessing the improvement of subjective symptoms after
CRP. Furthermore, the DHI score appeared to be related to the development of residual symptoms: the total DHI scores observed in patients complaining RD was significantly
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Table 4. Parameter Estimates. Variable DHI-E at diagnosis Intercept
Ba
SE
Wald’s Coefficient
Odds Ratio
0.325 –4.602
0.068 0.941
22.585 23.928
1.385 0.010
Abbreviation: DHI-E, Dizziness Handicap Inventory–emotional subdomain. a Coefficient B expressed an increasing likelihood of the dependent variable with respect to the occurrence of residual dizziness.
Table 5. Classification Table.a Predicted
Observed
RD1 RD– Global, %
RD1
RD–
%
48 13
5 20
90.6 60.6 79.1
Abbreviations: RD1, patients reporting residual dizziness; RD–, patients without residual dizziness. a Logistical regression model results versus observed categories.
6 days after the repositioning procedure. Our experience shows that older patients and patients with a higher DHI score at time of diagnosis of BPPV are at a higher risk for RD. In particular, a high DHI-E score represents a risk factor for the occurrence of RD. Therefore, the DHI score calculated at the time of diagnosis represents a useful tool not only to quantify the impact of vestibular disorder on the quality of life but also to estimate the risk of RD after CRP. Acknowledgments We thank Francesco Salate Santone for his help in statistical analysis and Helene Claudia Keiski for her help in manuscript preparation.
lower at the time of diagnosis than at the first clinical control after effective CRP. This difference was due mainly to the scores obtained from 2 domains: DHI-F and DHI-E. The DHI-F expresses the functional limitation in daily living, which can be influenced by the concern for the occurrence of further vertigo episodes, while the DHI-E refers to the emotional impact of dizziness. The items of the DHI-E, in particular, investigate the feelings of insecurity, anxiety, and depression experienced by patients as result of their disorders.13 In our experience, the DHI-E score resulted as the most important predictor for the occurrence of RD. This finding further stressed that the emotional aspect plays a preponderant role in the development of RD and suggested that the DHI might represent a simple tool to predict the occurrence of this disorder, particularly taking into account the DHI-E score. A DHI-E score .10 could represent an acceptable cutoff value above which a patient could be considered at risk of RD occurrence. For the treatment of residual symptoms after BPPV, vestibular rehabilitation and drugs (eg, benzodiazepines and betahistine) can be proposed.11,20,39 In our experience, however, RD was a temporary and self-limiting disorder, resolved in most cases within 6 days after the successful CRP. This suggests that the simple reassurance of patients about the benignity and transient nature of their symptoms is a suitable approach for those suffering from RD, reserving drug therapy and vestibular rehabilitation to cases of prolonged duration.
Conclusion RD after CRP for PC-BPPV is a frequent occurrence. This disorder has a variable duration, and its causal factors are still under debate but patients recover in most cases within
Author Contributions Salvatore Martellucci, writer, study design, article drafting, final approval, agreement to be accountable for all aspects of the work; Giulio Pagliuca, study design, data acquisition, article drafting, final approval, agreement to be accountable for all aspects of the work; Marco de Vincentiis, data analysis, article revision and final approval, agreement to be accountable for all aspects of the work; Antonio Greco, data acquisition, data analysis and interpretation, article revision, final approval, agreement to be accountable for all aspects of the work; Armando De Virgilio, data acquisition, statistical analysis, article revision, final approval, agreement to be accountable for all aspects of the work; Ferdinando Maria Nobili Benedetti, data acquisition, data analysis and interpretation, article revision, final approval, agreement to be accountable for all aspects of the work; Camilla Gallipoli, data acquisition, data analysis, drafting, final approval, agreement to be accountable for all aspects of the work; Chiara Rosato, data acquisition, data analysis, drafting, final approval, agreement to be accountable for all aspects of the work; Veronica Clemenzi, data acquisition, article drafting, final approval, agreement to be accountable for all aspects of the work; Andrea Gallo, study design, article drafting and revision, final approval, agreement to be accountable for all aspects of the work.
Disclosures Competing interests: None. Sponsorships: None. Funding source: None.
