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Auris Nasus Larynx

journal homepage: www.elsevier.com/locate/anl

Classification, diagnostic criteria and management of benign

paroxysmal positional vertigo
Takao Imai a,*, Noriaki Takeda b, Tetsuo Ikezono c, Kohichiro Shigeno d,
Masatsugu Asai e, Yukio Watanabe f, Mamoru Suzuki g Suzuki on behalf of Committee
for Standards in Diagnosis of Japan Society for Equilibrium Research
a
Department of Otorhinolaryngology – Head and Neck Surgery, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
b
Department of Otolaryngology, University of Tokushima School of Medicine, Tokushima 770-8503, Japan
c
Department of Otolaryngology, Saitama Medical University Hospital, Saitama 350-0495, Japan
d
Shigeno Otolaryngology Vertigo-Hearing Impairment Clinic, Nagasaki 852-8132, Japan
e
Department of Otorhinolaryngology – Head and Neck Surgery, University of Toyama, Toyama 930-0194, Japan
f
Ohsawano Rehabilitation Facility for the Elderly Kagayaki, Toyama 939-2224, Japan
g
Department of Otolaryngology, Tokyo Medical University Hospital, Tokyo 160-0023, Japan

A R T I C L E I N F O A B S T R A C T

Article history: Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vertigo and the
Received 2 January 2016 posterior and/or lateral semicircular canals are usually affected. BPPV is characterized by brief
Accepted 28 March 2016 attacks of rotatory vertigo associated with positional and/or positioning nystagmus, which are
Available online xxx
elicited by specific head positions or changes in head position relative to gravity. In patients with the
posterior-canal-type of BPPV, torsional nystagmus is induced by the Dix–Hallpike maneuver. In
Keywords:
patients with the lateral-canal-type of BPPV, horizontal geotropic or apogeotropic nystagmus is
Benign paroxysmal positional vertigo
Canalolithiasis
induced by the supine roll test. The pathophysiology of BPPV is canalolithiasis comprising free-
Cupulolithiasis floating otoconial debris within the endolymph of a semicircular canal, or cupulolithiasis
Canalith repositioning procedure comprising otoconial debris adherent to the cupula. The observation of positional and/or positioning
nystagmus is essential for the diagnosis of BPPV. BPPV is treated with the canalith repositioning
procedure (CRP). Through a series of head position changes, the CRP moves otoconial debris from
the affected semicircular canal to the utricle. In this review, we provide the classification, diagnostic
criteria, and examinations for the diagnosis, and specific and non-specific treatments of BPPV in
accordance with the Japanese practical guidelines on BPPV published by the Japan Society for
Equilibrium Research.
ß 2016 Elsevier Ireland Ltd. All rights reserved.

1. Introduction the mostcommon peripheral cause of vertigo. In most patients,

Robert Bárány first described positional vertigo in 1921 [1]
and the term ‘‘benign paroxysmal positional vertigo’’ (BPPV)
was coined by Dix and Hallpike in 1952 [2]. Currently, BPPV is
* Corresponding author at: Department of Otorhinolaryngology – Head and
Neck Surgery, Osaka University Graduate School of Medicine, 2-2 Yamadaoka,
Suita, Osaka 565-0871, Japan. Tel.: +81 6 6879 3951; fax: +81 6 6879 3959.
E-mail address: timai@ent.med.osaka-u.ac.jp (T. Imai).
http://dx.doi.org/10.1016/j.anl.2016.03.013
0385-8146/ß 2016 Elsevier Ireland Ltd. All rights reserved.
BPPV is characterized by brief attacks of rotatory vertigo with
torsional positioning nystagmus, which are elicited by changes in
the head position relative to gravity. Because their posterior
semicircular canal is affected, posterior-canal-type of BPPV is
diagnosed. In 1985, McClure first reported lateral-canal-type of
BPPV, in which the lateral semicircular canal was affected [3]. A
direction-changing geotropic or apogeotropic positional nystag-
mus is elicited when the head of the patient, with lateral-canal-
type of BPPV, is rolled from side to side on supine position.

