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Original Article

Pak Armed Forces Med J 2015; 65(3):363-66

Benign Paroxysmal Positional Vertigo


Kashif Obaid Khan Niazi, Majid Dastgir*, Muhammad Ashfaq**, Saad Bin Qamar**, Kamran Zamurrad Malik**,
Shadzad Nayyar**
Combined Military Hospital Khuzdar, *Combined Military Hospital Zhob, **Combined Military Hospital Rawalpindi

Objective: The objective is to compare the efficacy of Epleys maneuver and vestibular sedative,
prochlorperazine maleate in the management of benign paroxysmal positional vertigo (BPPV).
Study Design: Randomized Control Trial.
Place and Duration of Study: ENT department, Combined Military Hospital, Rawalpindi from 1st May 2011 to
1st November 2011.
Patients and Methods: After consent, 60 patients of BPPV fulfilling the inclusion criteria were randomly
allotted two groups. Group A was treated with Epleys maneuver (n=30) while group B with
prochlorperazine maleate (n=30). Outcomes were analyzed on disappearance of vertigo at follow-up
Results: 24 (80%) cases managed by Epleys maneuver showed relief of symptoms while only 14 (47%) treated
by prochlorperazine maleate showed recovery after 15 days.
Conclusion: Epleys maneuver was more effective than vestibular sedatives like prochlorperazine maleate in
treating patients of BPPV.
Keywords: Benign Paroxysmal Positional Vertigo, Dix-Hallpike, Epleys Maneuver, Prochlorperazine

positions which induce their symptoms.

Vestibular sedatives like prochlorperazine
maleate (PCPM) are also prescribed for
symptomatic relief which may have central
side effects. Several noninvasive techniques
are advocated to correct the pathology
directly, which include maneuver by Semont
and Epley, both aim at dislodging inorganic
fragments located on the cupula of the
posterior canal or floating in the canall0.

Benign paroxysmal positional vertigo
(BPPV) is characterized by transient episodes
of vertigo associated with nystagmus,
precipitated by changes in head position with
respect to gravity1 . It is the most common
vestibular disease effecting women more
frequently than the men2. It can affect any age
group, with the peak incidence occurring in
the sixties and seventies3. The two main
hypothesis; which explain the development of
BPPV are the cupulolithiasis and canalithiasis
theory, which is based on the presence of freefloating debris in the lumen of the canal which
is the cause of vertigo4. It can be idiopathic
or secondary due to head trauma5,6
vestibular neuronitis menieres disease7 and
Cogans syndrome.

Although, Epleys maneuver (EM) is now

widely practiced and considered very effective
but a trend has been noticed to treat the
disease with medication and moreover, advise
vestibular sedatives following the maneuver.
The purpose of this study was to compare the
efficacy of EM and PCPM in the management
of BPPV so that better treatment modality is
opted and unnecessary medications are
avoided which generally patients observed
using for months.

Although mostly BPPV is self-limiting8

the management has changed dramatically in
the past. Dix-Hallpike test is done to induce
Traditionally, patients are instructed to avoid


Correspondence: Dr Kashif Obaid Khan Niazi,

Graded ENT Specialist, CMH Khuzdar, Pakistan
Received: 13 Jan 2014; Accepted: 03 July 2014


These randomized controlled trials were

conducted at Combined Military Hospital
Rawalpindi from 1st May 2011 to 1 st November
2011 after prior permission from hospital
ethical committee. Sixty patients with BPPV

Benign Paroxysmal Positional Vertigo

Pak Armed Forces Med J 2015; 65(3):363-66

were included using WHO sample size

calculator 2.2a, keeping P1 92%, P2 65%,
power 80% and level of significance 5%.
Informed written consent was taken from all
the patients. The cases were selected after
detailed history and examination. Both males
and females between 25 to 70 years of age
having no hearing loss on pure tone
audiometry were included after being
diagnosed as a case of BPPV by Dix-Hallpike
test on 1st visit. However, patients with
tinnitus, aural fullness, recent head or neck
injury, cervical spondylosis or associated
medical illnesses including Diabetes Mellitus,
Anemia and cardiovascular disorders like
Ischemic Heart Disease, Hypertension,
Carotid artery stenosis and Postural
hypotension were excluded from the study.

start of treatment using visual analogue scale

(1-10) which was as follows:
No vertigo: 0
Mild vertigo: 1-4
Moderate vertigo: 5-7
Severe vertigo: 8-10
The method with absence / reduced
subjective symptom of vertigo was termed as
more effective.
Data analysis was done using SPSS
version 10. The quantitative variables were
described as mean and standard deviation
(SD). Qualitative variables like gender, VAS
scale of vertigo at baseline i.e. 1st day & 15th
day and efficacy of a technique were
presented as frequency and percentage. Chi
square test was used to compare the efficacy
between both groups. A p-value < 0.05 was
considered significant.