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3. Korres SG, Balatsouras DG. Diagnostic, pathophysiologic, and therapeutic aspects of benign paroxysmal positional vertigo. Otolaryngol Head and Neck Surg. 2004;131:438-444. 4. Zappia JJ. Benign paroxysmal positional vertigo. Curr Opin Otolaryngol Head Neck Surg. 2013;21:480-486. 5. Hornibrook J. Benign paroxysmal positional vertigo (BPPV): history, pathophysiology, office treatment and future directions. Int J Otolaryngol. 2011;2011:835671. 6. Nguyen-Huynh AT. Evidence-based practice: management of vertigo. Otolaryngol Clin North Am. 2012;45:925-940. 7. Vanni S, Pecci R, Casati C, et al. STANDING, a four-step bedside algorithm for differential diagnosis of acute vertigo in the Emergency Department. Acta Otorhinolaryngol Ital. 2014; 34:419-426. 8. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014;12:CD003162. 9. Seok JI, Lee HM, Yoo JH, Lee DK. Residual dizziness after successful repositioning treatment in patients with benign paroxysmal positional vertigo. J Clin Neurol. 2008;4:107-110. 10. Lee NH, Kwon HJ, Ban JH. Analysis of residual symptoms after treatment in benign paroxysmal positional vertigo using questionnaire. Otolaryngol Head Neck Surg. 2009;141:232-236. 11. Jung HJ, Koo JW, Kim CS, Kim JS, Song JJ. Anxiolytics reduce residual dizziness after successful canalith repositioning maneuvers in benign paroxysmal positional vertigo. Acta Otolaryngol. 2012;132:277-284. 12. Teggi R, Quaglieri S, Gatti O, Benazzo M, Bussi M. Residual dizziness after successful repositioning maneuvers for idiopathic benign paroxysmal positional vertigo. ORL J Otorhinolaryngol Relat Spec. 2013;75:74-81. 13. Epley JM. The canalith repositioning procedure for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992;107:399-404. 14. Jacobson GP, Newman CW, Hunter L, et al. Balance function test correlates of the Dizziness Handicap Inventory. J Am Acad Audiol. 1991;2:253-260. 15. Nola G, Mostardini C, Salvi C, Ercolani AP, Ralli G. Validity of Italian adaptation of the Dizziness Handicap Inventory (DHI) and evaluation of the quality of life in patients with acute dizziness. Acta Otorhinolaryngol Ital. 2010;30:190. 16. Lopez-Escamez JA, Gamiz MJ, Fernandez-Perez A, et al. Long-term outcome and health-related quality of life in benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol. 2005;262:507-511. 17. Magliulo G, Bertin S, Ruggieri M, Gagliardi M. Benign paroxysmal positional vertigo and post-treatment quality of life. Eur Arch Otorhinolaryngol. 2005;262:627-630. 18. Teggi R, Giordano L, Bondi S, et al. Residual dizziness after successful repositioning maneuvers for idiopathic benign paroxysmal positional vertigo in the elderly. Eur Arch Otorhinolaryngol. 2011;268:507-511. 19. Kim HA, Lee H. Autonomic dysfunction as a possible cause of residual dizziness after successful treatment in benign paroxysmal positional vertigo. Clin Neurophysiol. 2014;125:608-614.
20. Kim MB, Lee HS, Ban JH. Vestibular suppressants after canalith repositioning in benign paroxysmal positional vertigo. Laryngoscope. 2014;124:2400-2403. 21. Di Girolamo S, Paludetti G, Briglia G, et al. Postural control in benign paroxysmal positional vertigo before and after recovery. Acta Otolaryngol. 1998;118:289-293. 22. Von Brevern M, Schmidt T, Schonfeld U, et al. Utricular dysfunction in patients with benign paroxysmal positional vertigo. Otol Neurotol. 2006;27:92-96. 23. Gall RM, Ireland DJ, Robertson DD. Subjective visual vertical in patients with benign paroxysmal positional vertigo. J Otolaryngol. 1999;28:162-165. 24. Di Girolamo S, Ottaviani F, Scarano E, et al. Postural control in horizontal benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol. 2000;257:372-375. 25. Pollak L, Davies RA, Luxon LL. Effectiveness of the particle repositioning maneuver in benign paroxysmal positional vertigo with and without additional vestibular pathology. Otol Neurotol. 2002;23:79-83. 26. Stambolieva K, Angov G. Postural stability in patients with different durations of benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol. 2006;263:118-122. 27. Faralli M, Ricci G, Ibba MC, et al. Dizziness in patients with recent episodes of benign paroxysmal positional vertigo: real otolithic dysfunction or mental stress? J Otolaryngol Head Neck Surg. 2009;38:375-380. 28. Iwasaki S, Yamasoba T. Dizziness and imbalance in the elderly: age-related decline in the vestibular system. Aging Dis. 2014 9;6:38-47. 