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Dix and Hallpike also suggested that BPPV was caused by a
lesion of the otolith organ [2]. On postmortem examination of
the temporal bones, Schuknecht then reasoned that the otoconia
released from the otolithic membrane settled on the cupula
(cupulolithiasis) and that the cupula would respond to gravity
[4]. Hall et al. later hypothesized that the otoconial debris floats
freely within the endolymph of the semicircular canal
(canalolithiasis) [5]. Recently the canalolithiasis theory has
drawn a lot of attention related to the canalith repositioning
procedure (CRP) for the treatment of BPPV.
In this review, we provide the classification, diagnostic
criteria, and examinations for diagnosis and specific and non-
specific treatments of BPPV in accordance with the Japanese
practical guidelines on BPPV published by the Japan Society
for Equilibrium Research [6].
2. Diagnostic criteria for BPPV
Posterior-canal-type of BPPV (canalolithiasis)
A. Symptoms
1. Attacks of rotatory vertigo or dizziness are induced by
changes in the head position relative to gravity.
2. The vertigo appears with short latency, lasts for less than a
minute and is characterized by an increase followed by a
decrease in its intensity.
3. The intensity of the vertigo decreases or disappears after
repeated head positioning.
4. The vertigo is not associated with any cochlear symptoms
such as hearing loss, tinnitus, or ear fullness.
5. There are no neurologic symptoms other than vertigo.
B. Signs
1. Torsional nystagmus, in which the upper pole of the eye
rotates toward the affected ear, is induced by the Dix–
Hallpike maneuver where the patient is brought from the
upright to supine position with the head turned 458 to the
affected ear. The nystagmus often contains an additional
vertical (upward) component.
2. Torsional nystagmus, in which the upper pole of the eye
rotates toward the contralateral ear, is then induced by the
reverse Dix–Hallpike maneuver where the patient is
brought from the supine to upright position. The
nystagmus often contains an additional vertical (down-
ward) component.
3. The nystagmus appears with short latency, lasts for less
than a minute and is characterized by an increase
followed by a decrease in its intensity.
4. Other peripheral and central vestibular diseases causing
vertigo are excluded.
Diagnostic categories
Definite posterior-canal-type of BPPV (canalolithiasis)
To meet all the points in criteria A and B.
Probable BPPV
To meet all the points in criteria A in the history, but no
observable nystagmus and no vertigo with any positional or
Please cite this article in press as: Imai T, et al. Classification, diagnostic criteria and management of benign paroxysmal positional vertigo.
Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.03.013
positioning maneuver, probably because the BPPV is resolved
spontaneously.
Atypical BPPV
To meet all the points in criteria A and point 4 in criteria B,
but not any of points 1–3 in criteria B.
Note: The atypical BPPV consists of the anterior-canal-type
of BPPV (canalolithiasis), the posterior-canal-type of BPPV
(cupulolithiasis), and the multiple-canals-type of BPPV.
Lateral-canal-type of BPPV (canalolithiasis)
A. Symptoms
1. Attacks of rotatory vertigo or dizziness are induced by
changes in the head position relative to gravity.
2. The vertigo appears with short latency, lasts for less than a
minute and is characterized by an increase followed by a
decrease in its intensity.
3. The intensity of the vertigo decreases after repeated head
positioning.
4. The vertigo is not associated with any cochlear symptoms
such as hearing loss, tinnitus, or ear fullness.
5. There are no neurologic symptoms other than vertigo.
B. Signs
1. Geotropic positional nystagmus is induced by the supine
roll test: rightward horizontal nystagmus is induced by
the right-ear-down head position and leftward horizontal
nystagmus is induced by the left-ear-down head position
with the patient supine. The nystagmus consists of major
horizontal and minor torsional components.
2. The nystagmus appears with short latency, lasts for less
than a minute and is characterized by an increase
followed by a decrease in its intensity.
3. Other peripheral and central vestibular diseases causing
vertigo are excluded.
Diagnostic categories
Definite lateral-canal-type of BPPV (canalolithiasis)
To meet all the points in criteria A and B.
Probable BPPV
To meet all the points in criteria A in the history, but no
observable nystagmus and no vertigo with any positional or
positioning maneuver, probably because the BPPV is resolved
spontaneously.
Atypical BPPV
To meet all the points in criteria A and point 3 in criteria B
but not any of points 1 and 2 in criteria B.
Note: The atypical BPPV consists of the anterior-canal-type
of BPPV (canalolithiasis), the posterior-canal-type of BPPV
(cupulolithiasis), and the multiple-canals-type of BPPV.
Lateral-canal-type of BPPV (cupulolithiasis)
A. Symptoms
1. Attacks of rotatory vertigo or dizziness are induced by
specific head positions.
2. The vertigo appears without latency and lasts for more
than a minute without any decrease in its intensity.
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3. The vertigo is not associated with any cochlear symptoms
such as hearing loss, tinnitus, or ear fullness.
4. There are no neurologic symptoms other than vertigo.
B. Signs
1. Apogeotropic positional nystagmus is induced by the
supine roll test: leftward horizontal nystagmus is induced
by the right-ear-down head position and rightward
horizontal nystagmus is induced by the left-ear-down
head position with the patient supine. The nystagmus
consists of major horizontal and minor torsional
components.
2. The nystagmus appears without latency and lasts for more
than a minute without any decrease in its intensity.
3. Other peripheral and central vestibular diseases causing
vertigo are excluded.
1) The Stenger maneuver: sitting position ! head extended
to a position below the horizontal in the supine
position ! sitting position (Fig. 1A).
2) The right Dix–Hallpike maneuver and the reverse right
Dix–Hallpike maneuver: sitting position with the head
turned 458 to the right ! supine position with the head
turned 458 to the right and the neck extended
slightly ! seated position with the head turned 458 to
the right (Fig. 1B).
3) The left Dix–Hallpike maneuver and the reverse left Dix–
Hallpike maneuver: sitting position with the head turned
458 to the left ! supine position with the head turned 458
to the left and the neck extended slightly ! sitting
position with the head turned 458 to the left.

