A Pilot Study Using Intratympanic Methylprednisolone for Treatment of Persistent Posterior Canal Benign Paroxysmal Positional Vertigo

Abstract

OBJECTIVE:To assess the effect of intratympanic methylprednisolone (ITMP) in posterior canal benign paroxysmal positional vertigo (BPPV) that fails treatment involving repositioning maneuver in a case series. MATERIALS and METHODS:Nine patients with persistent posterior canal BPPV after 6 or more repositioning maneuvers were treated by ITMP (two weekly doses of 0.3-0.4 mL at 40 mg/mL) before repeating the repositioning procedures. RESULTS:Following ITMP treatment, 7 out of 9 patients were relieved of their symptoms and did not exhibit positional nystagmus after 1 or 2 repositioning maneuvers. The number of positional maneuvers performed before and after ITMP treatment in these 7 patients showed a statistically significant (p=0.016) reduction in the amount of repositioning treatments required. None of the 7 respondent patients showed any relapses during the follow-up period (follow-up range: 11-95 months). CONCLUSION:Administering ITMP before resuming repositioning procedures can be a useful treatment for persistent BPPV of the posterior canal. Intratympanic (IT) steroids are often used to treat inner ear disorders such as sudden idiopathic sensorineural hearing loss, autoimmune hearing loss, and Ménière's disease [14] . Corticosteroids exert their effects in the inner ear after interacting with intracellular glucocorticoid receptors by producing metabolic and anti-inflammatory effects. It is also known that glucocorticoid receptors are widespread throughout the inner ear, including semicircular canal duct epithelial cells, where they facilitate cation absorption via sodium channels [15][16][17] . KEYWORDS:Thus, considering the possibility of an inflammatory process of the labyrinth or an imbalance of Na + and Ca 2+ in the endolymph could be related with the intractability of BPPV, we have carried out a pilot study to assess the effect of IT methylprednisolone (ITMP) in persistent posterior canal BPPV. MATERIALS and METHODSThis prospective study included patients from 3 different hospitals. From January 2006 to March 2014, we diagnosed 187 patients affected from unilateral posterior canal BPPV. None of them had any symptoms or signs of central nervous system (CNS) disease. A complete otoneurological examination, including otoscopy, audiometry, head thrust test, spontaneous nystagmus recording, gaze-evoked nystagmus test, cover test, and Romberg and Fukuda tests, were performed in all the cases.The diagnosis of posterior canal BPPV was made by Dix-Hallpike test, showing a mixed vertical and torsional nystagmus beating toward the undermost ear, with appropriate latency and duration, and the direction of the nystagmus reversed on resuming the upright position. In every patient, the roll test and head hyperextension test were also performed in order to rule out lateral or superior canal BPPV.Patients with BPPV were treated by Epley or Semont maneuvers. We carried out only one of those maneuvers in every session. Each session, weekly programmed, began with a Dix-Hallpike test; if it was positive for the same posterior...

Review of the pathology underlying benign paroxysmal positional vertigo

“…Pérez et al. 86 reported successful intratympanic methylprednisolone treatment in seven of nine patients with persistent posterior canal BPPV. Amor-Dorado et al.…”

“…The results were significant, suggesting alternative pharmacological treatment. P erez et al 86 reported successful intratympanic methylprednisolone treatment in seven of nine patients with persistent posterior canal BPPV. Amor-Dorado et al 87 found that the incidence of BPPV among 59 patients with ankylosing spondylitis was low (10%).…”

Effect of the novel histamine H4 receptor antagonist SENS‐111 on spontaneous nystagmus in a rat model of acute unilateral vestibular loss

“…A wide range of agents are available, with the antihistamine meclizine (H 1 receptor antagonist) being widely prescribed for many conditions associated with vertigo and to manage motion sickness (Hain, 2017). Various steroids have also been advocated for vertigo‐associated pathologies and methylprednisolone improved recovery of peripheral vestibular function in patients with vestibular neuritis (Strupp et al, 2004), and more recently, positive outcomes have been reported with Ménière's disease and benign paroxysmal positional vertigo (Patel et al, 2016; Pérez, Franco, Oliva, & López Escámez, 2016). Nonetheless, these agents have associated side effects, with sedation being a common drawback of antihistamines, and in many cases, their efficacy in reducing vertigo is questionable (Strupp, Zwergal, Feil, Bremova, & Brandt, 2015).…”

Treatment of benign paroxysmal positional vertigo. A clinical review

“…Intractable BPPV management is mainly based on repeating repositioning manoeuvres. Recently, treatments based upon the putative risk factors of intractability have merged, such as corticosteroid intratympanic treatment ( Pérez et al., 2016 ) and D vitamin intake ( Talaat et al., 2016 ). Surgical treatments, such as posterior canal blocking and singular nerve section, should be the final step ( Kisilevsky et al., 2009 , Leveque et al., 2007 ).…”