Transcript Slide 1

Practice Parameter: Therapies
for benign paroxysmal
positional vertigo (an
evidence-based review)
Report of the Quality Standards
Subcommittee of the American Academy
of Neurology
T.D. Fife, MD; D.J. Iverson, MD; T. Lempert, MD; J.M. Furman,
MD, PhD; R.W. Baloh, MD; R.J. Tusa, MD, PhD; T.C. Hain, MD;
S. Herdman, PT, PhD, FAPTA; M.J. Morrow, MD; G.S. Gronseth,
MD
© 2006 American Academy of Neurology
The AAN develops these presentation
slides as educational tools for
neurologists and other health care
practitioners. You may download and
retain a single copy for your personal
use. Please contact [email protected]
to learn about options for sharing this
content beyond your personal use.
© 2006 American Academy of Neurology
Presentation Objectives
• To perform an evidence-based review of
the treatment of benign paroxysmal
positional vertigo
• To make evidence-based
recommendations
© 2006 American Academy of Neurology
Overview
•
•
•
•
Background
Gaps in care
AAN guideline process
Analysis of evidence, conclusions,
recommendations
• Recommendations for future research
© 2006 American Academy of Neurology
Background
• BPPV is a clinical syndrome characterized
by brief recurrent episodes of vertigo
triggered by changes in head position with
respect to gravity.
• BPPV is the most common cause of
recurrent vertigo, with a lifetime
prevalence of 2.4%.1
• The duration, frequency, and intensity of
symptoms of BPPV vary, and spontaneous
recovery occurs frequently.
© 2006 American Academy of Neurology
Inner ear
© 2008, Barrow
© 2006 American Academy of Neurology
BPPV by canal type
Posterior
Horizontal
Anterior
Estimated frequency2-6
81-89%
8-17%
1-3%
Provocative maneuver
Dix Hallpike*
Supine Roll Test (Pagnini-McClure)
Dix Hallpike*
Upbeat, torsional
Horizontal
Direction Changing
Downbeat**, torsional
Nystagmus
* In posterior canal benign positional vertigo, nystagmus is provoked
following Dix Hallpike positioning with the affected ear down. In
anterior canal benign positional vertigo, nystagmus is provoked
following Dix Hallpike positioning with the affected ear up.
** The observation of downbeating positional nystagmus requires
careful assessment to rule out brainstem or cerebellar lesions.
© 2006 American Academy of Neurology
Gaps in Care
• There are a number of repositioning
maneuvers in use, but they lack
standardization.
• Several video clips and figure drawings
are available at www.aan.com but do not
include all variations for treatment.
© 2006 American Academy of Neurology
AAN Guideline Process
Clinical Question
Evidence
Conclusions
Recommendations
© 2006 American Academy of Neurology
Clinical Questions
• First step of developing guidelines is to
clearly formulate questions to be answered.
• Questions address areas of controversy,
confusion, or variation in practice.
• Questions must be answerable with data
from the literature.
• Answering the question must have the
potential to improve care/patient outcomes.
© 2006 American Academy of Neurology
Literature Search/Review:
Rigorous, Comprehensive, Transparent
Complete
Search
Review abstracts
Review full text
Select articles
Relevant
© 2006 American Academy of Neurology
AAN Classification of
Evidence
• All studies rated Class I, II, III, or IV
• Five different classification systems:
– Therapeutic
• Randomization, control, blinding
– Diagnostic
• Comparison to gold standard
– Prognostic
– Screening
– Causation
© 2006 American Academy of Neurology
AAN Level of
Recommendations
• A = Established as effective, ineffective, or harmful for
the given condition in the specified population.
• B = Probably effective, ineffective, or harmful for the
given condition in the specified population.
• C = Possibly effective, ineffective, or harmful for the
given condition in the specified population.
• U = Data is inadequate or conflicting; given current
knowledge, treatment is unproven.
Note that recommendations can be positive or negative.
© 2006 American Academy of Neurology
Translating Class to
Recommendations
• A = Requires two consistent Class I
studies.
• B = Requires one Class I study or two
consistent Class II studies.
• C = Requires one Class II study or two
consistent Class III studies.
• U = Studies not meeting criteria for
Class I through Class III.
