The Laryngoscope

C 2014 The American Laryngological,

V
Rhinological and Otological Society, Inc.

Vestibular Suppressants After Canalith Repositioning in Benign

Paroxysmal Positional Vertigo

Min-Beom Kim, MD; Hyun S. Lee, MD; Jae H. Ban, MD, PhD

Objectives/Hypothesis: To investigate the characteristics of residual symptoms and to evaluate the effects of adjuvant
vestibular suppressants on residual symptoms after successful canalith repositioning procedures (CRPs).
Study Design: Individual randomized controlled trial.
Methods: One hundred fifty patients with idiopathic benign paroxysmal positional vertigo who achieved successful
CRPs on initial visit participated in this study. Dizziness Handicap Inventory (DHI) questionnaires were completed before
CRPs. All study populations were divided into three groups after successful CRPs on the initial visit day: the medication (V)
group (treated with a vestibular suppressant [dimenhydrinate 50 mg per day]), the placebo (P) group, and the no medication
(N) group. One week after successful CRPs, residual symptoms were checked and repeated DHI questionnaires were com-
pleted to compare residual symptoms.
Results: Among the 138 patients who did not show positional nystagmus at follow-up, 67 (48.5%) complained of resid-
ual symptoms. The presence of residual symptoms was more prevalent in the P and N group compared with the V group
(P 5.035, P 5.017, respectively). The most frequent residual symptom was lightheadedness (n 5 42). Moreover, in the V
group, lightheadedness was significantly reduced compared with the P group (P 5.029). However, in the analysis of DHI, total
and subscale scores did not differ across the three groups before or after successful CRP.
Conclusions: Vestibular suppressants significantly reduced residual symptoms compared to both placebo and no medi-
cation after CRP. However, there was no significant reduction in DHI score compared with the control group, suggesting that
the residual symptoms could not be evaluated by DHI score alone.
Key Words: Benign paroxysmal positional vertigo, vestibular suppressant, symptom, treatment.
Level of Evidence: 1b
Laryngoscope, 124:2400–2403, 2014

INTRODUCTION ing utricular dysfunction in BPPV patients is a possible

Canalith repositioning procedures (CRPs) are the
most effective treatment for benign paroxysmal positional
vertigo (BPPV).1–4 Appropriate CRPs depending on the
affected canal can provide rapid and long-lasting symp-
tom relief in BPPV patients.5–7 The results of a meta-
analysis suggest that CRPs are safe and the only proven
effective treatment for BPPV.5,6,8 According to clinical
practice guidelines for BPPV, medication therapy, such as
vestibular suppressants or antianxiety drugs, is not rec-
ommended for primary treatment.8 However, some
reports, including a previous study by the authors, have
found that residual nonspecific symptoms may remain
even after disappearance of typical vertigo and nystag-
mus following a successful CRP.9–11 These residual symp-
toms can be explained by a small amount of residual
canalith in the semicircular canal or increased emotional
sensitivity in postural control.10 In addition, accompany-
From the Department of Otolaryngology–Head and Neck Surgery,
Kangbuk Samsung Hospital, Sungkyunkwan University, School of Medi-
cine, Seoul, Korea.
Editor’s Note: This Manuscript was accepted for publication April
26, 2014.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Jae Ho Ban, MD, 108 Pyoung-dong
Jongno-gu, Seoul, Korea. E-mail: miphy87@naver.com
DOI: 10.1002/lary.24741
factor influencing residual symptoms.12 Psychological
problems, such as anxiety and depression, are also corre-
lated with residual symptoms.13 Recent studies have
reported that anxiolytics and betahistine can reduce
residual symptoms after successful CRP,9,10 but to the
best our knowledge there have been very few previous
studies analyzing the characteristics of residual symp-
toms in BPPV patients after CRP.
The goal of this study was to identify the character-
istics of residual symptoms after successful CRP in
patients with BPPV and to analyze the effects of vestibu-
lar suppressants on residual symptoms. Additionally, we
attempt to assess the feasibility of using Dizziness
Handicap Inventory (DHI) scores to assess residual
symptoms after CRP.
MATERIALS AND METHODS
Patients diagnosed with idiopathic BPPV between January
2011 and August 2012 at our tertiary referral hospital who
agreed to participate were enrolled in this study. The study pro-
tocol was approved by the institutional review board at our hos-
pital. The diagnostic procedure consisted of a detailed clinical
history, a neurologic bedside examination, and videonystagmog-
raphy (VNG). Inclusion criteria included: 1) idiopathic BPPV, 2)
confirmed successful CRPs (resolution of positional nystagmus
and symptoms) on the initial visit day, and 3) no current use of
any medication. Exclusion criteria included: 1) inability to
obtain successful CRP, 2) a history of inner ear disease or