Diagnostic categories
4. Characteristics of nystagmus associated with BPPV
Definite lateral-canal-type of BPPV (cupulolithiasis)
i) Positioning nystagmus of the posterior-canal-type of BPPV
To meet all the points in criteria A and B.
Probable BPPV
In patients with the right posterior-canal-type of BPPV, right
To meet all the points in criteria A in the history, but no
torsional nystagmus (upper pole of the eye rotates to the right)
observable nystagmus and no vertigo with any positional or
is induced by the right Dix–Hallpike maneuver (Fig. 2A, left).
positioning maneuver, probably because the BPPV is resolved
The nystagmus often contains an additional vertical (upward)
spontaneously.
component. The nystagmus appears with short latency, lasts for
Atypical BPPV
less than a minute and is characterized by an increase followed
To meet all the points in criteria A and point 3 in criteria B
but not any of points 1 and 2 in criteria B.
Note: The atypical BPPV consists of the anterior-canal-type
of BPPV (canalolithiasis), the posterior-canal-type of BPPV
(cupulolithiasis), and the multiple-canals-type of BPPV.

3. Examinations for the diagnosis of BPPV

Positional and/or positioning nystagmus should be observed

with Frenzel’s glasses or glasses equipped with an infrared CCD
camera and the characteristics of evoked nystagmus, namely
direction, amplitude, frequency, and torsional/vertical/horizontal
components of the nystagmus are examined. The latency that
elapses before the appearance of nystagmus and changes in the
intensity of nystagmus thereafter is also examined.
In patients who suffer from cervical vertebral disease, the
positional and/or positioning nystagmus test are contraindicated.
The test should be canceled when patients feel neck pain, sensory
disturbance and disturbance of consciousness.

i) The positional nystagmus test for diagnosis of the lateral-

canal-type of BPPV
The positional nystagmus test is performed in a supine
position and the head is rotated to the right-ear-down or left-
ear-down position. The positional nystagmus test is called
the supine roll test, which is useful for the diagnosis of the
lateral-canal-type of BPPV.
ii) The positioning nystagmus test for the diagnosis of the
posterior-canal-type of BPPV
In the positioning nystagmus test, the patient’s head
should be moved quickly. The Dix–Hallpike test is useful for Fig. 1. The positioning nystagmus test. (A) The Stenger maneuver. (B) The right
the diagnosis of the posterior-canal-type of BPPV. Dix–Hallpike maneuver.