© 2006 American Academy of Neurology
Applying This Process
to the Issue
We will now turn our attention to the
guidelines.
© 2006 American Academy of Neurology
Clinical Questions
1.
2.
3.
4.
5.
6.
7.
What maneuvers effectively treat posterior canal
BPPV?
Which maneuvers are effective for anterior and
horizontal canal BPPV?
Are postmaneuver restrictions necessary?
Is concurrent mastoid vibration important for efficacy of
the maneuvers?
What is the efficacy of habituation exercises, BrandtDaroff exercises, or patient self-administered treatment
maneuvers?
Are medications effective for BPPV?
Is surgical occlusion of the posterior canal or singular
neurectomy effective for BPPV?
© 2006 American Academy of Neurology
Methods
• Medline, EMBASE and Current Contents:
– 1966 to June 2006
– Relevant, fully published, peer-reviewed articles
– Supplemented through manual searches by panel
members
• Search terms:
– Benign paroxysmal positional vertigo, Semont
liberatory maneuver, canalith repositioning maneuver,
particle repositioning maneuver, Epley maneuver,
modified Epley maneuver
© 2006 American Academy of Neurology
Methods
• Panel comprised of otoneurologists with
expertise in BPPV and general neurologists with
methodologic expertise.
• At least two panelists reviewed each article for
inclusion.
• Risk of bias determined using the classification
of evidence for each study (Class I–IV).
• Strength of practice recommendations linked
directly to level of evidence (Level A–U).
• Conflicts of interests disclosed.
© 2006 American Academy of Neurology
Literature Review
399 abstracts
70 articles
© 2006 American Academy of Neurology
Inclusion criteria:
- Relevant to the
clinical questions
- Limited to human
subjects
-RCT, case control,
cohort studies, case
series > 6, metaanalysis
Exclusion criteria:
-Abstracts, reviews,
and undocumented or
unstated mention of
improvement
AAN Classification of Evidence
for Therapeutic Intervention
• Class I: Randomized, controlled clinical trial with masked
or objective outcome assessment in a representative
population. Relevant baseline characteristics are
presented and substantially equivalent among treatment
groups or there is appropriate statistical adjustment for
differences. The following are required:
a) concealed allocation
b) primary outcome(s) clearly defined
c) exclusion/inclusion criteria clearly defined, and
d) adequate accounting for drop-outs (with at least 80%
of enrolled subjects completing the study) and crossovers with numbers sufficiently low to have minimal
potential for bias.
© 2006 American Academy of Neurology
AAN Classification of Evidence
for Therapeutic Intervention
• Class II: Prospective matched group
cohort study in a representative population
with masked outcome assessment that
meets b-d above OR a randomized
controlled trial in a representative
population that lacks one criteria a-d.
© 2006 American Academy of Neurology
AAN Classification of Evidence
for Therapeutic Intervention
• Class III: All other controlled trials (including well-defined
natural history controls or patients serving as own
controls) in a representative population, where outcome
is independently assessed, or independently derived by
objective outcome measurement*.
• Class IV: Studies not meeting Class I, II, or III criteria
including consensus, expert opinion, or a case report.
*Objective outcome measurement: an outcome measure
that is unlikely to be affected by an observer’s (patient,
treating physician, investigator) expectation or bias (e.g.,
blood tests, administrative outcome data).
© 2006 American Academy of Neurology
Analysis of Evidence
Question 1: What maneuvers
effectively treat posterior canal
BPPV?
Canalith repositioning procedure (CRP)
• 15 RCTs identified (two Class I2,3 and three
Class II4-6 studies).
Semont maneuver
• 4 studies identified (one class II6, one Class III7
two Class IV8,9 studies).
© 2006 American Academy of Neurology
Analysis of Evidence (CRP)
• 36 patients2 compared CRP to sham in
supine position with affected ear down for
5 minutes and then sat up.
• All patients symptomatic for at least 2
months/ median duration of symptoms
was 17 months (range 2-240 months) in
treatment group and 4 months (range 2276 months) in control group.
© 2006 American Academy of Neurology
Analysis of Evidence (CRP)
• At 4 weeks, 61% of treated group reported
complete resolution vs. 20% of shamtreated group (p=0.032). NNT = 2.44.
