Combined liberatory repositioning procedure in treatment of benign paroxysmal positional vertigo

ABSTRACT

The development of optimal treatment for benign paroxysmal positional vertigo [BPPV] has been delayed because its pathophysiology has been clarified only recently liberatory maneuver of Semont [LM], which depends on "canalithiasis" theory, and canalith repositioning procedure of Epley [CRP], which depends on "cupulolithiasis" theory, were equally effective to a great extent in treatment of BPPV. However, both still have a considerable degree of failure and relatively high incidence of recurrence. Therefore, we suggest that canalithiasis and cupulolithiasis may sequentially and concurrently occur in the same semicircular canal "cupulocanalithiasis". To prove that, we designed a maneuver developed from both LM and CRP with some modifications and we named it combined liberatory repositioning maneuver [LRM]. Dix-Hailpike's provocative maneuver was used for selection of 78 patients having BPPV. The patients were randomly assigned to one of four treatment strategies our LRM [n = 21], CRP [n = 18], LM [n = 19] or they were left for spontaneous cure [n = 20].The patients were followed up for 6 months and the treatment outcome, in the form of improvement of symptoms and the disappearance of nystagmus on Hailpike's maneuver, was recorded throughout the follow up period. Repetition of LRM, or LM or CRP on the second visit, after one week, was planned to be done in case of failure of the first trial. Audiological assessment was done before and after the treatment. The mean age of the patients was 51 +/- 14 years. There was no significant difference in the age, distribution of the sex and duration of the disease between the treatment groups. After the first visit, the rate of complete improvement was 85.71% [18/21] in LRM group, 47.37% [9/19] in LM group and 55.56% [10/18] in CRP group. The difference was statistically significant. After the second visit and repetition of the maneuver the complete improvement increased to 90.48% [19/21] in LRM, 78.95% [15/19] in LM group and 72.22% [13/18] in CRP group. However, the difference was statistically insignificant. In the control group, the spontaneous improvement was 10% [2/20] after one week following the onset of the disease and it increased to [35%] [n = 7/20] after two weeks. The audiological changes after the maneuvers were insignificant. There was a highly significant difference between LRM, LM or CRP in comparison with the medical control group on the first and second weeks. The low incidence of recurrence after LRM [10.53% [6/13]] was statistically significant corresponding to that of CRP [46.15% [6/13]] or LM [46.67% [7/15]]. LRM can relieve BPPV within the first weeks that helps in speeding the diagnostic work up with relatively low incidence of recurrence. The significant difference and superiority of LRM over CRP and LM in improvement and recurrence could justify and confirm our suggestion that BPPV is not necessarily due to either cupulolithiasis theory or Canalithiasis theory alone, but both may be combined either sequentially or concurrently along the course of this disease