Patient was made to sit on a couch.
Examiner held the patients head turned to
450 towards right side and then placed the
patient in a supine position so that his head
hanged 300 below horizontal. Nystagmus or
vertigo was noticed in the patient. Procedure
was repeated for the left side.
Patients were randomly divided into 2 groups
of 30 each using random number table. Group
A was treated with EM.
Epleys maneuver

The mean age in group A was 41.67 7.92
years having minimum age of 28 and
maximum age of 55 years. In group B, mean
age was 42.38 9.897 years, ranging from 26
to 64 years. There were 23 (77%) females and 7
(23%) males in group A and 21 (70%) females
and 9 (30%) males in group B. Both the groups
are comparable with respect to age (p = 0.760)
and gender (p = 0.770).

The examiner waited till the symptoms of

vertigo and nystagmus which appeared on
Dix-Hallpike test, e.g., for right side, subsided.
Then head was turned so that affected ear was
up. The whole body and head were rotated
away from the affected ear to a lateral
recumbent position in a face-down position.
Finally the patient was made to sit in upright
position with head still turned to the
unaffected side by 450. The head was now
turned forward and chin was brought down

Majority of the patients presented with

moderate vertigo initially i.e. 53% in group A
and 47% in group B while 37% patients in
group A and 40% in group B had severe
vertigo. Only 10% patients in group A and
13% in group B presented with mild vertigo
on 1st day as shown in Fig-I. (p = 0.852)

While group B was treated with PCPM (5

mg) 1 tablet thrice daily.

In group A, only 6% patients remained

with severe vertigo and in group B 13%
remained with severe vertigo as shown in
figure 2. The proportion of patients with
moderate vertigo was also very high in group
B (23% vs 3%) in comparison with patients in
group A (p = 0.036)

There was significant difference between

cure rate of treatment groups after 15 days of
treatment. In group A, the complete cure rate
was significantly higher as compared with
group B i.e. 80% vs. 47% (p = 0.028)

The patients were examined on 15th day.

The results of the study were decided on the
basis of reduction / absence of vertigo on
repeating Dix-Hallpike test on 15th day of the

Benign Paroxysmal Positional Vertigo

Pak Armed Forces Med J 2015; 65(3):363-66

totally symptom free at the end of two weeks,

who were treated by the maneuver.

The symptoms of BPPV are very
disturbing and can be disabling. Patients
affected can become so alarmed by the
symptoms that they do not get out of bed or
carry out their daily activities11, 12 and may
confuse it with stroke. Some present with
these symptoms to their primary care


Different studies revealed that disease

was more common in 41 to 60 years of age2. In
another study it was found that idiopathic
BPPV is prevalent in the sixth decade while
post viral are common in the fourth and fifth
decades14. In Brandts series, BPPV was
considered as very common in elderly
patients, especially around age 70 years; at
this age, 30% of cases had presented this
disease at least once15,16.
In our study it was found that the mean
age of patients was 41.67 with a SD of 8.879.
The minimum age was 26 while maximum
was 64 years. The results show that majority
of patients were in the age interval of 40 to 52






Figure-1: Comparison of vertigo on 1st

day between both groups.

Treatment of vertigo is 6080% effective

with EM. Chronic drug administration has no
role in the management of BPPV17,18. Watchful
waiting or vestibulosuppressant medication is
being used as the first line treatment measure
in most of the cases. Although the condition
resolves without treatment, watchful waiting
involves weeks or months of discomfort and
vertigo with the danger of falls and other

Figure-2: Comparison of vertigo on 15th

day between both groups.
compliance with other studies conducted in
different settings. A study conducted in USA
showed a higher rate of success for the
treatment of BPPV. According to this study
the efficacy was 93.4%. All these patients
completely recovered from vertigo after

Although EM requires a little bit of time

to be spent with the patient but it is costeffective and rids the patient immediately of
the troublesome vertigo after a single therapy.
It addresses the underlying cause of positional
vertigo by repositioning of the offending
particles back to the utricle19,20. EM doesnt
bear any major complications or side effects
and can be repeated if required.

A randomized clinical trial conducted in

Royal United Hospital, UK proved that
patients who received the EM were more
likely to have complete resolution of their
symptoms (odds ratio 4.92) and more likely to
convert from a positive to negative DixHallpike test with odds ratio of 5.67.22.

Our results suggest EM to be a highly

effective single treatment approach towards
BPPV as 80 % of our patients were found to be

Vestibulosuppressant medication on the

other hand does not address the underlying
cause although it may provide temporary
relief for some patients by masking the

Benign Paroxysmal Positional Vertigo

Pak Armed Forces Med J 2015; 65(3):363-66


symptoms. These medicines are not free of

side effects and may itself cause dizziness and
sleepiness. From the literature some studies
have shown effectiveness against the vertigo.
The efficacy of PCPM in a clinical trial was
noted to be 64.5% along with head exercise,
but in 11 % patients adverse effects were





In the present study out of 30 patients

treated with PCPM only 47% patients become
completely free of symptoms of vertigo which
is significantly less efficient than EM.




EM is a non invasive and very effective

procedure for the management of BPPV which
can be performed in the office and gives
immediate results without any fear of
complications. Moreover, it is highlighted that
the custom of advising vestibular sedatives to
patients of BPPV should be curbed.






The authors of this study reported no

conflict of interest.







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