• Dix-Hallpike maneuver was negative in
88.9% of treated patients vs. 26.7% in
sham-treated patients (p<0.001, NNT =
1.60) as measured by an observer blinded
to treatment.
© 2006 American Academy of Neurology
Canalith Repositioning
Procedure
© 2008, Barrow
© 2006 American Academy of Neurology
Analysis of Evidence (CRP)
Randomized controlled trial and crossover study3
– 66 patients with a diagnosis of posterior BPPV based on a
positive Dix-Hallpike maneuver, compared a CRP with
sham.
– After 24 hours, 80% of treated patients were asymptomatic
and had no nystagmus compared with 10% of sham
patients (p<0.001, NNT = 1.43).
– Ninety-three percent of patients from original control
reported resolution of symptoms 24 hours after undergoing
CRP.
– By 1 week, 94% of patients in the original treatment group
and 92% of patients in original control were asymptomatic.
– At 4 weeks, 85% of patients in both groups were
asymptomatic.
© 2006 American Academy of Neurology
Analysis of Evidence (CRP)
Three studies were rated as Class II4-6 because the method of
allocation concealment* was not specified.
Remaining RCTs were graded Class IV because they did not clearly
state whether the outcomes were obtained in a blinded and
independent manner10-17 or because of important baseline difference
between study and control groups.18
Five additional studies were identified (four meta-analyses19-22 and
one systematic review). All references in the meta-analyses were
reviewed individually for this practice parameter.
*Technique for preventing researchers from inadvertently influencing which patients are
assigned to the treatment or placebo group (may cause selection bias that overestimates
the treatment effect).23
© 2006 American Academy of Neurology
Analysis of Evidence
Semont Maneuver
• One study6 showed patients treated with Semont
maneuver were “significantly” improved
compared to those treated with sham.
• One study randomized 156 patients to Semont
maneuver, medical therapy and no treatment.
– Six month follow-up, 94.2% of patients treated with
Semont maneuver reported symptom resolution, vs.
57.7% of patients treated medically and 34.6% of
patients who received no treatment.
© 2006 American Academy of Neurology
Semont maneuver
© 2008, Barrow
© 2006 American Academy of Neurology
Analysis of Evidence
Semont Maneuver
• One Class IV study8 comparing Semont
and a CRP with or without post-treatment
found success rates for all groups ranging
from 88% to 96%, with no difference
between groups.
© 2006 American Academy of Neurology
Analysis of Evidence
Semont Maneuver
• Another Class IV study9 compared patients
randomized to treatment with CRP, Semont
maneuver, or Brandt-Daroff exercises.
– Symptom resolution among those treated with either
CRP or Semont maneuver at 1 week was the same
(74% vs 71%; 24% for Brandt-Daroff exercises).
– At 3-month follow-up, 93% of patients treated with
CRP were asymptomatic vs. 77% of those treated
with Semont maneuver (p=0.027); 62% of patients
treated with Brandt-Daroff exercises were
asymptomatic at 3 months.
© 2006 American Academy of Neurology
Conclusions
• Two Class I studies and three Class II studies
have demonstrated a short-term (1 day to 4
weeks) resolution of symptoms in patients
treated with the CRP (NNT ranging from 1.43 to
3.7).
• The Semont maneuver is possibly more effective
than no treatment (Class III), a sham treatment
(Class II), or Brandt-Daroff exercises (Class IV)
as treatment for posterior canal BPPV.
• Two Class IV studies comparing CRP with
Semont maneuver have produced conflicting
results.
© 2006 American Academy of Neurology
Recommendations
• CRP is established as an effective and safe
therapy that should be offered to patients of all
ages with posterior semicircular canal BPPV
(Level A).
• The Semont maneuver is possibly effective for
BPPV (Level C).*
• There is insufficient evidence to establish the
relative efficacy of the Semont maneuver to CRP
(Level U).
* Single Class II study.
© 2006 American Academy of Neurology
Analysis of Evidence
Question 2: Which maneuvers are the
most effective treatments for
horizontal canal and anterior canal
BPPV?
Horizontal canal BPPV
• 21 studies identified24-44 (Class IV).
Anterior canal BPPV
• 2 studies identified45,46 (Class IV).
