Althea Medical Journal. 2016;3(2) 275 Characteristics of Patient with Benign Paroxysmal Positional Vertigo in Dr. Hasan Sadikin General Hospital Bandung from 2009–2013 Intan Datya Kirana,1 Yussy Afriani Dewi,2 Titing Nurhayati3 1Faculty of Medicine Universitas Padjadjaran, 2Department of Otorhinolaryngology Head and Neck Surgery Faculty of Medicine Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital Bandung, 3Department of Physiology Faculty of Medicine Universitas Padjadjaran Abstract Background: Benign Paroxysmal Positional Vertigo (BPPV) is a vestibular disorder marked by episodes of vertigo and triggered by a change in the head position. It is characterized by short yet severe episodes of vertigo and possibly accompanied by nausea and vomiting. The BPPV is usually idiopathic and found among people aged 46‒50 years old. There are pharmacological and non-pharmacological treatment used for BPPV. Non-pharmacological treatment includes Epley, Semont, Lempert, Forced Prolonged Position, and Brandt-Daroff maneuvers and pharmacological onebenzodiazepine and antihistamines. This study aimed to examine the characteristics of patient with BPPV based on their complaint and prescribed treatment. Methods: This was a descriptive-retrospective study conducted on April–June 2014 using secondary data from medical records of patient with BPPV in Dr. Hasan Sadikin General Hospital Bandung from 2009‒2013. The variables include gender, age, occupation, accompanying disease, complaints, supporting examinations, and treatment. Results: There were 74 subjects; 66.22% were female and 33.78% were male. Most of patients with BPPV aged around 41–50 years old (39.19%). Furthermore, 93.24% had a major complaint of headache and spinning sensation, and >60% nausea and vomiting. The most prescribed therapy was Betahistine (86.49%). Meanwhile, a maneuver of non-pharmacological treatment was rarely done (8.11%). Conclusions: The BPPV occurs more in older women. The major complaint is headache and spinning sensation affected by the head position and accompanied by nausea and vomiting. Lastly, non-pharmacological treatment is rarely performed in handling patient with BPPV. [AMJ.2016;3(2):275–9] Keywords: BPPV, clinical characteristic, treatment, vertigo Correspondence: Intan Datya Kirana, Faculty of Medicine, Universitas Padjadjaran, Jalan Raya Bandung-Sumedang Km.21, Jatinangor, Sumedang, Indonesia, Phone: +62 85352262206 Email: intandatya@gmail.com Introduction Vertigo is a sensation of rhythmical, unidirectional movement of the surrounding environment or the spinning sensation in the head and body of a person.1 Vertigo is classified into two types: central and peripheral. Central vestibular vertigo occurs due to lesions in the central nervous system.1,2 In peripheral vestibular vertigo, there are problems in the semicircular canals in the ear. One of the most prevalent peripheral vertigo types is Benign Paroxysmal Positional Vertigo (BPPV).3-6 The BPPV is a vestibular disorder characterized by episodes of vertigo and triggered by the changes in the head position. It occurs in certain head positions, for example when one is sleeping upside down, changes in sleeping position or a quick wake-up movement. Such an events usually occur in midnight or morning.1 The BPPV is marked by short yet severe episodes of vertigo and possibly accompanied by nausea or vomitin. These episodes typically last less than 30–40 seconds, but mostly about 15 seconds. The BPPV is usually idiopathic and found among people aged 46–50 year old.7 The method to diagnose BPPV is Dix-Halpike maneuver. It is used to induce nystagmus which is one of the characteristics of BPPV.8 Treatment of BPPV is divided into pharmacological and non-pharmacological therapies. The most frequently used in pharmacological treatments are benzodiazepine and antihistamines. Non- pharmacological treatment is in the forms of Althea Medical Journal. 