Laryngoscope 124: October 2014 Kim et al.: Symptoms After Canalith Reposition in BPPV
2400

Fig. 1. Schematic of the study protocol. BPPV 5 benign paroxys-
mal positional vertigo; CRP 5 canalith repositioning procedure;
DHI 5 Dizziness Handicap Inventory; P 5 placebo; N 5 no medica-
tion; V 5 vestibular suppressant.
surgery and trauma, 3) a history of persistent dizziness or
headache, 4) a history of psychiatric or neurologic disorders,
and 5) more than two semicircular canals affected. A total of
150 patients were finally enrolled and randomly divided into
three groups of 50 patients: a medication group (V; vestibular
suppressant), a placebo group (P), and a no medication group
(N). To evaluate patient life quality, daily activity, emotional
status, and dizziness severity, we used the Dizziness Handicap
Inventory (DHI), which is the most popular dizziness assess-
ment scale. All patients answered the questionnaires before
CRP and 1 week after CRP. Jacobson and Newman14 introduced
the DHI in 1990 to evaluate the self-perceived handicapping
effects of vestibular disease. The DHI consists of 25 items
derived from three content domains believed to encompass
the functional, emotional, and physical impacts of the disease.
Each subdomain is indicated by a letter preceding a question
number.
Patients with BPPV involving the posterior semicircular
canal underwent Epley’s maneuver, whereas patients with
BPPV involving the lateral canal underwent Barbeque rotation.
In cases of cupulolithiasis, the head shaking maneuver or mas-
toid vibration inducing canalolithiasis was followed by CRP.
After confirming the resolution of positional nystagmus by a
same-day serial positional test, the patients in the V group
were prescribed dimenhydrinate 25 mg twice daily (BID) for 1
week, patients in the P group were prescribed a placebo drug
BID for 1 week, and patients in the N group were not pre-
scribed any medication during the study period. The same phy-
sician applied appropriate CRPs to the patients in all groups
and was blinded to who was assigned to which group. Addition-
ally, study participants did not know their group assignment by
informed consent.
All patients were scheduled to return 1 week after CRP
and resolution of positional nystagmus was confirmed by VNG.
If positional nystagmus recurred on follow-up, appropriate CRP
was given, and these patients were excluded from the study
population because we aimed to evaluate residual symptoms
only in the absence of positional nystagmus. All patients were
asked to describe the characteristics of their subjective residual
symptoms and completed the DHI again at that time. Figure 1
shows the schematic study protocol. Statistical analysis was
performed with paired t tests and v2 tests using SPSS (version
Laryngoscope 124: October 2014
18.0; SPSS Inc., Chicago, IL). Statistical significance was
defined as P <.05.
RESULTS
Table I shows the demographics and clinical charac-
teristics of the study population. Of the 150 patients, 12
demonstrated recurrent positional nystagmus at follow-
up and were excluded. Finally, 138 patients were enrolled
(n 5 45, V group; n 5 46, P group; n 5 47, N group).
One hundred six (76.8%) of the patients were
women, and the patient ages ranged from 24 to 82 years.
Posterior semicircular canal BPPV constituted the larg-
est proportion of cases (53.6%). There were no differen-
ces in each group with respect to age, sex, affected side,
or involved semicircular canals.
Residual symptoms after successful CRP were found
in 15 of 45 patients in the V group, 25 of 46 patients in
the P group, and 27 of 50 patients in the N group (Fig. 2).
The V group showed a significantly smaller number of
patients with residual symptoms than the other groups
(v2, P 5.035 and P 5.017, respectively). This result sug-
gests that vestibular suppressants are effective for reduc-
tion of residual symptoms after successful CRP.
