Short-term outcomes of benign paroxysmal positional vertigo with and
without sudden sensorineural hearing loss: a retrospective study
Abstract
Objectives: This study aimed to investigate the outcome of adults with
benign paroxysmal positional vertigo(BPPV)secondary to sudden
sensorineural hearing loss(SSNHL).
Design: Retrospective study
Setting: removed for blind peer review
Participants: Six-four adults with BPPV secondary to SSNHL and 328
adults with idiopathic BPPV were included.
Main outcome measures: All participants were identified and categorized
by using the Dix-Hallpike test and roll test, followed by canalith
repositioning procedures (CRPs) that were repeated 2 to 3 times.
Assessment of the outcome was conducted one-hour and one-week post-CRPs,
respectively.
Results: The posterior canal was the most affected in both groups. At
one-hour posttreatment, the cured rate of the BPPV with SSNHL group was
45.31%, which was significantly lower than that of the i-BPPV group
(94.82%, P<0.01). At one-week posttreatment, the cured rate
of the BPPV with SSNHL group was 66.67%,which was significantly lower
than that of the i-BPPV group (98.78%, P<0.01). In the BPPV
with SSNHL group, the cured rate of 1 hour post-CRPs was 45.31%, which
was significantly lower than that of 1 week post-CRPs(65.63%,
P<0.05).
Conclusions: BPPV with SSNHL was associated with poorer outcomes than
i-BPPV in the short term.
Key words:Benign paroxysmal positional vertigo, Sudden sensorineural
hearing loss, Outcome
Keypoints
1.We retrospectively analysed the effectiveness of CRPs in SSNHL and
i-BPPV patients.
2. All patients received sufficient CRPs, and the cured rate was an
indicator of their effectiveness.
3.Sufficient CRPs meant that during one outpatient service, we perform
CRPs unti typical positional nystagmus disappeared. If the symptoms
remained, we performed CRPs a maximum of 3 times.
4. The BPPV with SSNHL group was associated with poorer outcomes than
the i-BPPV group 1hour and 1week post-CRPs.
5. The cured rate was significantly improved without repeated CRPs after
one week of medication in the BPPV with SSNHL group, which suggested
that repeated CRPs might not be necessary for patients with poor
effectiveness of BPPV with SSNHL.
1.Introduction
The prevalence of sudden sensorineural hearing loss (SSNHL) ranges from
5 to 27 per 100,000 people1. Meanwhile, the prevalence
of benign paroxysmal positional vertigo (BPPV) is 10.7
~140 per 100,000 people annually2.
Vertigo is reported in 30 to 40% of SSNHL cases and leads to the poor
prognosis of SSNHL3,4, while 8.8 to 12.7% of patients
with SSNHL present with BPPV5. SSNHL with vertigo
occurs in many kinds of specific disease conditions, and BPPV is the
most common type of vertigo, and can be effectively treated by canalith
repositioning procedures (CRPs)2,6. However, some
studies have shown that BPPV with SSNHL has different clinical
characteristics from idiopathic BPPV (i-BPPV)7,8. BPPV
with SSNHL is very problematic, and it has a prolonged
course9. In addition to these characteristics, on
caloric testing, more canal paresis was present in the BPPV with SSNHL
group10. Recent studies on BPPV with SSNHL focused on
the effectiveness of CRPs by comparing the number of CRPs, and these
studies treated BPPV with CRPs and improved hearing loss by medication
at the same time3,7,10,11. We found that it took
longer to achieve successful repositioning, and these studies ignored
the effects of medicines on the duration of treatment. This study aimed
to review the clinical characteristics of adults with BPPV and SSNHL and
to compare them with those of i-BPPV adults. Moreover, we explored the
effectiveness of medication treatment without repeated CRPs.
2.Materials and Methods
2.1 Participants
We retrospectively analysed 64 patients with BPPV and SSNHL and 328
patients with i-BPPV between January 1, 2016, and February 26, 2019, at
the Department of Otolaryngology, removed for blind peer review.
2.2 Audiological Examinations
Patients with BPPV secondary to SSNHL received additional measurements,
specifically pure-tone audiometry(Madsen Astera)and tympanometry(Madsen
Zodiac 901). Patients with SSNHL were divided into three types according
to their hearing loss: mild and moderate hearing loss
(26~60 dB HL), severe hearing loss(60~80
dB HL), or profound hearing loss (>80 dB HL).[12]
2.3 BPPV Specific Assessments
All patients completed a medical history and neurotologic test,
including video electronystamography (ICS Chartr 200) and positioning
tests (such as the Dix-Hallpike test and the roll test). We divided
patients into two groups:the i-BPPV group and the BPPV with SSNHL group.
The clinical characteristics of i-BPPV are typical BPPV-related
nystagmus without inner ear disease or any other abnormal neurotologic
findings13. The patients had unilateral sensorineural
hearing loss(SNHL) that occurred suddenly within a 72-hour window, and
the audiometric criterion was a decrease in hearing greater than or
equal to 20 dB, that affected at least two consecutive
frequencies14. Patients with additional established
diseases, such as Meniere’s disease, labyrinthitis, vestibular neuritis,
vestibular migraine, superior semicircular canal dehiscence syndrome,
posterior circulation ischaemia, postural hypotension, and central
paroxysmal positional vertigo, were excluded from this study.
