Updates in Neurotology

Repositioning Chair Treatment

Benign Paroxysmal Positional Vertigo (BPPV) is one of the most common peripheral vestibular disorders and a common cause of vertigo for which patients often visit a vertigo clinic. BPPV can be a very debilitating and traumatic condition. Moreover, several studies have shown a significant relationship between psychological conditions (depression, anxiety) and BPPV. The morbidity related to anxiety and depression can be very easily evaluated with self-assessments tools like Dizziness Handicap Inventory (DHI), the Visual Analog Scale (VAS), and the Hospital Anxiety and Depression Scale (HADS). A study was done by Neil West et al. at Department of Otorhinolaryngology & Head and Neck Surgery, Rigshospitalet, Copenhagen, Denmark and published in Journal of International Advanced Otology, to evaluate the symptoms of subjective vertigo and associated emotional problems like anxiety & depression during and after the reposition chair management for refractory BPPV patients. Refractory BPPV is defined as definite or suspected BPPV that did not respond to repeated attempts of manual Canalith Repositioning Maneuver (CRM) treatment. Several limitations in the manual repositioning treatment of BPPV have led to the development of mechanical reposition devices. One of these devices is the TRV chair (TRV Chair; Interacoustics, Denmark; the name ‘TRV’ is after the inventor/developer of the chair Thomas Richard-Vitton) which is a mechanical diagnostic and reposition device innovated by him for the management of recurrent BPPV. The advantages of the TRV chair as compared with the conventional way of manual repositioning maneuvers (CRM) are:-1) Improved analytical feasibility 2) Accurate navigation of the head for very precise movement of the contents in the semicircular canals 3) Treat the patients those are unfit for manual treatments like very obese patients or patients with spinal problems4) Allows the examiner to easily rotate the patient 360 degrees along the plane of each semicircular canal(S.C.C) 5) Helps to hold the patient in any position for detailed evaluation of any eye movements ([Fig. 1]).

Fig. 1 BPPV treated via the TRV chair. (image courtesy: https://www.interacoustics.com/).

The study was performed in a tertiary referral center which is an university medical institution. The patient group was those who were diagnosed to have intractable BPPV that has failed to conventional manual repositioning(CRM) treatments. Apart from vertigo many patients were also burdened with emotional issues like anxiety, fear and depression. TRV chair offers strict objective control of the head movement in very accurate 3D rotational planes that can be monitored in the computer while recording the precise eye movement by videonystagmography (VNG). The objective of the study was to evaluate the subjective complaints and emotional issues of the patients with BPPV through questionnaires like VAS, Dizziness Handicapped Index (DHI), and Hospital Anxiety Depression Scale (HADS) after treatment with reposition maneuvers in the TRV chair. The TRV device has a preset 360°planes for each of the semi-circular canals allowing 360°movement of the patient along the plane of each semicircular canal in tandem with simultaneous analysis of nystagmus (if any) via the infrared goggles in a computer screen. TRV chair treatment is based on the Epley and the Barbeque (180–270 rotations) maneuvers for posterior and horizontal canal BPPV respectively. Multicanal BPPV is addressed by treating canalolithiasis before cupulolithiasis and repositioning the posterior canal otoliths before the horizontal canal ones. Furthermore, the TRV chair has a potentiated “impact” function, applying decelerating manual forces upon the reposition maneuvers. It was evident from the study that patients with refractory BPPV improved significantly, according to subjective outcomes reported by the patients and measurement of the symptoms by the above mentioned questionnaires after the TRV chair management. During the TRV chair management the BPPV was resolved after a mean of two treatment sessions. Thus, the reposition device could significantly reduce disease morbidity burden both physically and psychologically in the group of patients with BPPV who previously failed to respond to conventional manual treatment.