29. Baloh RW, Enrietto J, Jacobson KM, Lin A. Age-related changes in vestibular function: a longitudinal study. Ann N Y Acad Sci. 2001;942:210-219. 30. Eagger S, Luxon LM, Davies RA, et al. Psychiatric morbidity in patients with peripheral vestibular disorder: a clinical and neuro-otological study. J Neurol Neurosurg Psychiatry. 1992; 55:383-387. 31. Simon NM, Pollack MH, Tuby KS, Stern TA. Dizziness and panic disorder: a review of the association between vestibular dysfunction and anxiety. Ann Clin Psychiatry. 1998;10:75-80. 32. Staab JP, Ruckenstein MJ. Which comes first? Psychogenic dizziness versus otogenic anxiety. Laryngoscope. 2003;113: 1714-1718. 33. Eckhardt-Henn A, Breuer P, Thomalske C, et al. Anxiety disorders and other psychiatric subgroups in patients complaining of dizziness. J Anxiety Disord. 2003;17:369-388. 34. Balaban CD. Neural substrates linking balance control and anxiety. Physiol Behav. 2002;77:469-475. 35. Lahmann C, Henningsen P, Brandt T, et al. Psychiatric comorbidity and psychosocial impairment among patients with vertigo and dizziness. J Neurol Neurosurg Psychiatry. 2015;86: 302-308 36. Honaker JA, Gilbert JM, Shepard NT, et al. Adverse effects of health anxiety on management of a patient with benign paroxysmal positional vertigo, vestibular migraine and chronic subjective dizziness. Am J Otolaryngol. 2013;34:592-595.
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37. Pollak L, Segal P, Stryjer R, Stern HG. Beliefs and emotional reactions in patients with benign paroxysmal positional vertigo: a longitudinal study. Am J Otolaryngol. 2012;33: 221-225. 38. Whitney SL, Marchetti GF, Morris LO. Usefulness of the dizziness handicap inventory in the screening for benign paroxysmal positional vertigo. Otol Neurotol. 2005;26:1027-1033.
39. Guneri EA, Kustutan O. The effects of betahistine in addition to Epley maneuver in posterior canal benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2012;146:104108.
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Features of Residual Dizziness after Canalith Repositioning Procedures for Benign Paroxysmal Positional Vertigo
Otolaryngology– Head and Neck Surgery 1–9 Ó American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599815627624 http://otojournal.org
Salvatore Martellucci, MD1, Giulio Pagliuca, MD, PhD1, Marco de Vincentiis, MD2, Antonio Greco, MD2, Armando De Virgilio, MD2,3, Ferdinando Maria Nobili Benedetti, MD1, Camilla Gallipoli, MD1, Chiara Rosato, MD1, Veronica Clemenzi, MD1, and Andrea Gallo, MD, PhD1
No sponsorships or competing interests have been disclosed for this article.
Abstract Objectives. To assess factors related to residual dizziness (RD) in patients who underwent successful canalith repositioning procedures (CRPs) for benign paroxysmal positional vertigo (BPPV).
Keywords benign paroxysmal positional vertigo, BPPV, residual dizziness, vertigo, imbalance, repositioning maneuver, canalith repositioning procedures, DHI, anxiety, elderly Received August 20, 2015; revised November 5, 2015; accepted December 29, 2015.
Study Design. Prospective cohort study. Setting. Academic center. Subjects and Methods. Ninety-seven consecutive patients with BPPV of the posterior semicircular canal were initially enrolled. Diagnosis was assessed according to clinical history and bedside evaluation. All patients were treated with CRPs until nystagmus disappeared. Three days after the successful treatment, presence of RD was investigated. If RD was present, patients were monitored every 3 days until the symptoms disappeared. Subjects who required 4 CRPs or who failed to meet the follow-up visit were excluded. The Dizziness Handicap Inventory (DHI) was obtained from patients at the time of diagnosis and at every subsequent visit. Results. At the end of selection, 86 patients were included; 33 (38.36%) reported RD after successful treatment. A significant difference in the incidence of RD was observed in consideration of the age of the subjects (P = .0003) and the DHI score at the time of diagnosis (P \ .001). A logistic regression analysis showed that the probability of RD occurrence increased with the increase of the emotional subdomain score of the DHI questionnaire. Conclusion. RD is a common self-limited disorder, more frequent in the elderly, which may occur after the physical treatment for BPPV. The DHI score at the time of BPPV diagnosis represents a useful tool to quantify the impact of this vestibular disorder on the quality of life and to estimate the risk of RD after CRPs.
