Comparison of the efficacy of the Epley maneuver and repeated Dix-Hallpike tests for eliminating positional nystagmus: A multicenter randomized study

Takao Imai; Atsuhiko Uno; Akiyuki Yamato; Yasumitsu Takimoto; Go Sato; Kazunori Matsuda; Noriaki Takeda; Suetaka Nishiike; Kayoko Kawashima; Tomoko Iga; Yuya Ueno; Yumi Ohta; Takashi Sato; Takefumi Kamakura; Kayoko Shingai-Higashi; Shinji Mikami; Naomiki Kimura; Takashi Nakajima; Akihisa Tanaka; Hidenori Inohara

doi:10.3389/fneur.2023.1095041

Comparison of the efficacy of the Epley maneuver and repeated Dix-Hallpike tests for eliminating positional nystagmus: A multicenter randomized study

Front Neurol. 2023 Feb 27:14:1095041. doi: 10.3389/fneur.2023.1095041. eCollection 2023.

Authors

Takao Imai^{1

2}, Atsuhiko Uno³, Akiyuki Yamato⁴, Yasumitsu Takimoto^{1

5}, Go Sato⁶, Kazunori Matsuda⁷, Noriaki Takeda⁶, Suetaka Nishiike⁸, Kayoko Kawashima⁹, Tomoko Iga¹, Yuya Ueno¹, Yumi Ohta¹, Takashi Sato¹, Takefumi Kamakura¹, Kayoko Shingai-Higashi¹, Shinji Mikami², Naomiki Kimura², Takashi Nakajima², Akihisa Tanaka², Hidenori Inohara¹

Affiliations

¹ Department of Otorhinolaryngology - Head and Neck Surgery, Osaka University Graduate School of Medicine, Osaka, Japan.
² Department of Otorhinolaryngology - Head and Neck Surgery, Bell Land General Hospital, Osaka, Japan.
³ Department of Otorhinolaryngology - Head and Neck Surgery, Osaka General Medical Center, Osaka, Japan.
⁴ Department of Otolaryngology, Suita Municipal Hospital, Osaka, Japan.
⁵ Takimoto Ear, Nose & Throat Clinic, Osaka, Japan.
⁶ Department of Otorhinolaryngology - Head and Neck Surgery, Tokushima University Graduate School of Biomedical Sciences, Tokushima, Japan.
⁷ Department of Otolaryngology, Tokushima Prefectural Central Hospital, Tokushima, Japan.
⁸ Department of Otorhinolaryngology - Head and Neck Surgery, Osaka Rosai Hospital, Osaka, Japan.
⁹ Department of Otolaryngology, Osaka Habikino Medical Center, Osaka, Japan.

Abstract

Background and objectives: Patients with benign paroxysmal positional vertigo of the posterior canal (pc-BPPV) exhibit BPPV fatigue, where the positional nystagmus diminishes with the repeated performance of the Dix-Hallpike test (DHt). BPPV fatigue is thought to be caused by the disintegration of lumps of otoconial debris into smaller parts and can eliminate positional nystagmus within a few minutes [similar to the immediate effect of the Epley maneuver (EM)]. In this study, we aimed to show the non-inferiority of the repeated DHt to the EM for eliminating positional nystagmus after 1 week.

Methods: This multicenter, randomized controlled clinical trial was designed based on the CONSORT 2010 guidelines. Patients who had pc-BPPV were recruited and randomly allocated to Group A or Group B. Patients in Group A were treated using the EM, and patients in Group B were treated using repeated DHt. For both groups, head movements were repeated until the positional nystagmus had been eliminated (a maximum of three repetitions). After 1 week, the patients were examined to determine whether the positional nystagmus was still present. The groups were compared in terms of the percentage of patients whose positional nystagmus had been eliminated, with the non-inferiority margin set at 15%.

Results: Data for a total of 180 patients were analyzed (90 patients per group). Positional nystagmus had been eliminated in 50.0% of the patients in Group A compared with 47.8% in Group B. The upper limit of the 95% confidence interval for the difference was 14.5%, which was lower than the non-inferiority margin.

Discussion: This study showed the non-inferiority of repeated DHt to the EM for eliminating positional nystagmus after 1 week in patients with pc-BPPV and that even the disintegration of otoconial debris alone has a therapeutic effect for pc-BPPV. Disintegrated otoconial debris disappears from the posterior canal because it can be dissolved in the endolymph or returned to the vestibule via activities of daily living.

Classification of evidence: This study provides Class II evidence of the non-inferiority of repeated DHt to the EM for eliminating positional nystagmus after 1 week.

Registration number: UMIN000016421.

Keywords: BPPV fatigue; canalolithiasis; cupulolithiasis; positional nystagmus; posterior canal.

Grants and funding

This study was supported by a JSPS KAKENHI grant (grant numbers 20K09691 and 21K09560). The organization that funded this study was not involved in the study design, data collection, data analysis, or writing of the manuscript. The corresponding author had full access to the data and final responsibility for the decision to submit this manuscript for publication.