© 2006 American Academy of Neurology
Analysis of Evidence
Horizontal Canal BPPV
• Horizontal canal BPPV accounts for 1017% of BPPV,24-28 though some reports
have been even higher.29,30
• The nystagmus and vertigo of horizontal
canal BPPV may be provoked by the DixHallpike maneuver but are more reliably
induced by the supine head roll test
(Pagnini-McClure maneuver).33-35
© 2006 American Academy of Neurology
Analysis of Evidence
Horizontal Canal BPPV
• CRP or modified Epley maneuvers are
usually ineffective for horizontal canal
BPPV,7-9,24-33,47 so a number of alternative
maneuvers have been devised.
– Modified maneuvers include the Lempert
maneuver (barbecue roll), the Gufoni
maneuver, and the Vanucchi-Asprella
liberatory maneuver. Success in treatment for
each of these maneuvers is based on Class
IV data.
© 2006 American Academy of Neurology
Supine roll test
(Pagnini-McClure maneuver)
© 2008, Barrow
© 2006 American Academy of Neurology
Lempert roll maneuver
© 2008, Barrow
© 2006 American Academy of Neurology
Analysis of Evidence
Anterior Canal BPPV
• Anterior canal BPPV is usually transitory and
most often the result of “canal switch” that
occurs in the course of treatment more common
forms of BPPV.47
• Success rates were between 92-97%,45, 46
though there were no controls to determine
whether this represents an improvement over
the natural history of this frequently selfresolving form of BPPV.
© 2006 American Academy of Neurology
Conclusions/Recommendation
• Based on Class IV studies, variations of the
Lempert supine roll maneuver, the Gufoni
method, or forced prolonged positioning seem
moderately effective for horizontal canal BPPV.
• Two uncontrolled Class IV studies report high
response rates to maneuvers for anterior canal
BPPV.
• No recommendation can be made (Level U).
© 2006 American Academy of Neurology
Analysis of Evidence
Question 3: Are postmaneuver activity
activity restrictions necessary after
canalith repositioning treatment?
One Class I2, one Class II4 and six Class
IV studies.8,48-52
© 2006 American Academy of Neurology
Analysis of Evidence
• One Class I study2 and one Class II study4
demonstrating the benefit of CRP, patients wore
a cervical collar for 48 hours and avoided
sleeping on the affected side for 1 week.
• Five Class IV studies8,48-52 comparing CRP with
and without post-treatment activity restriction
showed no added benefit from post-treatment
activity restriction or positions.
• One Class IV study52 showed minimal benefit in
patients with post-activity restrictions.
© 2006 American Academy of Neurology
Conclusion/Recommendation
• Based on six Class IV studies, there is
insufficient evidence to determine the
efficacy of post-maneuver restrictions in
patients treated with CRP.
• No recommendation can be made
(Level U).
© 2006 American Academy of Neurology
Analysis of Evidence
Question 4: Is it necessary to include
mastoid vibration with repositioning
maneuvers?
One Class II,53 one Class III54 and three
Class IV studies.11,55,56
© 2006 American Academy of Neurology
Analysis of Evidence
• One Class II study53 comparing patients with
posterior canal BPPV treated by “appropriate
canalith repositioning maneuvers,” performed
with and without vibration, showed no
difference in immediate symptom resolution or
relapse rate between groups.
• One Class III study54 compared patients
treated by CRP with and without mastoid
vibration. There was no difference in symptom
relief between the groups at 4 to 6 weeks
(p=0.68).
© 2006 American Academy of Neurology
Analysis of Evidence
• Two Class IV studies55,56 showed no
difference in the rate of symptom
resolution between patients treated by a
CRP with or without mastoid vibration.
• A third Class IV study11 reported that of
patients treated by a CRP with vibration,
92% were “improved,” vs. 60%
improvement with CRP alone.
© 2006 American Academy of Neurology
Conclusion
• One Class II, one Class III, and two Class
IV studies showed no added benefit when
mastoid vibration was added to a CRP as
treatment for posterior canal BPPV.
© 2006 American Academy of Neurology
Recommendation
• Mastoid oscillation is probably of no added
benefit to patients treated with CRP for
posterior canal BPPV (Level C).
© 2006 American Academy of Neurology
Analysis of Evidence
Question 5: What is the efficacy of
Brandt-Daroff exercises, habituation
exercises, or patient self-administered
treatments for BPPV?