B
enign paroxysmal positional vertigo (BPPV) is a common disorder of the inner ear characterized by repeated episodes of vertigo that are triggered by changes in head position.1,2 BPPV is the most prevalent peripheral vestibular impairment during the life span, which accounts for approximately 17% of complaints of vertigo.1-4 The suggested pathophysiology is a displacement of otoconial matter from the utricle to the semicircular canals. The movement of the otoconial matter due to gravity causes the flow of endolymph, which consequently causes vertigo and nystagmus. BPPV is usually idiopathic but can occur after head trauma or secondary to various disorders that damage the inner ear and detach the otolith from the utricular macule. The posterior semicircular canal is affected in most cases.1-5 BPPV is effectively managed via different repositioning maneuvers, which are noninvasive procedures meant to
1 Department of Surgical Biotechnologies and Science, ENT Section, Sapienza University of Rome, Rome, Italy 2 Department of Sensorial Organs, ENT Section, Sapienza University of Rome, Rome, Italy 3 Department of Surgical Science, Sapienza University of Rome, Rome, Italy
This article was presented at the 2015 AAO-HNSF Annual Meeting & OTO EXPO; September 27-30, 2015; Dallas, Texas. Corresponding Author: Salvatore Martellucci, MD, Department of Surgical Biotechnologies and Science, ENT Section, Sapienza University of Rome, Italy, Via Giulio Cesare 41\B, 04100 Latina, Italy. Email: [email protected]
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remove the otoconial debris into utricular cavity. Although many maneuvers have been described for the treatment of posterior canal BPPV (PC-BPPV), the canalith repositioning procedure (CRP) proposed by Epley is the most widely prevalent as a first-line treatment of this variant of BPPV and has been found to be safe and effective.1-8 However, in many patients, residual symptoms may remain even after disappearance of typical vertigo and nystagmus following a successful CRP. These residual symptoms, also called residual dizziness (RD), consist of nonpositional, persistent imbalance of variable duration, and its causal factors are still under debate.9-12 The goal of this study was to identify the clinical features of RD after successful CRP in patients with PC-BPPV, analyzing the factors related to the occurrence of this disorder.
Methods With the approval of the Institutional Review Board of the Department of Surgical Biotechnologies and Science of the Sapienza University of Rome, 97 consecutive patients (35 male and 62 female, mean age: 58.23 6 15) affected by PC-BPPV were initially enrolled in this prospective trial from June 2013 to January 2015. Patients with the involvement of multiple semicircular canals or with clinical history of previous episodes of dizziness (including previous episodes of BPPV) were excluded from the study, as well as patients unable to understand Italian language and those who did not undergo the follow-up visits as planned. A flowchart describing the study design is illustrated in Figure 1. All patients underwent a bedside neurotologic evaluation, including examinations for ocular alignment, spontaneous and gaze-evoked nystagmus, vestibuloocular reflex, saccades, smooth pursuit, and balance. During the evaluation, patients also underwent diagnostic positional tests for BPPV assessment. Once the diagnosis of PC-BPPV was reached and other vestibular pathologies were excluded, patients were treated with CRP and asked to return for a posttreatment visit 3 days later. During the first visit, patients again underwent diagnostic positional tests. In case of negative test results (absence of positional vertigo and undetectable positional nystagmus), the last CRP performed during the previous examination was defined as ‘‘successful.’’ Conversely, in case of positive positional test results, CRP was repeated, and the patients were reevaluated every 3 days until the disappearance of positional vertigo and positional nystagmus (ie, until the achievement of a successful CRP). Patients who required 4 CRPs were excluded from the study. During the first visit after the successful CRP, the presence of RD was investigated. RD was defined as feeling of unsteadiness and/or light-headedness and/or dizziness in the absence of true vertigo and nystagmus. Then, patients reporting RD were evaluated every 3 days until the residual symptoms disappeared. The Dizziness Handicap Inventory
Figure 1. Study design. BPPV, benign paroxysmal positional vertigo; CRP, canalith repositioning procedure; DHI, Dizziness Handicap Inventory; PC-BPPV, posterior canal BPPV; RD, residual dizziness.
(DHI) was submitted to all patients at the diagnosis and at every follow-up visit.
