http://orcid.org/0000-0003-3064-8310
Abstract
Background: Horizontal canal BPPV (HC-BPPV) has a higher recurrence rate than PC-BPPV. Which maneuver is better for its prognosis is still uncertain.
Objective: To compare the long-term recurrence rate after Gufoni and Barbecue maneuver.
Materials and methods: We prospectively collected 61 cases of HC-BPPV which were initially diagnosed in our hospital from the first episode, and had already ruled out other diseases. Roll them into Gufoni group and Barbecue group alternatively. After the maneuver, we followed them up until December 2016. Mean follow-up time was 49.25 months.
Results: The recurrence rate is 18.0% in the first year, 14.8% after the first year, and 31.1% overall. There is no statistically significant difference between Gufoni group and Barbecue group (p > .05). Age is statistically significant as a risk factor of recurrence (p<.05).
Conclusions and significance: Barbecue maneuver is as good as Gufoni maneuver. The recurrence rate is only related to age. We suggest the disease relapsed within the 1st year as recurrence rather than a new disease.
Chinese abstract
背景：水平管良性阵发性位置性眩晕（HC-BPPV）的复发率高于PC-BPPV。哪种方式对其有更好的预后尚不确定。
目的：比较Gofani术和烧烤术后的长期复发率。
材料与方法：我们前瞻性地收集了61例HC-BPPV患者, 这些患者从发病开始就在我院得到初步诊断, 并且已经排除了其他疾病。把他们分为Gufoni组和烧烤组。治疗结束后, 我们一直随访到2016年12月。平均随访期为49.25个月。
结果：第1年复发率18.0%, 1年以后的复发率14.8%, 总复发率31.1%。Gufoni 组与烧烤组之间的差异无统计学意义（p>0.05）。年龄作为复发的危险因素, 具有统计学意义（p<0.05）。
结论及意义：烧烤法和Gufoni法效果相当。复发率只与年龄有关。我们认为该病在1年内复发, 而不是作为一种新的疾病出现。
Introduction
Benign paroxysmal positional vertigo (BPPV) is the most common kind of vertigo in out-patient. Vogel [Citation1] was the first to report that horizontal semicircular canal was a possible site of BPPV. Subsequent studies confirmed the existence of BPPV in the horizontal semicircular canal [Citation2]. Horizontal canal BPPV (HC-BPPV) is about 10–30% of total BPPV [Citation3], which is fewer than posterior canal BPPV (PC-BPPV), and has a higher recurrence rate than PC-BPPV [Citation4]. It has been reported that BPPV may occur after even slight head trauma [Citation5]; but mostly in PC-BPPV, very rare in HC-BPPV [Citation6].
Canalith-repositioning maneuver (CRM) is safe and effective for the treatment of BPPV. There are no other side effects except dizziness and symptoms of the vegetative nervous system. Persistent nystagmus has occasionally been reported after restoration, but it can be rapidly alleviated [Citation7]. Brandt-Daroff exercise method and repeated CRM are recommended for the cases of CRM failure; while drug therapy is only auxiliary [Citation8] and they all have no impact on the recurrence rate [Citation9].
Thus, various effective CRMs were widely studied and discussed [Citation10,Citation11]. There are also some studies which explored new CRMs, but the effectiveness did not increase significantly [Citation12]. After treatment, there are still cases of recurrence months or years after CRM therapy. Gufoni method was reported to have lower recurrence rate than Barbecue method [Citation11,Citation13]. However, it was also reported that the long-term efficacy of these two maneuvers is comparable [Citation14]. Till now, which maneuver is better for prognosis is still uncertain. We designed this prospective study to compare the long-term recurrence rate after Gufoni and Barbecue maneuver.
Methods
Participants
We prospectively collected outpatients who first diagnosed HC-BPPV under videonystagmography (VNG) in our hospital from July 2011 to December 2014.
All patients have undergone otoneurotologic examination, cranial MRI, pure tone audiometric test, VNG viewing and recording (including Dix–Hallpike and Supine Roll test) without medication for at least three days before test, and fulfilled the detailed history questionnaires. All candidates were informed with a informed consent following all the guidelines for investigation with human subjects required by Ethics Committee of our hospital. The patients who agreed to sign it were included in the study. After the history taking, physical examinations and tests, some patients were excluded (). Sixty-two patients who agreed to do the treatment and signed the informed consent are investigated, including one who lost to follow-up for unknown reasons. The final number of participants is 61.
Table 1. Symptoms and/or signs and/or diseases that were excluded.
The sample size of 61 participants would give a power of 0.72 to detect a hazard ratio of 0.6 when comparing the Barbecue group to the Gufoni group.
Grouping and follow-up
The patients were alternatively divided them into the Gufoni method group and the Barbecue method group, according to the sequence of reaching vestibular examination. Gufoni method group were odd numbers, and Barbecue method group were even numbers. The Gufoni method was conducted to rapidly bent the trunk of patient towards the healthy side, followed by a quick rotation of the head downwards to look at the floor. Then maintain this position for at least 1 min before change to the sitting position. The Barbecue method was conducted to rotating the supine patient for 360°from the involved side to the healthy side, the head and back of which is asked to maintain the 30° angle all the time during the maneuver. These two CRM were all conducted in continuously two times by the same experienced doctor.
We followed up until the end of 2016. One patient lost to follow-up for unknown reasons. Other patients were followed for a period of 24–65 months.