2016;3(2) 276 AMJ June 2016 maneuvers, e.g. Brandt-Daroff, Semont, and Epley which is the most frequently performed maneuver.9–11 The incidence of vertigo amounted to 54.48% of the central type and 45.52% of the peripheral type.10 This study aimed to examine the characteristics of patient with BPPV based on their complaint and prescribed treatment. Methods This was a descriptive-retrospective study conducted on April–June 2014 using secondary data collected from the medical records of the patients with BPPV in Dr. Hasan Sadikin General Hospital Bandung from 2009‒2013. It was found 74 out of 107 patients who fulfilled the inclusion criteria. The studied variables include gender, age, occupation, accompanying disease, complaints, supporting examinations, and treatment. Thirty three patients were excluded due to missing or incomplete variable data in their medical records. Results There were 49 (66.22%) female patients with BPPV and 25 (33.78%) were male. Most of patients with BPPV aged around 41–50 year old with 29 (39.19%) people, followed by patients aged 51–60 year old with 18 (24.32%) people. Two patients with BPPV aged under 20 year old was also found. The most primary occupation was housewives with 13 (17.57%) people, followed by civil servant and others with 6 (8.11%) people (Table 1). Hypertension was the most frequent accompanying disease in patients with BPPV with 38 (51.35%) people. The second most frequent accompanying disease was Hypercholesteronemia with 25 (33.78%) people (Table 2). The most frequently complained by the patients is headache and spinning sensation with 69 (93.24%) cases. The rest include weakness of the limbs, and vomiting with 5 (6.76%) cases (Table 3). The most major accompanying symptoms in patients with BPPV are nausea with 50 (67.57%) cases and vomiting with 49 (66.22%) cases (Table 3). Table 4 shows the rarely-performed supporting examinations on BPPV . The Romberg test was only performed on 22 (29.73%) patients, resulting 4 (5.41%) positive responses and 18 (18.32%) negative responses. There were 52 (70.27%) patients in which the Romberg test was not performed. Table 1 Characteristic of Patients with BPPV Characteristic N % Sex Female 49 66.22 Male 25 33.78 Age (years old) <20 2 2.7 21–30 0 0 31–40 8 10.81 41–50 29 39.19 51–60 18 24.32 61–70 12 16.22 >70 5 6.76 Type of Job Housewives 13 17.57 Civil Servant 7 9.46 Others* 6 8.11 Not Listed 48 64.86 Note: *Others: Retired, private workers Althea Medical Journal. 2016;3(2) 277Intan Datya Kirana, Yussy Afriani Dewi, Titing Nurhayati: Characteristics of Patient with Benign Paroxysmal Positional Vertigo in Dr. Hasan Sadikin General Hospital Bandung from 2009–2013 Table 2 Other Accompanying Diseases of Patients with BPPV Accompanying Disease N % Hypertension 38 51.35 Hypercholesteronemia 25 33.78 Trauma 7 9.46 DM 12 16.22 TIA/Stroke 12 16.22 Kidney Disease 3 4.05 Heart Disease 4 5.41 Gastric Disease 12 16.22 Other Disease 32 43.24 Note: *other diseases are osteoatrhitis, lung tuberculosis, gout arthritis, and neoplasia The Gait test was only performed on 10 (13.52%) patients, resulting 5 (6.76%) positive responses and 5 (6.76%) negative responses. The remaining 64 (86.49%) patients did not receive thegait examination (Table 4). The most frequently prescribed pharmacologic treatment was from the Betahistine group in 64 (86.49%) cases. The examples of drugs from the betahistine group were Merislon, Betaserc, Vastigo, Mertigo, and Metoclopramide, which were given in 28 (37.84%) cases. Antihistamines such as Dramamine and stugeron were also used in 27 (36.49%) cases. Ranitidine was prescribed in 27 cases (36.49%) and vitamin B supplements such as