Acta Oto-Laryngologica, 2011; 131: 4145

ORIGINAL ARTICLE

Effect of the canalith repositioning procedure on subjective visual horizontal in patients with posterior canal benign paroxysmal positional vertigo

SHINICHI IWASAKI1, YASUHIRO CHIHARA1, MUNETAKA USHIO1, ATSUSHI OCHI1, TOSHIHISA MUROFUSHI2 & TATSUYA YAMASOBA1
1

Department of Otolaryngology, Faculty of Medicine, University of Tokyo, Tokyo and 2Department of Otolaryngology, Teikyo University School of Medicine Mizonokuchi Hospital, Kawasaki, Japan

Abstract Conclusion: Substantial numbers of patients with posterior canal benign paroxysmal positional vertigo (p-BPPV) have signs of utricular dysfunction at baseline. This improves after performing the canalith repositioning procedure. Objective: To evaluate the changes of subjective visual horizontal (SVH) in patients with p-BPPV before and after treatment with the canalith repositioning procedure. Methods: Twenty-six patients with p-BPPV were treated with the canalith repositioning procedure, Epleys maneuver, according to the affected side. Baseline SVH measurements were taken before performing the DixHallpike maneuver and Epleys maneuver, for comparison with measurements taken just after Epleys maneuver, and 2 weeks after Epleys maneuver. Results: Among 26 patients with p-BPPV, 11 (42%) showed abnormal deviation of SVH at baseline. Just after performing Epleys maneuver, the number of patients who showed an abnormal deviation of SVH decreased signicantly to 15% (4 of 26 patients; p < 0.05). Two weeks after performing Epleys maneuver, only two patients (8%) showed an abnormal deviation of SVH (p < 0.001).

Keywords: Epleys maneuver, utricle, Dix-Hallpike maneuver

Introduction Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder. It is characterized by brief attacks of vertigo associated with head movements [1,2]. BPPV is considered to be caused by small particles trapped in the semicircular canals [3,4]. These particles most likely consist of otoconia dislodged from the utricular macula. The canalith repositioning maneuver, which relocates the freeoating particles from the affected semicircular canal back into the utricle, has been shown in numerous studies to be effective for treating patients with BPPV [58]. Subjective visual horizontal/vertical (SVH/V) is considered to be a simple test of otolith function,

especially utricular function [911]. In this test, subjects are asked to set a bar at the true gravitational horizontal/vertical in a totally darkened room. The deviation from true horizontal/vertical closely correlates with the amount of ocular torsion in each subject. This ocular torsion could result from tonic offsets of the dynamic ocular counter-rolling mechanism that appears to be under utricular control [10,12]. Involvement of the otoliths in BPPV has been shown in post-mortem studies [1,13] and surgical ndings [3,14], leading to the assessment of otolith function in patients with BPPV using vestibular evoked myogenic potentials [15], the otolith-ocular reex [16], and SVH/V [9,1618]. However, the results of SVH/V in patients with BPPV have been controversial. Several studies have reported that there were no signicant

Correspondence: Shinichi Iwasaki MD, Department of Otolaryngology, Faculty of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. Tel: +81 3 5800 8655. Fax: +81 3 3814 9486. E-mail: iwashin-tky@umin.ac.jp

(Received 25 June 2010; accepted 2 August 2010)

ISSN 0001-6489 print/ISSN 1651-2251 online 2011 Informa Healthcare DOI: 10.3109/00016489.2010.514008

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S. Iwasaki et al. wide dimly lit light bar that could be rotated by the patients in the frontal plane, approximately at the midpoint using an electric motor and a control device. The motor speed was 1 /s. The task involved adjusting the bar four times to SVH, starting from an oblique position of approximately 30 from true gravitational horizontal. Deviation of SVH down from the true horizontal on the affected side was given a positive value. No time limit was given for performing the test. After testing, the mean value of four trials was calculated as the subjects score. As a control, 20 healthy volunteers (mean age 43.6 years, range 2865 years) without any history of vestibular or neurologic disorders underwent SVH testing on two occasions: (1) before performing the Dix-Hallpike test and Epleys maneuver (baseline) and (2) approximately 10 min after performing the Dix-Hallpike test and Epleys maneuver (post-Epley). The Epleys maneuver for the right p-BPPV was performed in 10 subjects and that for the left p-BPPV was performed in the other 10 subjects. Data are presented as means SD. Statistical analyses were evaluated using paired t test, Fishers exact probability test, KruskalWallis test or Mann Whitney U test, and p < 0.05 was taken as the level of signicance.

differences in SVH/V between patients with BPPV and normal controls [9,16,18]. On the other hand, Gall et al. reported that half of the patients with BPPV showed an abnormal deviation of SVH/V [17]. These differences may arise from the timing of the measurement of SVH/V, because performance of the Dix-Hallpike maneuver or the canalith repositioning procedure could affect the value of SVH/V. Gall et al. measured SVH/V before treating with the canalith repositioning procedure [17]. In the present study, we measured SVH in patients with posterior canal BPPV (p-BPPV) before the Dix-Hallpike maneuver and the canalith repositioning procedure and just after performing the canalith repositioning procedure, as well as 2 weeks after treatment. The aim of the present study was to compare the value of SVH before and after treatment.