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Diagnosis and Treatment of PC-BPPV The diagnosis of unilateral PC-BPPV, suspected by clinical history, was confirmed by positioning tests for the vertical canals (Dix-Hallpike test unilaterally positive) and horizontal canals (supine head roll test bilaterally negative). Dix-Hallpike test was considered ‘‘positive’’ for PCBPPV if able to evoke the typical paroxysmal nystagmus— upbeating and torsional (with the upper pole of the eyes beating toward the ear in a lower position)—developed with a latency of several seconds and resolved within 1 minute. In all cases, PC-BPPV was treated with Epley’s CRP.1,13 The patient was placed in the upright position with the head turned 45° toward the ear that was positive on the DixHallpike test. Then, the patient was rapidly laid back to the supine head-hanging position, which was maintained for about 30 seconds. Next, the head was turned 90° toward the unaffected side and held for about 30 seconds. Following this rotation, the patient’s head was turned 90° reaching the facedown position while the patient’s body moved from the supine position to the lateral decubitus position. After about 30 seconds, the patient was brought into the upright sitting position, completing the maneuver. Diagnostic tests and CRPs were performed 1 or more times during the same session until the disappearance of positioning nystagmus.
Dizziness Handicap Inventory The DHI evaluates the self-perceived handicapping effects of vestibular disease and its impact on quality of life.14 In this study, we used the Italian version of the DHI, validated in 2010.15 The DHI consists of 25 items divided into 3 domains believed to encompass the impact of the disease: functional (DHI-F, 9 questions), emotional (DHI-E, 9 questions), and physical (DHI-P, 7 questions; Table 1). Each item is assigned 0, 2, or 4 points; therefore, the DHI score is between 0 and 100 points. In this study, the total DHI score and the score for each domain were calculated.
Statistical Analysis Continuously distributed variables were described by the mean and SD; categorical variables were described by frequencies and percentages. Comparisons of qualitative and quantitative variables (after the normal distribution was verified) were performed with the chi-square test and Student’s t test, respectively. P \ .05 was considered statistically significant. A binary logistic regression model was fitted to examine the statistical relationship between RD and a set of selected factors, enabling predictions about RD based on covariates such as sex, age, duration of BPPV before diagnosis, number of CRPs performed, and the DHI score at the time of diagnosis (considering both the total score and that of each of the 3 domains). All variables that were associated with the dependent variable at significance level of .05 were candidates to be included in the model as potential covariates.
All data were analyzed with SPSS 15.0 for Windows.
Results Eleven patients who initially met the inclusion criteria were later excluded from the study. Five of them (5.15%) failed to attend the follow-up visits, while 6 (6.18%) required .3 CRPs to treat their BPPV. Then, 86 patients (88.65%) were finally included. The demographics of patients included in this study are summarized in Table 2. A statistically significant difference between the DHI score at the time of diagnosis and the DHI score after successful CRP was observed both in patients who developed RD and in those free from residual symptoms. Thirty-three subjects (38.36%) reported RD after the third day from the successful CRP. In 18 patients (54.54%), this disorder resolved within 6 days after CRP, while 4 subjects (12.12%) recovered within 9 days. Only in 11 patients (33.33%) did RD last for .10 days but not exceed 15 days. Statistical analysis did not show differences in the incidence of RD according to sex, side of involved canal, number of repositioning maneuvers, and duration of BPPV before diagnosis. Conversely, we observed a significant difference in the incidence of RD taking into account the age of the subjects (P = .0003) and the DHI score at the diagnosis (P \ .001; Figure 2). Taking into account the age, we considered all subjects ‘‘elderly’’ who were .65 years old. According to this cutoff, the incidence of RD was significantly greater in the elderly (P = .002; Figure 2). The relative risk of RD in this group of patients was 2.29 with a 95% confidence interval ranging from 1.34 to 3.91. The scores derived from the 3 subdomains of DHI were also compared. We observed a significant difference between patients who experienced RD and those who did not develop this disorder accounting for the DHI-F and DHI-E scores at the time of diagnosis (P \ .001). There were no differences in the incidence of RD based on the DHI-P (P = .25; Figure 3). Similar results were observed by analyzing the DHI scores obtained at the time of first visit. Results are summarized in Table 3. With respect to the binary logistic regression model, a stepwise selection method filtered predictors to include in the model only essential parameters, in observance of parsimony and interpretability principles. The resulting model consists of 2 significant parameters: the intercept and the DHI-E score at the time of diagnosis. The value beyond the significance threshold of Hosmer-Lemeshow goodness-of-fit statistic (.256) meant that the model reasonably approximated the behavior of data. Nagelkerke’s R2 (.535) showed that a limited amount of variation is explained by the model. Table 4 summarizes the effect of each predictor. The resulting odds ratio (1.385) meant that the probability of RD occurrence increases with an increasing DHI-E score at the time of diagnosis. The classification table (Table 5) shows practical results of using the binary logistic regression model; overall, the fitted model had a high predictive
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Table 1. Dizziness Handicap Inventory.a No.