neurodex were prescribed in 24 (32.43%) cases (Table 5). A total of 68 patients (91.89%) did not perform in the form of treatment maneuvers. Only 5 patients (6.76%) were given the treatment of Epley maneuver and 1 patient (1:35%) was given the Brandt-Daroff treatment maneuvers. Discussion Gender was considered to be the risk factor of BPPV; there were more female patients than male. This conformed to a study by Von Brevern et al.12 which states that females are more vulnerable to BPPV even though the exact mechanism is still unknown. Von Breven et al.12 also discovers that the group of patients aged 46-50 years old had the highest frequency of BPPV case. The large number of older patients Table 3 Major Complaints of BPPV Patients N % Major Complaints Headache and spinning sensation 69 93.24 Others* 5 6.76 Accompanying Complaints Nausea 50 67.57 Vomiting 49 66.22 Ringing ears 20 27.03 Double vision 4 5.41 Anesthesia 2 2.70 Cold Sweat 5 6.76 Others** 18 24.32 Note: * Headache, weakness of the limbs, and vomiting, ** Fever, Epigastric pain, episodes of black out, and hearing problems Althea Medical Journal. 2016;3(2) 278 AMJ June 2016 with BPPV supported the “aging hypothesis” that theorizes degenerative changes in the utricles, usually due to chronic ischemia which causes the detachment of otoconia from the macule.12,13 In a study by Parham14, it is discovered that the prevalence of BPPV is quite large among the young age in America, i.,e. 9%. This can be caused by several factors such as trauma, surgery, or physical activities like sports. Hypertension and hypercholesteronemia were the most frequent accompanying diseases in patients with BPPV. This result is similar with the study by Von Bavern et al.12, that study explains that hypertension and hypercholesteronemia can result in vascular damages in the inner ears due to the ischemia of labyrinth, leading to the attachment of otoconia towards the otolith membrane. Headache and spinning sensation were the most frequently complained that encouraged patients with BPPV to ask for a treatment. In accordance to a study by Bhattacharyya et al.16, most of patients complain of headache and spinning sensation accompanied by nausea and vomiting as the effects of vestibular imbalance on the afferent nerves of the extra medullary centers in the brain. Positional change also has an effect on the vertigo as it causes displacement of otolith and makes it attach to the utricles and semicircular canals.9,15,16 Betahistine and metoclopramide is the pharmacologic treatment for patients with BPPV.17 The most frequently prescribed pharmacologic treatment was betahistine, which functions as an anti-vertigo and histamine precursor that repairs vestibular microcirculation.13 Metoclopramide was frequently given to treat symptoms such as nausea and vomiting, e.g. primpenan. Bhattacharyya et al.16 states that antihistamines such as Dramamine and sturgeon were also frequently used. Their anticholinergic properties can reduce vestibular stimulation, suppress the labyrinth’s functions, and Table 4 Supporting Examination in BPPV Patient Supporting test (+) % (-) % Unrecorded % Romberg Test 4 5.41 18 24.32 52 70.27 Gait test 5 6.76 5 6.76 64 86.49 Table 5 Treatment in Patients with BPPV Treatment n % Pharmacological treatment Antihistaminic (Dramamine, Stugeron) 27 36.49 Betahistine (Merislon, Betaserc, Vastigo, Mertigo) 64 86.49 Metoclopramid (Primpenan) 28 37.84 Vitamin B (Neurodex) 24 32.43 Flunarizine (Unalium, Frego) 9 12.16 Antihipertensi (amlodopin , captopril) 17 22.97 Ranitidine 27 36.49 Proton Pump Inhibitor (Omeprazole) 15 20.27 Simvastatin 18 24.32 IVFD 19 25.68 Obat Lain 30 40.54 Non pharmacological treatment Epley Manuever 5 6.76 Brandt-Daroff Manuever 1 1.35 Not conducted Manuever 68 91.89 Althea Medical Journal. 