Online Journal Club-Article Review
Article Citation
Study Objective/Purpose
(hypothesis)
Brief Background (why issue is important;
summary of previous literature)
Study Design (type of trial, randomization,
blinding, controls, study groups, length of
study, follow-up)
9.12.12
Background/Overview
Benign Paroxysmal Positional Vertigo Associated With Meniere's Disease: Epidemiological,
Pathophysiologic, Clinical, and Therapeutic Aspects. Dimitrios G. Balatsouras, MD; Panayotis Ganelis,
MD; Andreas Aspris, MD; Nicolas C. Economou, MD; Antonis Moukos, MD; George Koukoutsis, MD.
Annals of Otology. Rhinoiogy & Laryngology . 2012. 121(10):682-688.
The purpose of the study was to examine the demographic, pathogenetic, and clinical features of
benign paroxysmal positional vertigo (BPPV) associated with Meniere's disease and determine
whether this presentation varied from persons with idiopathic BPPV without a history of Meniere’s
disease.
BPPV is a common cause of vertigo and is the most frequent condition diagnosed at outpatient
neurotology clinics. It is characterized by transient vertigo experienced with rapid changes in head
position which is accompanied by a characteristic paroxysmal positional nystagmus. There are two
basic types of BPPV, either of which can occur in the three semicircular canals (anterior, posterior,
horizontal) within the inner ear. Canalithiasis is the most common type; it occurs when particles called
otoconia become dislodged from their central location and free-float in one of the semicircular canals
(SCC). The other type, cupulolithiasis, occurs when the otoconia attach to an area of the affected
canal called the cupula. Both types cause vertigo when the head is moved into a provoking position
and can cause imbalance, nausea and motion sensitivity as well. The treatment involves mechanical
repositioning of the head in specific positions to guide the otoconia out of the canal. The specific
treatment techniques vary depending on the type and canal involved.
BPPV typically occurs spontaneously, but its prevalence increases with age and it may occur
secondary to various other conditions, including head trauma, prolonged bed rest, viral
neurolabyrinthitis, Meniere's disease, and/or vertebral-basilar ischemia. Although there are findings
in the literature to support increased incidence of secondary causes, few studies have investigated
this relationship.
Methods
Retrospective review of 29 medical records of persons with Meniere’s disease which were selected
out of 345 patients seen in an outpatient neurotology unit over the course of 5 years. The clinical
findings of these persons were compared to 233 patients with idiopathic BPPV.
Target Population (dx, acuity,
inclusion/exclusion critieria)
Interventions (if applicable):
(specificity of interventions, ability to
replicate, frequency, duration)
Outcome Measures (relevant to purpose of
the study; reliable, valid, clinical utility)
Statistical Analysis (statistics used,
appropriate application)
Enrollment/Subject Characteristics (sample
size, gender, age, functional level; were
groups similar on important variables prior to
application of the intervention)
The target population was persons treated in the outpatient neurotology unit with a confirmed
diagnosis of Meniere’s disease based on the guidelines of the American Academy of OtolaryngologyHead and Neck Surgery (AAO-HNS). The control group included persons treated at the same clinic
during the same five year window that were diagnosed with idiopathic BPPV. Patients hospitalized
during the study period with an acute exacerbation of Meniere’s disease were excluded.
All patients reviewed received the Dix-Hallpike maneuver and the supine Roll test; both of which are
used to assess for the presence of BPPV. Posterior SCC BPPV was the most common and was treated
by the modified Epley canalith repositioning procedure. Horizontal SCC BPPV was treated by the
barbecue maneuver or the Gufoni maneuver. In some cases, more frequently in the control group,
one treatment maneuver may have remediated the BPPV. When symptoms remained, the same
repositioning maneuvers were performed every 2 or 3 days, up to a maximum of 7 sessions. The
treatment was considered successful once the patient was symptom-free for two months and tested
negative for the Dix-Hallpike maneuver and supine Roll test. When symptoms re-occurred the same
procedure for assessment and interventions was performed.
The only measurement tool mentioned was a nominal scale from 1-3 used to evaluate the severity of
the vertiginous symptoms. The scale was described as follows: 1 — slight vertigo in the provoking
position without autonomous symptoms; 2 — severe vertigo with nausea; 3 — severe vertigo with
severe nausea, vomiting, or hypotension. This scale appears to be unique to this study.
The researches described the prevalence of continuous variables as mean ±
SD. Categorical variables were expressed as frequencies and percentages. The significance of
differences between groups was evaluated by t-test for independent samples. The x2 test was used to
evaluate any potential association between categorical variables. The researchers used the Fisher
exact probability test for comparisons with small samples. Odds ratios and 95% confidence intervals
were calculated to estimate intervention results.