Items
Yes
Sometimes
No
P1 E2 F3 P4 F5 F6
Does looking up increase your problem? Because of your problem, do you feel frustrated? Because of your problem, do you restrict your travel for business or recreation? Does walking down the aisle of a supermarket increase your problems? Because of your problem, do you have difficulty getting into or out of bed? Does your problem significantly restrict your participation in social activities, such as going out to dinner, going to the movies, dancing, or going to parties? Because of your problem, do you have difficulty reading? Does performing more ambitious activities such as sports, dancing, household chores (sweeping or putting dishes away) increase your problems? Because of your problem, are you afraid to leave your home without having without having someone accompany you? Because of your problem have you been embarrassed in front of others? Do quick movements of your head increase your problem? Because of your problem, do you avoid heights? Does turning over in bed increase your problem? Because of your problem, is it difficult for you to do strenuous homework or yard work? Because of your problem, are you afraid people may think you are intoxicated? Because of your problem, is it difficult for you to go for a walk by yourself? Does walking down a sidewalk increase your problem? Because of your problem, is it difficult for you to concentrate Because of your problem, is it difficult for you to walk around your house in the dark? Because of your problem, are you afraid to stay home alone? Because of your problem, do you feel handicapped? Has the problem placed stress on your relationships with members of your family or friends? Because of your problem, are you depressed? Does your problem interfere with your job or household responsibilities? Does bending over increase your problem?
4 4 4 4 4 4
2 2 2 2 2 2
0 0 0 0 0 0
4 4
2 2
0 0
4
2
0
4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
F7 P8 E9 E10 P11 F12 P13 F14 E15 F16 P17 E18 F19 E20 E21 E22 E23 F24 P25
a A progressive number and a letter mark each item. The letter indicates the domain of the inventory: E, emotional; F, functional; P, physical. (Reproduced with permission from Archives of Otolaryngology–Head & Neck Surgery. 1990;116(4):424-427. Copyright Ó 1990 American Medical Association. All rights reserved.)
Table 2. Demographic Data. Characteristics Subjectsa Sex Male Female Canal involved Right Left Duration of BPPV \4 h 2-7 d 1-4 wk . 4 wk No. of CRPs performed 1 2 3
Values, n(%) 86 33 (38.36) 53 (61.64) 44 (51.16) 42 (48.84) 41 (47.67) 24 (27.9) 9 (10.46) 12 (13.97) 60 (69.76) 22 (25.58) 4 (4.66)
Abbreviations: BPPV, benign paroxysmal positional vertigo; CRP, canalith repositioning procedure. a Age mean 6 SD, 58.59 6 14.98 years.
capability, with 79.1% of cases that were correctly classified. The median of the DHI-E score at the time of diagnosis was 10 (range, 0-36). Performing a chi-square test, we compared the incidence of RD in patients with a DHI-E score less or equal to the median value or greater than the median. The difference was statistically significant (P = .0001). Then, adopting the median as cutoff value, we calculated the relative risk of RD occurrence for patients with a DHI-E score .10 at the time of diagnosis. Relative risk was equal to 7.60 with a 95% confidence interval ranging from 2.92 to 19.76.
Discussion Finding of residual symptoms after the resolution of BPPV, often defined as ‘‘nonspecific’’ dizziness, is a common occurrence.9-12,16,17 RD, however, has never been considered a disease entity with its own features but rather the short and unpleasant side effects of the earlier BPPV. This consideration, partly justified by the benignity and
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Figure 2. Patients at diagnosis: (A) age and (B) Dizziness Handicap Inventory (DHI) score. RD1, patients reporting residual dizziness; RD–, patients free from residual dizziness.