2016;3(2) 279 suppress the conduction in vestibulo- cerebellar tract. In this study, it was found that maneuver was rarely used as a treatment for patients though it is a more effective treatments for BPPV.16 The limitations of this study lies in the time insufficiency to access the central medical record facility in Dr. Hasan Sadikin General Hospital during the weekdays and the insufficiency of complete medical records kept in the facility. This study recommends the hospital to be more systematic in the fulfillment, safekeeping, and well-organized sorting of the medical records so as to expedite further researches. In addition, the provision of the maneuver as primary treatment of patients with BPPV is more advisable than pharmacological drug delivery as it is more effective. From this study, it can be concluded that most BPPV patients are females in the group of 41-50 years old. Hypertension and hypercholesterolemia are the most frequent accompanying diseases in patients with BPPV. The major complaint of the patients is headache and spinning sensation accompanied by nausea and vomiting. Pharmacologic treatments including the use of Betahistine, Metoclopramide, and Antihistamines involving maneuver is rarely prescribed. References 1. Sura SD, Newell S. Vertigo- diagnosis and management in primary care. BJMP. 2010;3(4):a351 2. Alvarenga GA, Barbosa MA, Porto CC. Benign paroxysmal positional vertigo without nystagmus: diagnosis and treatment. Braz J Otorhinolaryngol. 2011;77(6):799–804. 3. Lai YT, Wang TC, Chuang LJ, Chen MH, Wang PC. Epidemiology of vertigo: a national survey. Otolaryngol Head Neck Surg. 2011;145(1):110–6. 4. Wang H, Yu D, Song N, Su K, Yin S. Delayed diagnosis and treatment of benign paroxysmal positional vertigo associated with current practice. Eur Arch Otorhinolaryngol. 2014;271(2):261–4. 5. Neuhauser HK, Lempert T. Vertigo: epidemiologic aspects. Semin Neurol. 2009;29(5):473–81. 6. Garrigues HP, Andres C, Arbaizar A, Cerdan C, Meneu V, Oltra J, et al. Epidemiological aspects of vertigo in the general population of the Autonomic Region of Valencia, Spain. Acta Otolaryngol. 2008;128(1):43–7. 7. Isaradisaikul S, Navacharoen N, Hanprasertpong C, Kangsanarak J, Panyathong R. Causes and time-course of vertigo in an ear, nose, and throat clinic. Eur Arch Otorhinolaryngol. 2010;267(12):1837–41. 8. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003;169(7):681–93. 9. Lee JD, Shim DB, Park HJ, Song CI, Kim MB, Kim CH, et al. A multicenter randomized double-blind study: comparison of the Epley, Semont, and sham maneuvers for the treatment of posterior canal benign paroxysmal positional vertigo. Audiol Neurootol. 2014;19(5):336–41. 10. Purnamasari PP. Diagnosis and management benign paroxysmal positional vertigo (BPPV). E-Jurnal Medika Udayana. 2013;2(6):1056–80. 11. Brandt T, Dieterich M, M. S. Vertigo and dizziness: common complaints. 2nd ed. London: Springer; 2013. 12. Von Brevern M, Radtke A, Lezius F, Feldmann M, Ziese T, Lempert T, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007;78(7):710–5. 13. Lea P, Kushnir M, Shpirer Y, Zomer Y, Flechter S. Approach to benign paroxysmal positional vertigo in old age. Isr Med Assoc J. 2005;7(7):447–50. 14. Parham K. Benign paroxysmal positional vertigo: an integrated perspective. Advances in Otolaryngology. 2014;2014:792635. 15. Kim JS, Zee DS. Benign paroxysmal positional vertigo. N Engl J Med. 2014;370:1138–47. 16. Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008;139(5 Suppl 4):S47–81. 17. Cash JC, Glass CA. Family practice guidelines. 3rd Ed. New York: Springer Publishing Company; 2014. p. 27. Intan Datya Kirana, Yussy Afriani Dewi, Titing Nurhayati: Characteristics of Patient with Benign Paroxysmal Positional Vertigo in Dr. Hasan Sadikin General Hospital Bandung from 2009–2013