One Class II6 and one Class IV study.9
© 2006 American Academy of Neurology
Analysis of Evidence
One Class II study6 randomized patients to a
CRP, a “liberatory maneuver,” Brandt-Daroff
exercises, “habituation exercises,” or sham
treatment found that patients treated with
habituation exercises did no better than those
treated with sham. Patients treated with BrandtDaroff exercises did worse than those treated
with CRP or liberatory maneuvers, but were not
compared with sham treated patients.
© 2006 American Academy of Neurology
Analysis of Evidence
• One Class IV study9 compared Brandt-Daroff
exercises, performed three times daily, with the
Semont maneuver or CRP.
– Patients treated with maneuvers were pretreated with
diazepam and given postmaneuver activity
restrictions; patients treated with Brandt-Daroff
exercises were not. Compliance was not recorded.
– At 1-week follow-up, 24% of patients treated with
Brandt-Daroff exercises were symptom free, vs. 74%
of those treated with the Semont maneuver or CRP.
© 2006 American Academy of Neurology
Conclusion
• One Class II and one Class IV study
suggest that Brandt–Daroff exercises or
habituation exercises are less effective
than CRP in the treatment of posterior
canal BPPV.
© 2006 American Academy of Neurology
Recommendations
• Self-administered Brandt–Daroff exercises
or habituation exercises are less effective
than CRP in the treatment of posterior
canal BPPV (Level C).
• There is insufficient evidence to
recommend or refute self-treatment using
Semont maneuver or CRP for BPPV
(Level U).
© 2006 American Academy of Neurology
Analysis of Evidence
Question 6: What is the efficacy of
medication treatments for BPPV?
Two Class III studies.47,57
© 2006 American Academy of Neurology
Analysis of Evidence
• One Class III study57 found no difference
between lorazepam, 1mg three times daily;
diazepam, 5mg three times daily; or placebo
over the 4-week study period.
• One Class III study47 found that flunarizine was
more effective than no treatment but less
effective than Semont maneuver in eliminating
symptoms.
• There are no randomized controlled trials of
meclizine or other drugs used for motion
sickness in the treatment of BPPV.
© 2006 American Academy of Neurology
Conclusions/Recommendation
• A single Class III study did not demonstrate that
lorazepam or diazepam hastened resolution of
symptoms in BPPV.
• Another Class III study demonstrated some
benefit of flunarizine (unavailable in the US) in
BPPV.
• There is no evidence to support or refute a
recommendation of any medication in the
routine treatment for BPPV (Level U).
© 2006 American Academy of Neurology
Analysis of Evidence
Question 7: What are the safety and
efficacy of surgical treatments for
posterior canal BPPV?
Six Class IV studies.58-63
© 2006 American Academy of Neurology
Analysis of Evidence
• Five Class IV studies58-62 with a total of 86
patients undergoing canal occlusion, reported
“complete relief” of BPPV symptoms in 85, as
ascertained by the treating surgeon.
– Reported complications included a “mild” conductive
hearing loss for 4 weeks or less, “mild” and “transient”
unsteadiness in most patients, and a high frequency
sensorineural hearing loss in 6 patients.
• One Class IV study63 of singular neurectomy as
a treatment for intractable BPPV, 96.8% were
reported to have “complete relief.”
– Severe sensorineural hearing loss occurred in 3.7%
of patients.
© 2006 American Academy of Neurology
Conclusion/Recommendation
• Six unblinded, retrospective Class IV studies
report relief from symptoms of BPPV in nearly
every patient undergoing posterior semicircular
canal occlusion or singular neurectomy.
• The studies do not provide sufficient
evidence to recommend or refute posterior
semicircular canal occlusion or singular
neurectomy as treatment for BPPV (Level U).
© 2006 American Academy of Neurology
Future Research
Class I studies are needed to clarify the
best treatments for horizontal canal BPPV.
Future studies on these topics should
adhere to the Consolidated Standards of
Reporting Trials (CONSORT) criteria using
validated, clinically relevant outcomes.
© 2006 American Academy of Neurology
References
1.
2.
3.
4.
5.
6.
7.
von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal
positional vertigo: a population based study. J Neurol Neurosurg Psychiatr 2007;
78:710–715.