We instructed all participants to quickly come back to our department to re-exam if they feel things around are rotating again. If we found the same nystagmus, we repeated to do the same maneuver again and recorded. We checked the follow-up of patients by telephone at the time point of one week, 3 months, and every 12 months after the first CRM. Finally, all patients were phone contacted one last time in December 2016. If patients did not complain about vertigo and we did not find nystagmus we take them as no recurrence. One patient who was suspected of having relapsed but recovered the same day by himself was not taken into account, because it was not confirmed.
Statistical analysis
Statistical analysis was performed using Med Calc v13.0. The recurrence rates were obtained for Gufoni group and Barbecue group, and the difference between the two groups was tested using one-way analysis of variance and Fisher’s exact test. Cox proportional hazards regression was used to compare between the two groups and to evaluate influence from relevant factors. p Values <.05 were considered as statistically significant.
Results
General data
The Gufoni method group (Gufoni group) has 33 patients, and the Barbecue method group (Barbecue group) has 28 patients. Patients were followed for a period of 24–65 months; average follow-up time is 49.25 months (216.89 weeks).
Patient characteristics: 19 male and 42 female, sex ratio 1:2.2. The average age is 50.95 (19–74) years old. Right ear HC-BPPV 27 cases, left ear 34 cases, side ratio 1:1.3, left side is slightly more than the right side. There is no bilateral HC-BPPV.
Comparison between Gufoni and Barbecue groups
The recurrence rate is 18.0% in the first year, 14.8% after the first year, and 31.1% overall. The recurrence rates between Gufoni group and Barbecue group are not statistically significant (p > .05; ).
Table 2. Descriptive data.
Hazard ratios of risk factors
Among the potential risk factors, the recurrence rate of HC-BPPV is only related to age (p<.05). The risk of recurrence increased with aging. There is no statistical significance between Gufoni group and Barbecue group ().
Table 3. Hazard ratio (HR) from Cox regression analysis.
Discussion
All the patients in our study are instructed with the postural restriction (avoid sudden head movements and lying on their affected side) in at least three days after the CRM, in order to prevent canalith from going back to the affected canal. There are some reports that show postural restrictions appeared significant as a post-treatment instruction [Citation15], while some others show it did not affect the outcomes of CRM, as well as the recurrence rate [Citation16].
There are also some reports about canal conversions after reposition. But there is no such conversion in our 61 cases; maybe because the PC-BPPV is more likely to convert than HC-BPPV [Citation17]. It is also reported that Gufoni group had more canal conversions than Barbecue group [Citation11], this may be due to the unsteady way of lying down and up during the Gufoni maneuver. However, the number is too small to draw any conclusion.
The recurrence rate in our research is similar to other reports [Citation18], but we have not found any significant differences between Gufoni group and Barbecue group. It is reported that Gufoni method is superior to Barbecue method in rapidly relieving symptoms, but the long-term efficacy is comparable [Citation14]. It is also reported that the recurrence rate of Gufoni method is lower than Barbecue method [Citation13]. But their follow-up time is no longer than three months.
It has been reported that the days of natural remission in BPPV was 39 days for PC-BPPV and 16 days for HC-BPPV [Citation3]. This outcome is also similar to our daily work, about 45 days for PC-BPPV, but we lack the statistics for HC-BPPV. Therefore, the spontaneous remission of the HC-BPPV was faster, which was not conducive to determining the efficacy of effect in the short term, and doctors should be aware of this when taking the vertigo history. This is one reason why we divided the results of follow-up into the first year and after the first year in order to observe the difference between short term and long term. Furthermore, if the patient is naturally remissed, they will usually relapse within one year according to our usual experience. That was why we set the time point one year as the dividing line of short term and long term.
Another reason we divided the results of follow-up into short term (less than one year) and long term (longer than one year) is due to the different mechanism of recurrence. In long term, the recurrence may be more impacted by systematic disorders like vitamin D deficiency, while in short term it may be due to the maneuver failure. So, we considered the disease relapse within the 1st year as recurrence rather than a new disease. There are no significant differences between Gufoni group and Barbecue group in both short and long terms in our finding.
On the other side, we want to mention about keeping the 30°angle between the patient’s head and back all the time during Barbecue maneuver. Especially for the overweighted, who has thick fat pad on the back of the neck, so it is hard to make the right angle to keep the horizontal canal in vertical during the Barbecue maneuver, which may lead the Barbecue maneuver less effective than it should be. This may be the reason why we found our Barbecue group is as good as Gufoni group.
Furthermore, we found the recurrence rate is only related to the age, which is similar to other reports [Citation5]. Disorders of the central nervous system such as cerebellar nodule infarction can cause positional nystagmus [Citation19]. Thus, we examined patients with wide methods to exclude all possible intracranial factors, so the age of our patients was relatively young. Some reports emphasized that age is the biggest risk factor of BPPV in the Chinese population [Citation20]. However, there are also reports stated that BPPV did not correlate with age [Citation18]. Age may influence the recurrence as it is related to lack of calcium or vitamin D, hyperglycemia or hyperinsulinemia. These factors may also be related to age. So it will be better to take these factors into account as independent factors in the future study.
Author contributions
HZ, SL, MD, and QD design the study. HZ, QD and CQ conceived the study, participated in its design and coordination. MD, QD, and YL performed the statistical analyses. HZ, QD, SL, and MD drafted the manuscript.
Disclosure statement
The authors report no conflict of interest.
Additional information
Funding
References
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