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Fig. 2. The positioning nystagmus test with evoked nystagmus. (A) A patient
with the right posterior-canal-type of BPPV. (B) A patient with the left
posterior-canal-type of BPPV.
by a decrease in its intensity. Torsional nystagmus, in which the
upper pole of the eye rotates toward the left ear, is then induced
by the reverse Dix–Hallpike maneuver (Fig. 2A, right). The
nystagmus often contains an additional vertical (downward)
component. Positioning nystagmus in patients with the left
posterior-canal-type of BPPV is shown in Fig. 2B.
In most patients with the posterior-canal-type of BPPV, the
transient torsional nystagmus with latency is induced by
canalolithiasis in the posterior canal. But, some patients with
the posterior-canal-type of BPPV show persistent torsional
nystagmus without latency, the pathophysiology of which is
considered to be cupulolithiasis in the posterior semicircular
canal [7].
ii) Positional nystagmus in patients with the lateral-canal-type
of BPPV
In some patients with the lateral-canal-type of BPPV,
geotropic positional nystagmus, i.e. rightward horizontal
nystagmus, is induced by the right-ear-down head position
and leftward horizontal nystagmus is induced by the left-ear-
down head position with the patient supine by the supine roll
test (Fig. 3A). The nystagmus consists of major horizontal and
minor torsional components. The nystagmus appears with short
latency, lasts for less than a minute and is characterized by an
increase followed by a decrease in its intensity. Transient
geotropic nystagmus with latency is induced by canalolithiasis
in the lateral canal.
In the other patients with the lateral-canal-type of BPPV,
apogeotropic positional nystagmus, i.e. leftward horizontal
nystagmus, is induced by the right-ear-down head position and
rightward horizontal nystagmus is induced by the left-ear-down
head position with the patient supine by the supine roll test
(Fig. 3B). The nystagmus consists of major horizontal and
minor torsional components. The nystagmus appears without
latency and lasts for more than a minute without any decrease in
its intensity. Persistent apogeotropic nystagmus without latency
is induced by cupulolithiasis in the lateral canal.
Please cite this article in press as: Imai T, et al. Classification, diagnostic criteria and management of benign paroxysmal positional vertigo.
Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.03.013
Fig. 3. The supine roll test. (A) A patient with the lateral-canal-type of BPPV.
Geotropic positional nystagmus due to canalolithiasis in the lateral semicircular
canal. (B) A patient with lateral-canal-type of BPPV. Apogeotropic positional
nystagmus due to cupulolithiasis in the lateral semicircular canal.
iii) Positional and/or positioning nystagmus in patients with
probable and atypical BPPV
In patients with probable BPPV, the characteristics of
vertigo meet all the points of criteria A for the posterior- or
lateral-canal-type of BPPV in the history. On the other hand,
they show neither observable nystagmus nor vertigo with any
positional or positioning maneuver. Because their BPPV seems
to be resolved spontaneously, probable BPPV is diagnosed.
In patients with atypical BPPV, the characteristics of vertigo
meet all the points of criteria A for the posterior- or lateral-
canal-type of BPPV. On the other hand, they show atypical
nystagmus that does not meet criteria B points except for point
B4 of the posterior-canal-type of BPPV and point B3 of the
lateral-canal-type BPPV. The atypical BPPV consists of the
anterior-canal-type of BPPV (canalolithiasis), the posterior-
canal-type of BPPV (cupulolithiasis), and the multiple-canals-
type of BPPV.
5. Treatment for BPPV
i) The canalith repositioning procedure (CRP) and non-specific
exercise
Patients with BPPV, the pathophysiology of which is
assumed to be canalolithiasis, are treated with the CRP [8–
11]. Non-specific exercise is used regardless of the pathophysi-
ology and affected canals.
1) The Epley maneuver
Epley first reported the CRP in 1992 [9]. Thereafter, his
method is called the Epley maneuver for the treatment of the