Lynn S, Pool A, Rose D, Brey R, Suman V. Randomized trial of the canalith
repositioning procedure. Otolaryngol Head Neck Surg 1995;113:712–720.
von Brevern M, Seelig T, Radtke A, Tiel-Wilck K, Neuhauser H. Long-term efficacy
of Epley’s manoeuvre: a double-blind randomized trial. J Neurol Neurosurg
Psychiatr 2006;77:980–982.
Froehling DA, Bowen JM, Mohr DN, et al. The canalith repositioning procedure for
the treatment of benign paroxysmal positional vertigo: a randomized controlled
trial. Mayo Clin Proc 2000;75:695–700.
Yimtae K, Srirompotong S, Srirompotong S, Sae-Seaw P. A randomized trial of the
canalith repositioning procedure. Laryngoscope 2003;113:828–832.
Cohen HS, Kimball KT. Effectiveness of treatments for benign paroxysmal
positional vertigo of the posterior canal. Otol Neurotol 2005;26:1034–1040.
Salvinelli F, Casale M, Trivelli M, et al. Benign paroxysmal positional vertigo: a
comparative prospective study on the efficacy of Semont’s maneuver and no
treatment strategy. Clin Ter 2003;154:7–11.
© 2006 American Academy of Neurology
References (cont.)
8.
9.
10.
11.
12.
13.
14.
Massoud EA, Ireland DJ. Post-treatment instructions in the nonsurgical
management of benign paroxysmal positional vertigo. J Otolaryngol 1996;25:121–
125.
Soto Varela A, Bartual Magro J, Santos Perez S, 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;122:179–183.
Sherman D, Massoud EA. Treatment outcomes of benign paroxysmal positional
vertigo. J Otolaryngol 2001;30:295–299.
Li JC. Mastoid oscillation: a critical factor for success in canalith repositioning
procedure. Otolaryngol Head Neck Surg 1995;112:670–675.
Blakley BW. A randomized, controlled assessment of the canalith repositioning
maneuver. Otolaryngol Head Neck Surg 1994;110:391–396.
Lempert T, Wolsley C, Davies R, et al. Three hundred sixty-degree rotation of the
posterior semicircular canal for treatment of benign positional vertigo: a placebocontrolled trial. Neurology 1997;49:729–733.
Wolf M, Hertanu T, Novikov I, Kronenberg J. Epley’s manoeuvre for benign
paroxysmal positional vertigo: a prospective study. Clin Otolaryngol 1999;24:43–
46.
© 2006 American Academy of Neurology
References (cont.)
15.
16.
17.
18.
19.
20.
Asawavichianginda S, Isipradit P, Snidvongs K, et al. Canalith repositioning for
benign paroxysmal positional vertigo: a randomized, controlled trial. Ear Nose
Throat J 2000;79:732–734.
Angeli SI, Hawley R, Gomez O. Systematic approach to benign paroxysmal
positional vertigo in the elderly. Otolaryngol Head Neck Surg 2003;128:719–725.
Sridhar S, Panda N. Particle repositioning manoeuvre in benign paroxysmal
positional vertigo: is it really safe? J Otolaryngol 2005;34:41–45.
Chang AK, Schoeman G, Hill M. A randomized clinical trial to assess the efficacy
of the Epley maneuver in the treatment of acute benign positional vertigo. Acad
Emerg Med 2004;11:918–924.
Lopez-Escamaez J, Gonzalez-Sanchez M, Salinero J. Meta-analysis of the
treatment of benign paroxysmal positional vertigo by Epley and Semont
maneuvers. Acta Otorrinolaringol Esp 1999;50:366–370.
Woodworth BA, Gillespie MB, Lambert PR. The canalith repositioning procedure
for benign positional vertigo: a meta-analysis. Laryngoscope 2004;114:1143–
1146.
© 2006 American Academy of Neurology
References (cont.)
21.
22.
23.
24.
25.
26.
27.
Teixeira LJ, Machado JN. Maneuvers for the treatment of benign positional
paroxysmal vertigo: a systematic review. Rev Bras Otorrinolaringol (Engl Ed)
2006;72:130–139.
Hilton M, Pinder D. The Epley manoeuvre for benign paroxysmal positional
vertigo: a systematic review. Clin Otolaryngol Allied Sci 2002;27:440–445.