Material and methods Twenty-six patients (22 women, 4 men) with unilateral p-BPPV were enrolled in the present study. The patients ages ranged from 19 to 76 years with a mean age of 60.1 12.3 (SD) years. The duration from the onset of the disease to the rst measurement of SVH ranged from 1 day to 1 year (median: 10 days). None of the patients had a history of Menieres disease, other vestibular diseases apart from BPPV, or any other ear diseases. The diagnoses of p-BPPV were made according to the following criteria. (1) A history of vertigo lasting less than 1 min precipitated by changes in head position. (2) Mixed torsional or upbeating nystagmus with the torsional component towards the undermost ear in one of the lateral head hanging (Dix-Hallpike) positions. (3) A brief latency between head positioning and the onset of nystagmus. Patients with bilateral BPPV or involvement of the horizontal canal, and patients who had previously received Epleys maneuver were excluded from the study. All of the patients with p-BPPV were treated with Epleys maneuver [5] just after making the diagnosis with the Dix-Hallpike test. We measured SVH on three occasions: (1) before performing the DixHallpike test and Epleys maneuver (baseline), (2) approximately 10 min after treatment with Epleys maneuver (post-Epley), and (3) 2 weeks after Epleys maneuver (2 weeks-Epley). The methods of measuring SVH have been described elsewhere [19,20]. Briey, subjects sat upright in darkness with their head immobilized with straps against an adjustable head rest. Situated 65 cm in front of the patient was a laser projection of a 10 cm long, 2 mm

Results In healthy subjects, the mean values of SVH were 0 1.09 under baseline condition and 0.17 1.00 under post-Epley conditions. There were no signicant differences between them (p > 0.5, paired t test). Based on the results under the baseline condition, the normal range of SVH was set at 2.18 (mean 2 SD). In 26 patients with p-BPPV under baseline condition, which is before performing the Dix-Hallpike and Epleys maneuvers, 11 patients (42%) showed abnormal deviation (>2.18 ) of SVH. Among them, eight patients showed a deviation toward the affected side while three patients showed a deviation toward the unaffected side (Figure 1). SVH measurement approximately 10 min after performing Epleys maneuver (post-Epley) revealed that the number of patients who showed an abnormal deviation of SVH had decreased to 15% (4 of 26 patients). Among them, three patients showed deviation toward the affected side, whereas one showed a deviation toward the unaffected side. There was a signicant difference in the ratio of abnormal deviations between the baseline and post-Epley conditions (p < 0.05, Fishers exact probability test). Two weeks after treatment with Epleys maneuver (2 weeks-Epley), only two patients (8%) showed an

Subjective visual horizontal in BPPV

Affected side down Unaffected side down

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50

** *

Abnormality ratio of SVH (%)

40

SVH, 3 then showed an abnormal deviation of SVH just after performing Epleys maneuver (Figure 2B). In the 2 weeks-Epley condition, only two patients showed an abnormal deviation of SVH. These two patients had no complaints of vertigo and showed negative Dix-Hallpike tests in the 2 weeks-Epley conditions.

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Discussion In the present study, we have shown that approximately 40% of patients with p-BPPV showed an abnormal deviation of SVH under baseline conditions and that their SVH signicantly improved after treatment with Epleys maneuver. Most previous studies concerning SVH/V in BPPV have measured SVH/V after performing the canalith repositioning procedure and reported normal or slightly abnormal SVH in patients with BPPV [9,16,18]. On the other hand, Gall et al. reported that 8 of 16 patients with BPPV showed an abnormal deviation of SVV before performing the canalith repositioning procedure [17]. Our results may be able to explain the apparent discrepancies among the previous studies. In the present study, 11 of the 26 patients (42%) showed an abnormal deviation of SVH in the baseline condition. What could be the cause of an abnormal deviation of SVH/V in BPPV? One possible explanation is that dislodgement of otoconia from the utricular maculae may affect steady-state activities of the utricular nerve, since BPPV is considered to be caused by free-oating otoconia [4,5]. The effect of the dislodgement of otoconia on utricular nerve activity may vary from excitation to inhibition depending on the region of the dislodgement from the utricular maculae, since polarity of the hair cells of the utricular macula is reversed across the striola [21]. In fact, otolithic dysfunction has been reported in some patients with BPPV using the otolith-ocular reex during centrifuge [16] and vestibular evoked myogenic potentials [15]. Another possible cause of the abnormal SVH in patients with BPPV is the involvement of the posterior semicircular canal. Pavlou et al. [22] showed that stimulation of the posterior semicircular canals by yaw rotation affected the perception of SVV. Stimulation of the posterior semicircular canals caused by free-oating otoconia during head movements may also affect the deviation of SVH/V. In the present study, 8 of 11 patients (73%) with abnormal SVH at baseline showed SVH deviation toward the affected side. The side toward which the SVH/V deviates in patients with BPPV has varied among previous studies [11,17,18]. van Nechel et al. [11] measured SVV in 1000 consecutive patients with