posterior-canal-type of BPPV. The sequential head movements
of the Epley maneuver cause otoconial debris to move from the
semicircular canal to the utricle. Some modified Epley
maneuvers have been proposed. A large body of evidence
supports the clinical efficacy of the Epley maneuver [12–28],
although there is a high rate of spontaneous resolution of BPPV.
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Nystagmus should be observed with Frenzel’s glasses or
glasses equipped with an infrared CCD camera during the
Epley maneuver. The Epley maneuver is contraindicated in
patients who suffer from cervical vertebral disease. The
maneuver should be canceled when patients feel neck pain,
sensory disturbance and disturbance of consciousness.
Fig. 4 shows the methods of the Epley maneuver with
movements of otoconial debris at each head position of patients
with the left posterior-canal-type of BPPV.
(1) The patient’s head is rotated 458 to the left affected ear in a
sitting position.
(2) The head is moved to position (2), where the head is turned
458 to the left and the neck is extended slightly with the
patient supine and kept there until the evoked nystagmus
disappears.
(3) The head is moved to position (3), where the head is turned
458 to the right and the neck extended slightly with the
patient supine and kept there until the evoked nystagmus
disappears or for 2 min.
(4) The head is moved to position (4), where the patient’s trunk
is turned 908 to the right while keeping the head position
against the trunk with the patient supine. Then the head is
finally turned 1358 to the right with the patient supine. The
head position is maintained until the evoked nystagmus
disappears or for 2 min.
(5) The head is moved to position (5) with the patient sitting.
Fig. 4. The Epley maneuver for the treatment of the left posterior-canal-type of
BPPV. Otoconial debris in the left posterior semicircular canal move into the
utricle after the sequential head movements.
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5
(6) The head is bowed 458 forward in the sitting position
immediately after position (5) and kept for 2 min.
2) Other CRPs
In addition to the Epley maneuver, the Semont maneuver,
another CRP, is also used for the treatment of the posterior-
canal-type of BPPV [10]. The Lempert maneuver is used for the
treatment of the lateral-canal-type of BPPV [11].
3) Non-specific exercises
Non-specific exercises for the treatment of BPPV such as
Brandt–Daroff exercise [8] have been reported. It is self-
treatment and applied regardless of the pathophysiology and
affected canals.
ii) Medications
Anti-vertiginous, anti-anxiety, and anti-emetic drugs may be
used for the treatment of BPPV. However, there is no evidence
that has demonstrated their clinical efficacy. Such drug
treatment has some effects in relieving the symptoms of
dizziness and/or vertigo induced by the CRP.
6. Conclusions
In this review, we have provided the classification,
diagnostic criteria, the examinations for diagnosis, and specific
and non-specific treatments of the posterior- and lateral-canal-
type of BPPV in accordance with the Japanese practical
guidelines on BPPV published by the Japan Society for
Equilibrium Research [6].
Conflict of interest
None.
Acknowledgements
The members of Committee for Standards in Diagnosis of
Japan Society for Equilibrium Research who edited part of the
Japanese practical guidelines on BPPV, with the exception of
the authors, are as follows: Prof. Masahiko Yamamoto, Dr.
Setsuko Takemori, Dr. Tadashi Nakamura, Mr. Naofumi
Tsuruoka, Dr. Motoyuki Hashiba, Dr. Takashi Fukaya, Prof.
Kazuo Ishikawa, and Dr. Takao Yabe.
References
[1] Bárány R. Diagnose von Krankheitserscheinungen im Beriche des
Otolithenapparates. Acta Otolaryngol 1921;2:434–7.
[2] Dix M, Hallpike C. The pathology, symptomatology and diagnosis of
the vestibular system. Proc R Soc Med 1952;45:341–54.
[3] McClure JA. Horizontal canal BPV. J Otolaryngol 1985;14:30–5.
[4] Schuknecht H. Cupulolithiasis. Arch Otolaryngol 1969;90:765–78.
[5] Hall S, Ruby P, McClure J. The mechanics of benign paroxysmal