Schulz KF, Grimes DA. Allocation concealment in randomised trials: defending
against deciphering. Lancet 2002;359:614–618.
White JA, Coale KD, Catalano PJ, Oas JG. Diagnosis and management of
horizontal semicircular canal benign paroxysmal positional vertigo. Otolaryngol
Head Neck Surg 2005;133:278–284.
Prokopakis EP, Chimona T, Tsagournisakis M, et al. Benign paroxysmal positional
vertigo: 10-year experience in treating 592 patients with canalith repositioning
procedure. Laryngoscope 2005;115:1667–1671.
Caruso G, Nuti D. Epidemiological data from 2270 PPV patients. Audiological Med
2005;3:7–11.
Leopardi G, Chiarella G, Serafini G, et al. Paroxysmal positional vertigo: short- and
long-term clinical and methodological analyses of 794 patients. Acta Otolaryngol
Ital 2003;23:155–160.
© 2006 American Academy of Neurology
References (cont.)
28.
29.
30.
31.
32.
33.
34.
35.
Fife TD. Recognition and management of horizontal canal benign positional
vertigo. Am J Otol 1998;19:345–351.
Koo JW, Moon IJ, Shim WS, Moon SY, Kim JS. Value of lying-down nystagmus in
the lateralization of horizontal semicircular canal benign paroxysmal positional
vertigo. Otol Neurol 2006;27:367–371.
Nuti D, Agus G, Barbieri M-T, Passali D. The management of horizontal-canal
paroxysmal positional vertigo. Acta Otolaryngol 1998;118:455–460.
Casani AP, Vannucchi G, Fattori B, Berrettini S. The treatment of horizontal canal
positional vertigo: our experience in 66 cases. Laryngoscope 2002;112:172–178.
Appiani GC, Catania G, Gagliardi M, Cuiuli G. Repositioning maneuver for the
treatment of the apogeotropic variant of horizontal canal benign paroxysmal
positional vertigo. Otol Neurotol 2005;26:257–260.
Lempert T, Tiel-Wilck K. A positional maneuver for treatment of horizontal-canal
benign positional vertigo. Laryngoscope 1996;106:476–478.
McClure JA. Horizontal canal BPV. J Otolaryngol 1985;14:30–35.
Appiani GC, Gagliardi M, Magliulo G. Physical treatment of horizontal canal benign
positional vertigo. Eur Arch Otorhinolaryngol 1997;254:326–328.
© 2006 American Academy of Neurology
References (cont.)
36.
37.
38.
39.
40.
41.
42.
Han BI, Oh HJ, Kim JS. Nystagmus while recumbent in horizontal canal benign
paroxysmal positional vertigo. Neurology 2006;66:706–710.
Asprella Libonati G. Diagnostic and treatment strategy of the lateral semicircular
canal canalolithiasis. Acta Otorhinolaryngol Ital 2005;25:277–283.
Tirelli G, Russolo M. 360-Degree canalith repositioning procedure for the
horizontal canal. Otolaryngol Head Neck Surg 2004;131:740-6.
Chiou W-Y, Lee H-L, Tsai S-C, Yu T-H, Lee X-X. A single therapy for all subtypes
of horizontal canal positional vertigo. Laryngoscope 2005;115:1432-5.
Gufoni M, Mastrosimone I, DiNasso F. Repositioning maneuver in benign
paroxysmal positional vertigo of the horizontal semicircular canal. Acta
Otorhinolarynol Ital 1998;18:363-7.
Appiani GC, Catania G, Gagliardi M. A liberatory maneuver for the treatment of
horizontal canal paroxysmal positional vertigo. Otol Neurol 2001;22:66-9.
Asprella Libonati G, Gagliardi G, Cifarelli D, Larotonda G. “Step by step” treatment
of lateral semicircular canal canalolithiasis under videonystagmoscopic
examination. Acta Otorhinolaryngol Ital 2003;23:10-15.
© 2006 American Academy of Neurology
References (cont.)
43.
44.
45.
46.
47.
48.
49.
Vannucchi P, Asprella Libonati G, Gufoni M. The physical treatment of lateral
semicircular canal canalolithiasis. Audiol Med 2005;3:52-56.