transience of RD, probably explains the lack of epidemiologic studies about this disorder. In this series, 38.36% of patients affected by PC-BPPV and managed by CRP reported RD. In literature, the incidence of RD after physical therapy for BPPV ranges between 36.6% and 61%.9-12,16-20 This variability could be due, for the most part, to the lack of a shared definition for RD and, second, to the different inclusion criteria in the trials. To avoid selection bias, we included in this study only patients with involvement of the posterior canal alone and treated by the same procedure. We considered patients affected by RD as all those who reported instability, light-headedness, or other balance disorders in absence of true vertigo and nystagmus at time of the first control after the successful CRP. The symptoms reported by patients with RD usually consist of subjective imbalance and are often difficult to describe, suggesting features of a complex vestibular disorder. Several theories have been proposed to explain the occurrence of residual symptoms after a successful treatment for PC-BPPV. A possible explanation may be the persistence of debris in the canal insufficient to provoke noticeable positional nystagmus,21 a utricular dysfunction,22,23 a coexisting vestibular disease, or an incomplete central adaptation.24-26 These hypotheses, although theoretically valid, have not yet been supported by definitive data. To limit the role of comorbid vestibular disorders as a confounding factor for development of RD, we excluded patients with a prior history of dizziness from our study. As mentioned above, some theories about the pathogenesis of RD postulated that a longer time needed for central adaptation after particle repositioning might have a role in the occurrence of the residual symptoms.24-26 A delayed
central adaptation might be related to several factors, including the duration of BPPV,26 age of subjects,9,10,12,18 and anxiety.11,12,17,18,27 Nevertheless, unlike what has been reported by other authors, our study found no statistically significant correlation between RD and duration of BPPV. This difference may be due to differences in patient selection and distribution among the different studies. Our study observed a significant correlation between the age of patients and the occurrence of RD. Older patients are commonly affected by deterioration of the visual and proprioceptive systems but also a global impairment of vestibular function.28,29 The age-related decline of the vestibular system can explain the decreased balance compensation ability in case of peripheral vestibular deficit in the elderly and may be related to the greater incidence of RD in this group of patients. It is well known that anxiety plays a contributory role in dizziness, which may represent a somatoform disorder in some patients who experienced stressor events.30-35 The intense episodes of paroxysmal vertigo, which characterize BPPV, can themselves represent a stressor event due to the severity of the symptoms and the unpredictability of vertigo attacks.36,37 Several studies correlate anxiety, fear of vertigo recurrence, and residual symptoms after BPPV,12,17,18 which point to RD as the expression of psychogenic disorders.27 The DHI is a survey that includes functional, emotional, and physical effects of dizziness on an individual.14,15 It can be used for many pathologies dealing with dizziness, and it fits well with BPPV.38 Moreover, in the literature, this questionnaire was already used to assess the residual symptoms after Epley maneuver,10 although some authors suggested that the residual symptoms could not be effectively evaluated by the DHI score.20
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Table 3. Incidence of RD according to Sex, Canal, Number of CRPs, Duration of BPPV, and DHI Score.a
Subjects Age Sex Male Female Canal involved Right Left Duration of symptoms \24 h 2-7 d 1-4 wk .4 wk No. of CRPs performed 1 2 3 DHI score: diagnosis Total DHI-F DHI-E DHI-P DHI score: first visit Total DHI-F DHI-E DHI-P
RD1
RD–
P Value
33 (38.36) 65.85 6 13.10
53 (61.64) 54.08 6 14.54
14 (42.42) 19 (35.84)
19 (57.58) 34 (64.16)
.649
18 (40.90) 15 (35.71)
26 (59.1) 27 (64.29)
.662
17 (41.43) 9 (37.5) 1 (11.11) 6 (50)
24 (58.57) 15 (62.5) 8 (88.89) 6 (50)
.297
22 (36.66) 10 (45.45) 1 (25)
38 (63.34) 12 (54.55) 3 (75)
.656
60.67 6 10.96 24.85 6 4.12 17.09 6 5.39 19.15 6 4.09
45.55 6 10.59 18.75 6 5.69 8.79 6 4.39 18.04 6 4.60
\.0001 \.0001 \.0001 .258
24.73 6 8.42 10.12 6 4.09 7.76 6 3.60 6.42 6 3.70
11.70 6 3.87 5.21 6 2.58 1.81 6 1.58 4.70 6 2.05
\.0001 \.0001 \.0001 .006
.0003
Abbreviations: BPPV, benign paroxysmal positional vertigo; CRP, canalith repositioning procedure; DHI, Dizziness Handicap Inventory; DHI-E, emotional subdomain; DHI-F, functional subdomain; DHI-P, physical subdomain; RD, residual dizziness; RD1, patients reporting RD; RD–, patients without RD. a Values presented in n (%) or mean 6 SD.