In the analysis of symptom characteristics (total
n 5 67), the most common residual symptom was light-
headedness (n 5 42). The next most common symptom
was a floating sense (n 5 13). Despite the absence of
positional nystagmus at follow-up, vertigo was present
in seven patients (Fig. 3). In the comparison of residual
symptoms, each group showed similar patterns overall,
with the vestibular suppressant group having a smaller
number of patients with lightheadedness (Fig. 4).
All groups showed a significant decrease in total
DHI score after successful CRP. However, post-CRP total
DHI score was not significantly different among the
three groups. Additionally, subscale DHI scores (physi-
cal, functional, and emotional scales) after CRP were not
significantly different among the three groups (Fig. 5).
DISCUSSION
BPPV is one of the most common peripheral verti-
gos. It is characterized as a rotational vertigo that con-
tinues for a few seconds to a few minutes and a
positional nystagmus depending on changes in the
TABLE I.
Demographics of the Study Population.
Group
Vestibular
Suppressant Placebo, No Medication,
Medication, n 5 45 n 5 46 n 5 47
Male/female 11/34 12/34 9/38
Age, yr (mean) 24–82 (54.6) 29–74 (52.9) 27–81 (34)
Side (right/left) 30/15 20/26 27/20
Canal (PC/LC-canalo/ 25/12/8 23/10/13 26/12/9
LC-cupulo)
LC-canalo, lateral semicircular canalolithiasis; LC-cupulo, lateral
semicircular cupulolithiasis; PC 5 posterior semicircular canalolithiasis.
Kim et al.: Symptoms After Canalith Reposition in BPPV
2401
Fig. 2. Comparison of residual symptoms after a successful canal-
ith repositioning procedure (CRP) among the groups. One week
after CRP, the vestibular suppressant group showed a significantly
smaller number of patients with residual symptoms (v2 test).
P 5 placebo; N 5 no medication; V 5 vestibular suppressant.
patient’s head position.15 CRP is the basis for effective
therapies for the treatment of BPPV.5–7,15,16 However,
patients sometimes complain of residual symptoms even
after a successful CRP. There are many hypotheses for
these residual symptoms. Mendel et al. argues that
residual symptoms are a cause of psychological anxiety
or fear about dizziness recurrence. In addition, loss of
confidence or deterioration of overall physical condition
may be caused by the residual symptoms.17,18 Gacek,
who analyzed the temporal bone of BPPV patients sug-
gested degeneration of vestibular nerve findings,19 and
other authors have also suggested the possibility of
organic problems such as neuritis or viral infection.20–22
Previous studies have reported the prevalence of resid-
ual dizziness as 36.6% to 61%,4,23 and our study found
that 57% of patients who underwent successful CRP and
were given no additional medication complained of resid-
ual dizziness, similar to these other studies.
There have been a few studies on the characteris-
tics of residual symptoms after successful CRP. Jung
et al. reported on residual symptoms, but considered
only continuous or intermittent lightheadedness and did
not mention other characteristics of residual symp-
toms.10 Our study showed that the most common resid-
ual symptom was lightheadedness (63% of patients with
residual symptoms). The next most common symptom
was a floating sensation, followed by vertigo.
Fig. 3. Characteristics of residual symptoms 1 week after suc-
cessful canalith repositioning procedure (CRP). The most common
residual symptom was lightheadedness. However, in seven
patients, vertigo presented at follow-up even in the absence of
positional nystagmus.
Laryngoscope 124: October 2014
2402
Fig. 4. Comparison of residual symptoms among the three groups.
The vestibular suppressant group had smaller number of patients
with lightheadedness than did the placebo and no medication
groups (v2 test).
According to another study, the DHI score in
patients treated with anxiolytics was significantly lower
than in non-treated patients.10 Guneri et al. also