Vannucchi P, Giannoni B, Pagnini P. Treatment of horizontal semicircular canal
benign paroxysmal positional vertigo. J Vestib Res 1997;7:1-6.
Rahko T. The test and treatment methods of benign paroxysmal positional vertigo
and an addition to the management of vertigo due to the superior vestibular canal
(BPPV-SC). Clin Otolaryngol 2002;27:292-5.
Kim YK, Shin JE, Chung JW. The effect of canalith repositioning for the anterior
semicircular canal canalithiasis. Otorhinolaryngol 2005;67:56-60.
Herdman SJ, Tusa RJ. Complications of the canalith repositioning procedure. Arch
Otolaryngol Head Neck Surg 1996;122:281–286.
Nuti D, Nati C, Passali D. Treatment of benign paroxysmal positional vertigo: no
need for postmaneuver restrictions. Otolaryngology - Head & Neck Surgery
2000;122:440-4.
Moon SJ, Bae SH, Kim HD, Kim JH, Cho YB. The effect of postural restrictions in
the treatment of benign paroxysmal positional vertigo. European Archives of OtoRhino-Laryngology 2005;262:408-11.
© 2006 American Academy of Neurology
References (cont.)
50.
51.
52.
53.
54.
55.
56.
Marciano E, Marcelli V. Postural restrictions in labyrintholithiasis. European
Archives of Oto-Rhino-Laryngology 2002;259:262-5.
Roberts RA, Gans RE, DeBoodt JL, Lister JJ. Treatment of benign paroxysmal
positional vertigo: necessity of postmaneuver patient restrictions. Journal of the
American Academy of Audiology 2005;16:357-66.
Çakir BÖ, Ercan I, Çakir ZA, Turgut S. Efficacy of postural restriction in treating
benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg
2006;132:501-5.
Macias JD, Ellensohn A, Massingale S, Gerkin R. Vibration with the canalith
repositioning maneuver: a prospective randomized study to determine efficacy.
Laryngoscope 2004;114:1011-4.
Motamed M, Osinubi O, Cook JA. Effect of mastoid oscillation on the outcome of
the canalith repositioning procedure. Laryngoscope 2004;114:1296-8.
Hain TC, Helminski JO, Reis IL, Uddin MK. Vibration does not improve results of
the canalith repositioning procedure. Archives of Otolaryngology - Head & Neck
Surgery 2000;126:617-22.
Sargent EW, Bankaitis AE, Hollenbeak CS, Currens JW. Mastoid oscillation in
canalith repositioning for paroxysmal positional vertigo. Otology & Neurotology
2001;22:205-9.
© 2006 American Academy of Neurology
References (cont.)
57.
58.
59.
60.
61.
62.
63.
McClure JA, Willett JM. Lorazepam and diazepam in the treatment of benign
paroxysmal vertigo. J Otolaryngol 1980;9:472-7.
Dingle AF, Hawthorne MR, Kumar BU. Fenestration and occlusion of the posterior
semicircular canal for benign positional vertigo. Clinical Otolaryngology & Allied
Sciences 1992;17:300-2.
Zappia JJ. Posterior semicircular canal occlusion for benign paroxysmal positional
vertigo. American Journal of Otology 1996;17:749-54.
Pulec JL. Ablation of posterior semicircular canal for benign paroxysmal positional
vertigo. Ear, Nose, & Throat Journal 1997;76:17-22, 24.
Walsh RM, Bath AP, Cullen JR, Rutka JA. Long-term results of posterior
semicircular canal occlusion for intractable benign paroxysmal positional vertigo.
Clinical Otolaryngology & Allied Sciences 1999;24:316-23.
Agrawal SK, Parnes LS. Human experience with canal plugging. Annals of the
New York Academy of Sciences 2001; 942:300-5.
Gacek RR, Gacek MR. Results of singular neurectomy in the posterior ampullary
recess. Journal of Oto-Rhino-Laryngology & its Related Specialties 2002;64:397402.
© 2006 American Academy of Neurology
To access the full guideline please visit:
AAN.com/Guidelines
Published in Neurology May 27, 2008 70:2067-2074
© 2006 American Academy of Neurology
Questions/Comments
© 2006 American Academy of Neurology
Thank you for your
participation!
© 2006 American Academy of Neurology