Figure 3. Scores derived from the subdomains of DHI. DHI, Dizziness Handicap Inventory; DHI-E, emotional subdomain; DHI-F, functional subdomain; DHI-P, physical subdomain; RD1, patients reporting residual dizziness; RD– patients without residual dizziness.
In this study, according to literature, we verified the effectiveness of physical therapy for BPPV using the DHI, assessing the improvement of subjective symptoms after
CRP. Furthermore, the DHI score appeared to be related to the development of residual symptoms: the total DHI scores observed in patients complaining RD was significantly
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Table 4. Parameter Estimates. Variable DHI-E at diagnosis Intercept
Ba
SE
Wald’s Coefficient
Odds Ratio
0.325 –4.602
0.068 0.941
22.585 23.928
1.385 0.010
Abbreviation: DHI-E, Dizziness Handicap Inventory–emotional subdomain. a Coefficient B expressed an increasing likelihood of the dependent variable with respect to the occurrence of residual dizziness.
Table 5. Classification Table.a Predicted
Observed
RD1 RD– Global, %
RD1
RD–
%
48 13
5 20
90.6 60.6 79.1
Abbreviations: RD1, patients reporting residual dizziness; RD–, patients without residual dizziness. a Logistical regression model results versus observed categories.
6 days after the repositioning procedure. Our experience shows that older patients and patients with a higher DHI score at time of diagnosis of BPPV are at a higher risk for RD. In particular, a high DHI-E score represents a risk factor for the occurrence of RD. Therefore, the DHI score calculated at the time of diagnosis represents a useful tool not only to quantify the impact of vestibular disorder on the quality of life but also to estimate the risk of RD after CRP. Acknowledgments We thank Francesco Salate Santone for his help in statistical analysis and Helene Claudia Keiski for her help in manuscript preparation.
lower at the time of diagnosis than at the first clinical control after effective CRP. This difference was due mainly to the scores obtained from 2 domains: DHI-F and DHI-E. The DHI-F expresses the functional limitation in daily living, which can be influenced by the concern for the occurrence of further vertigo episodes, while the DHI-E refers to the emotional impact of dizziness. The items of the DHI-E, in particular, investigate the feelings of insecurity, anxiety, and depression experienced by patients as result of their disorders.13 In our experience, the DHI-E score resulted as the most important predictor for the occurrence of RD. This finding further stressed that the emotional aspect plays a preponderant role in the development of RD and suggested that the DHI might represent a simple tool to predict the occurrence of this disorder, particularly taking into account the DHI-E score. A DHI-E score .10 could represent an acceptable cutoff value above which a patient could be considered at risk of RD occurrence. For the treatment of residual symptoms after BPPV, vestibular rehabilitation and drugs (eg, benzodiazepines and betahistine) can be proposed.11,20,39 In our experience, however, RD was a temporary and self-limiting disorder, resolved in most cases within 6 days after the successful CRP. This suggests that the simple reassurance of patients about the benignity and transient nature of their symptoms is a suitable approach for those suffering from RD, reserving drug therapy and vestibular rehabilitation to cases of prolonged duration.
Conclusion RD after CRP for PC-BPPV is a frequent occurrence. This disorder has a variable duration, and its causal factors are still under debate but patients recover in most cases within
Author Contributions Salvatore Martellucci, writer, study design, article drafting, final approval, agreement to be accountable for all aspects of the work; Giulio Pagliuca, study design, data acquisition, article drafting, final approval, agreement to be accountable for all aspects of the work; Marco de Vincentiis, data analysis, article revision and final approval, agreement to be accountable for all aspects of the work; Antonio Greco, data acquisition, data analysis and interpretation, article revision, final approval, agreement to be accountable for all aspects of the work; Armando De Virgilio, data acquisition, statistical analysis, article revision, final approval, agreement to be accountable for all aspects of the work; Ferdinando Maria Nobili Benedetti, data acquisition, data analysis and interpretation, article revision, final approval, agreement to be accountable for all aspects of the work; Camilla Gallipoli, data acquisition, data analysis, drafting, final approval, agreement to be accountable for all aspects of the work; Chiara Rosato, data acquisition, data analysis, drafting, final approval, agreement to be accountable for all aspects of the work; Veronica Clemenzi, data acquisition, article drafting, final approval, agreement to be accountable for all aspects of the work; Andrea Gallo, study design, article drafting and revision, final approval, agreement to be accountable for all aspects of the work.
Disclosures Competing interests: None. Sponsorships: None. Funding source: None.
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