The involved semicircular canal was confirmed by positioning tests in
all patients, which determined the manoeuvres used in canalith
repositioning. If the typical positional nystagmus did not disappear or
decrease after CRP, we would perform sufficient CRPs, up to maximum of 3
times15. All patients with SSNHL had medication
according to the clinical practice guidelines: sudden sensorineural
hearing loss (2015) by the Chinese Academy of Otolaryngology-Head and
Neck Surgery(The guidelines referred to the German guidelines for sudden
idiopathic sensorineural hearing loss (2004) and the USA guidelines for
sudden hearing loss(2012)).
The outcome used two grades: cured and uncured, which were evaluated at
1 hour and 1 week after the initial CRPs.
2.4 Statistical analysis
We employed statistics for independent groups with a threshold ofp <0.05, using SPSS statistical software for Windows,
version 21.0 (IBM, Armonk, NY). χ2tests were used to
determine the association between categorical variables. Statistical
significance was set at p <0.05.
3.Results
3.1 Comparison of effectiveness between two groups at 1hour post-CRPs
and 1week post-CRPs
Based on the inclusion criteria, we recruited 64 patients with BPPV
secondary to SSNHL and 328 patients with i-BPPV (Table 1). The two
groups were both slightly female dominant, and sex distributions were
not different between the BPPV with SSNHL and i-BPPV groups. However,
the age of the two groups was significantly different
(p <0.001). The percentage of patients with profound
hearing loss was the highest, and patients with profound or severe
hearing loss made up the majority (Figure 1). Comparing the
effectiveness of CRPs 1 hour after treatment by χ2test(Fig 2), there was a significant difference between the BPPV with
SSNHL group and the i-BPPV group (p <0.001). Comparing
the effectiveness of CRPs 1 week after treatment by Fisher’s exact test
(Figue 3), there was a significant difference between the BPPV with
SSNHL group and the i-BPPV group (p <0.001).
3.2 The effectiveness of CRPs at 1 hour and 1 week after treatment
Comparing the effectiveness of CRPs 1hour and 1week after treatment with
CRPs with a χ2 test for trends, there was a
significant difference (p =0.021), (Figure 4).
4. Discussion
SSNHL is often associated with vertigo, and BPPV is one of the common
causes of vertigo in patients with SSNHL9. BPPV is due
to the detachment of the otolith from the utricle, which can be
effectively treated by canalith repositioning procedures
(CRPs)6. However, the cause of detachment is still
unclear. In our study, we found that most of the patients in the BPPV
with SSNHL group had severe or profound hearing loss, which was
consistent with published studies10,16,17. SSNHL with
severe or profound hearing loss is often associated with vascular
causes13. This suggests that the aetiology and
pathophysiology of BPPV with SSNHL is mainly related to vascular
factors.
In our study, there was no difference between the two groups in terms of
sex composition or involved semicircular canal type, only in terms of
age. Junghee Yoon reported that age >50 years was one of
the risk factors associated with the effectiveness of
CRPs18. However, although the mean age of the BPPV
with SSNHL group was younger than 50 years and that of the i-BPPV group
was older than 50 years, the effectiveness of CRPs in the BPPV with
SSNHL group was worse than that in the i-BPPV group. Other studies have
also shown that BPPV with SSNHL is often
intractable7,8,10. Although we found that the CRPs
were valid for the BPPV with SSNHL and i-BPPV groups, the effectiveness
of the CRPs in the BPPV with SSNHL group was significantly worse than
that in the i-BPPV group. This result suggested that BPPV with SSNHL was
caused not only by the detachment of otoliths but also by other reasons.
Some studies might help explain this phenomenon. Kim(2014) showed that
blood debris in the endolymph due to inner ear haemorrhage was one of
the causes of BPPV in patients with ipsilateral
SSNHL19, and CRPs were ineffective in this kind of
patient. Gacek (2003) proposed a pathophysiological mechanism for BPPV
that included loss of the inhibitory effect of the otolith organs on the
canal sense organs by studying five temporal bones from patients with
BPPV, and atlthough these patients had symptoms of BPPV ,there was no
detachment of the otoliths20. Both of the
abovementioned hypotheses could lead to the failure of CRPs. Therefore,
we deduced that the above multiple reasons caused BPPV with SSNHL.
Studies have shown that the number of CRPs needed to treat BPPV with
SSNHL was greater than that needed to treat
i-BPPV3,10,16. In these studies, CRPs were usually
conducted every 2 to 3 days, which meant that repeated CRPs eventually
cured BPPV with SSNHL in one or two weeks. Moreover, upon completion of
the treatment, all patients with SSNHL received medication for hearing
loss. In our study, patients did not receive repeated CRPs between the
two evaluations;they only received medication for hearing loss. We found
that the cured rate was significantly improved without repeated CRPs
after medication for one week in the BPPV with SSNHL group. We chose the
cured rate rather than the effective rate for comparing the
effectiveness of CRPs 1 hour and 1 week post treatment between two
groups because the typical positional nystagmus(TPN) in many patients
had decreased but not disappeared at 1 hour post-CRPs and TPN
disappeared at 1 week post-CRPs. These results suggested that medication
might be one of the choices that could improve the cured rate of
intractable BPPV with SSNHL, similar to repeated CRPs.
5. Conclusion
The clinical characteristics of BPPV with SSNHL are similar to those of
i-BPPV, while BPPV with SSNHL is associated with poorer outcomes than
i-BPPV in the short term. The cured rate was significantly improved
without repeated CRPs after 1 week of medication in the BPPV with SSNHL
group. Thus, due to adverse reactions such as vertigo, vomiting, and
hyperventilation during CRP, and its high cost, it might be
cost-effective to take medication after the initial CRPs and not
repeating CRPs in the first week for BPPV with SSNHL.
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