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10

0 Baseline post-Epley 2 weeks-Epley

Figure 1. Abnormality ratio of subjective visual horizontal (SVH) in patients with posterior canal benign positional vertigo (p-BPPV). SVH was measured before Dix-Hallpike and Epleys maneuvers (baseline), just after performing Epleys maneuver (post-Epley), and 2 weeks after performing Epleys maneuver (2 weeks-Epley). *p < 0.05, **p < 0.01.

abnormal deviation of SVH. Both of them showed deviation of SVH toward the affected side. However, these patients both had a smaller deviation of SVH at 2 weeks-Epley than post-Epley. There was a signicant difference in the ratio of abnormal deviation between the baseline and 2 weeks-Epley conditions (p < 0.01, Fishers exact probability test), while there was no signicant difference between post-Epley and 2 weeks-Epley conditions. At the 2 week follow-up, 24 of the 26 patients showed considerable improvement in their vertigo and had negative Dix-Hallpike tests. The remaining two patients were successfully treated by the second Epleys maneuver performed at the 2 week follow-up. The mean value of SVH under the three conditions were: 1.61 5.81 (SD) at the baseline, 0.82 2.22 at post-Epley, and 0.05 1.31 at 2 weeks-Epley. There were no signicant differences among these mean values (p > 0.5, Krusukal-Wallis test). The mean values of SVH at the baseline and at postEpley in patients were not signicantly different from the mean values at the baseline and at postEpley in healthy subjects, respectively (p > 0.3, MannWhitney U test). Successive changes in the value of SVH in each patient are plotted in Figure 2. Of the 11 patients who showed an abnormal deviation of SVH in the baseline condition, 8 patients showed normal SVH just after performing Epleys maneuver (Figure 2A). On the other hand, of the 15 patients who showed normal

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S. Iwasaki et al.
A 25 20 Mean deviation of SVH () 15 10 5 0 5 Baseline post-Epley 2 weeks-Epley Mean deviation of SVH () B 25 20 15 10 5 0 5 Baseline post-Epley 2 weeks-Epley

Figure 2. Successive changes of the mean value of SVH in 11 patients who showed abnormal SVH at the baseline condition (A) and 15 patients who showed normal SVH at the baseline condition (B). Dotted lines show the upper and lower limits of normal SVH (+ 2.18 and 2.18 ). Positive values indicate affected side down and negative values indicate unaffected side down.

BPPV and reported that the deviation was more often ipsilateral to the side of the lesion. They also showed that the distribution of the values of SVV was greater than that of normal controls. On the other hand, Ushio et al. [18] measured SVH in patients with BPPV after the Dix-Hallpike maneuver and showed that the deviation was toward the unaffected side in approximately 80% of the patients. These contrasting results might be explained by the different location of dislodgement of the otoconia from the utricular macula, where the polarity of the hair cells is reversed across the striola [21]. The canalith repositioning procedure had a significant effect on the deviation of SVH in the present study. Just after performing Epleys maneuver, 73% of the patients who showed abnormal baseline SVH now showed normal SVH. On the other hand, 20% of the patients with normal baseline SVH changed to show an abnormal deviation of SVH in the post-Epley conditions. During performance of Epleys maneuver, the otoconia oating in the semicircular canal are thought to relocate on the utricular macula [5]. The changes in the value of SVH observed after Epleys maneuver might be due to the relocation of the otoconia on the utricular macula from the semicircular canal, and the side to which SVH deviates might be dependent on the site of relocation on the utricular macula [21]. Two weeks after treatment, most patients showed normal SVH. This result is compatible with the results of previous reports that measured SVH/V after treatment [9,16,18]. von Brevern et al. [16] measured SVH in patients with BPPV at least 1 week after successful

treatment with the canalith repositioning procedure. They reported that there was no signicant difference in SVV between normal controls and patients with BPPV after treatment. Their results are consistent with the results from our patients just after Epleys maneuver. The mechanism by which SVH normalizes in patients with BPPV after treatment may be due to the recovery of utricular function after repositioning of the otoconia. The normalization of SVH after 2 weeks from the rst repositioning maneuver may additionally be due to compensation by the central and peripheral vestibular systems. It has been shown that the deviation of SVH/V can be compensated for after sudden onset vestibular disease, even in cases without recovery of vestibular dysfunction [9,10,19]. In conclusion, this study showed that approximately 40% of patients with p-BPPV show an abnormal deviation of SVH, which signicantly improved after performing Epleys maneuver. This result suggests that a substantial number of patients with BPPV might have utricular dysfunction, which may be caused by dislocation of otoconia from the utricular macula. The canalith repositioning procedure may not only remove the otoconia from the semicircular canals, but may also affect the function of the utricle itself.

Acknowledgment This work was supported by grants from the Ministry of Health, Labor and Welfare (22141101) and Education, Culture and Technology (22591875).

Subjective visual horizontal in BPPV Declaration of interest: The authors report no conicts of interest. The authors alone are responsible for the content and writing of the paper.

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