positional vertigo. J Otolaryngol 1979;8:151–8.
[6] Watanabe Y, Ishikawa K, Yamamoto M, Nakamura T, Shineno K, Asai
M, et al. Japanese practical guideline of BPPV. Equilib Res 2009;68:
218–225.
G Model
ANL-2117; No. of Pages 6
6 T. Imai et al. / Auris Nasus Larynx xxx (2016) xxx–xxx
[7] Imai T, Takeda N, Ito M, Sekine K, Sato G, Midoh Y, et al. 3D analysis
of benign positional nystagmus due to cupulolithiasis in posterior
semicircular canal. Acta Otolaryngol 2009;129:1044–9.
[8] Brandt T, Daroff R. Physical therapy for benign paroxysmal positional
vertigo. Arch Otolaryngol 1980;106:484–5.
[9] Epley JM. The canalith repositioning procedure: for treatment of
benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg
1992;107:399–404.
[10] Semont A, Freyss G, Vitte E. Curing the BPPV with a liberatory
maneuver. Adv Otorhinolaryngol 1988;42:290–3.
[11] Lempert T, Tiel-Wilck K. A positional maneuver for treatment of
horizontal-canal benign positional vertigo. Laryngoscope 1996;106:
476–478.
[12] Asawavichianginda S, Isipradit P, Snidvongs K, Supiyaphun P. Cana-
lith repositioning for benign paroxysmal positional vertigo: a random-
ized, controlled trial. Ear Nose Throat J 2000;79:732–4.
[13] Nunez R, Cass S, Furman J. Short- and long-term outcomes of canalith
repositioning for benign paroxysmal positional vertigo. Otolaryngol
Head Neck Surg 2000;122:647–52.
[14] Sherman D, Massoud E. Treatment outcomes of benign paroxysmal
positional vertigo. J Otolaryngol 2001;30:295–9.
[15] Soto Varela A, Bartual Magro J, Santos Pérez S, Vélez Regueiro M,
Lechuga Garcı́a R, Pérez-Carro Rı́os A, et al. Benign paroxysmal
vertigo: a comparative prospective study of the efficacy of Brandt and
Daroff exercises, Semont and Epley maneuver. Rev Laryngol Otol
Rhinol (Bord) 2001;122:179–83.
[16] Simhadri S, Panda N, Raghunathan M. Efficacy of particle reposition-
ing maneuver in BPPV: a prospective study. Am J Otolaryngol
2003;24:355–60.
[17] Angeli S, Hawley R, Gomez O. Systematic approach to benign
paroxysmal positional vertigo in the elderly. Otolaryngol Head Neck
Surg 2003;128:719–25.
Please cite this article in press as: Imai T, et al. Classification, diagnostic criteria and management of benign paroxysmal positional vertigo.
Auris Nasus Larynx (2016), http://dx.doi.org/10.1016/j.anl.2016.03.013
[18] Kitajima N, Suzuki M, Horiguchi S, Ichimura A, Ogawa Y, Shimizu S,
et al. The clinical course of BPPV after the canalith repositional
procedure. Equilib Res 2004;63:28–33.
[19] Woodworth B, Gillespie M, Lambert P. The canalith repositioning
procedure for benign positional vertigo: a meta-analysis. Laryngoscope
2004;114:1143–6.
[20] Hilton M, Pinder D. The Epley (canalith repositioning) manoeuvre for
benign paroxysmal positional vertigo. Cochrane Database Syst Rev
2014;12. CD003162.
[21] Del Rio M, Arriaga M. Benign positional vertigo: prognostic factors.
Otolaryngol Head Neck Surg 2004;130:426–9.
[22] Salvinelli F, Trivelli M, Casale M, Firrisi L, DiPeco V, D’Ascanio L,
et al. Treatment of benign positional vertigo in the elderly: a random-
ized trial. Laryngoscope 2004;114:827–31.
[23] White J, Savvides P, Cherian N, Oas J. Canalith repositioning for
benign paroxysmal positional vertigo. Otol Neurotol 2005;26:
704–710.
[24] Richard W, Bruintjes T, Oostenbrink P, van Leeuwen R. Efficacy of the
Epley maneuver for posterior canal BPPV: a long-term, controlled
study of 81 patients. Ear Nose Throat J 2005;84:22–5.
[25] Cohen H, Kimball K. Effectiveness of treatments for benign paroxys-
mal positional vertigo of the posterior canal. Otol Neurotol 2005;26:
1034–1040.
[26] Sekine K, Imai T, Sato G, Ito M, Takeda N. Natural history of benign
paroxysmal positional vertigo and efficacy of Epley and Lempert
maneuvers. Otolaryngol Head Neck Surg 2006;135:529–33.
[27] von Brevern M, Seelig T, Radtke A, Tiel-Wilck K, Neuhauser H,
Lempert T. Short-term efficacy of Epley’s manoeuvre: a double-blind
randomized trial. J Neurol Neurosurg Psychiatry 2006;77:980–2.
[28] Brandt T, Huppert D, Hecht J, Karch C, Strupp M. Benign paroxysmal
positioning vertigo: a long-term follow-up (6–17 years) of 125 patients.
Acta Otolaryngol 2006;126:160–3.