Results
This retrospective study found 29 persons with Meniere's disease in a group of 345 persons with BPPV
(8.4%). The mean age was 55.6 + 9.5 years old in the study group with a range of 37-74 years of age.
The mean in the control group was 53.1 + 9.9 years old; range 25-86 years of age. The gender was
predominately female in the study group (93.1% vs 6.9% male). The difference in gender was not as
prevalent in the control group (59.2% female vs 40.8% male). This study, as well as several others
cited, found that almost all patients had BPPV in the same ear as their Meniere's disease. This finding
led researchers to describe a causal relationship between these two conditions. Some explanations
for this finding include the theory that the presence of endolymphatic hydrops may result in
destruction of the maculae of the utricle and saccule, from either compromised vascular supply or
2
Summary of Primary and Secondary
Outcomes (include aggregate and sub-group
findings if reported); note results that were
statistically significant; How many reached a
level of clinical significance (exceed MCID if
known); Was there retention of changes
following intervention (if studied)
Brief Summary of Authors’ Main Discussion
Points; Authors’ Conclusion
Study Strengths
Study Limitations and
Potential for Bias
detachment of otoconia increasing the prevalence of BPPV. This theory is strengthened by the finding
that those with advanced Meniere’s, who are more likely to have these structural changes, were more
likely than those in the beginning stages to have secondary BPPV.
Statistically significant differences in the study group, as compared to the idiopathic BPPV group,
were found for several variables. These included: female gender, increased duration of symptoms,
and more frequent involvement of the horizontal SCC. Furthermore, canal paresis also occurred at a
higher rate in the study group (p <0.005): 17 patients (58.6%); compared to 19 persons (24.3%) in the
control group. The final rates of treatment success were similar between the two groups but the
persons in the study group required more therapy sessions for successful treatment of BPPV. Only
20.7% had resolution of symptoms with one treatment intervention compared to 78.5% in the
control. Furthermore, the recurrence rate was significantly higher in the study group (44.4% vs 13.3 in
the control group; p< 0.001.
Authors’ Discussion and Conclusions
This study is in agreement with previous studies finding that there is an increased incidence of BPPV
in persons with Meniere’s disease and that the course of the condition varies from idiopathic BPPV in
its epidemiology and disease course.
Reviewer’s Discussion and Conclusion
The study did a great job of describing secondary BPPV in persons with Meniere’s disease and how
these patients often differ from those with idiopathic BPPV. The description of the medical
assessment for both the study and control groups was sound. The assessment and treatment of BPPV
was also thorough and followed current practice guidelines for this patient population. The findings
are conclusive for the specific patient population described and may provide useful considerations
when treating persons with Meniere’s disease.
The sample was a sample of convenience, reviewing persons with BPPV and Meniere’s disease who
were all treated at the same out-patient neurotology unit. The use of an outcome measure such as
the Dizziness Handicap Inventory would have been helpful to measure pre and post intervention
subjective reports of dizziness and participation limitation. Finally, the study did not specify the type
of BPPV for anterior or posterior canal; only for horizontal canal BPPV. Because the types are often
treated with different interventions this information would have been useful.
Applicability:
 Types of patients (dx) that results apply to Persons with Meniere’s disease being seen on an out-patient basis; excluding those with an acute
 Types of settings or patient acuity that the flare. The results of this study cannot be extrapolated to those with an acute flare of Meniere’s
disease.
results apply to
3

Can interventions be reproduced? Can
results be applied to other pt
populations?
How will study results impact PT
management of this patient population?; List
suggestions for how to implement changes in
your clinic/department to integrate study
findings into patient care
Interventions can easily be reproduced as the assessments and interventions described used are
commonly used. The results may apply to persons with Meniere’s in other settings, as long as they are
not experiencing an acute attack, but cannot be generalized to persons found to have BPPV as a
secondary diagnosis to a condition other than Meniere’s disease.
Because the incidence of BPPV in the study population was higher than the control group, clinicians
should more frequent screening for BPPV in persons with Meniere’s disease. Because the incidence of
horizontal canal BPPV was higher in the study group than in the control the Roll test should always be
used to screen for BPPV, not just the Dix-Hallpike. Also, the persons in the study with Meniere’s
disease who also had BPPV required increased treatment time for resolution of symptoms and tended
to have more frequent reoccurrence. This knowledge should influence the treating therapist educate
the patient better about what to expect for the treatment course and influence the plan of care.
4