reported the positive effects of betahistine in posterior
canal BPPV after successful CRPs by randomized con-
trolled trial.9 However, our study is the largest random-
ized controlled study to evaluate medication effects on
residual symptoms. We revealed that the vestibular sup-
pressant (dimenhydrinate) group had a significantly
smaller number of patients with residual symptoms
after CRP than the placebo and no medication groups.
In addition, there was substantial improvement in light-
headedness in the vestibular suppressant group. Though
we could not convincingly determine the reason for this,
according to hypotheses regarding residual symptoms,
temporary vestibular function defects in the affected ear
can exist in BPPV patients.21 Thus, vestibular suppres-
sants could help reduce symptoms through the recovery
period similar to mild vestibular neuritis. We hypothe-
sized that abnormal function of the otolithic organ
(utricular dysfunction) could be an additional cause of
residual symptoms after successful CRP. Some reports
have found utricular dysfunction in BPPV patients.12
Although we do not know whether the dysfunction is
permanent or temporary, it may last until the follow-up
period in some patients who complain of residual symp-
toms such as lightheadedness. Also, because very tiny
otoliths remain that cannot induce positional nystagmus
after successful CRP, only lightheadedness or a floating
sensation may present at follow-up (and not vertigo).
Both utricular dysfunction and tiny residual otoliths can
be reduced by vestibular suppressants in our opinion.
A variety of questionnaires to assess subjective diz-
ziness have been developed. In the present study, the
DHI was used. DHI was introduced by Jacobs and New-
man in 1990, and consists of physical, emotional, and
functional subscales. The physical items were designed
to assess changes in bodily ability after dizziness,
whereas the emotional and functional items were
designed to assess the extent of the patient’s social and
psychological adjustment.14 We found no statistically
Kim et al.: Symptoms After Canalith Reposition in BPPV
Fig. 5. Analysis of the Dizziness Handicap Inventory (DHI) scores among groups. (A) Comparison of total DHI score. (B) Comparison of sub-
scale items of the DHI score. There was a significant decrease in the total DHI score after successful canalith repositioning procedures
(CRPs) in all groups (all P <.001). At post-CRP (1 week after CRP), however, there was no statistical difference in total DHI score among
the three groups. Similar to (A), there was a significant decrease in subscale DHI scores after CRP in all groups (all P <.001). However,
there were no statistical differences in each subscale item among the three groups during the post-CRP period. E 5 emotional subscale
scores; F 5 functional subscale scores; P 5 physical subscale scores.
significant difference in follow-up DHI score in the V
group compared to the P group and no medication group,
and the same held for each subscale. This may be
because the major residual symptoms were lightheaded-
ness or a mild headache, which could not be assessed by
the DHI questionnaire. In the detail review of the DHI
questionnaire, there were no questions about lighthead-
edness or mild headache. Therefore, the DHI question-
naire could not gather information regarding residual
symptoms in this study population, and no statistically
significant difference among the three groups was found
after successful CRPs.
CONCLUSION
This study demonstrates that vestibular suppres-
sant (dimenhydrinate) treatment after CRP may help to
reduce residual symptoms in patients with BPPV, the
most common of which is lightheadedness. However,
since residual symptoms are difficult to assess using the
DHI score, we found no significant differences in DHI
score between the medication, placebo, and no medica-
tion groups.
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