Correspondence / American Journal of Emergency Medicine 32 (2014) 86106 95

Zhi Wan MD nerve terminals resulting in illusion of the movement. The

Yu Cao MD physical maneuvers help to move these crystals out of the
Department of Emergency medicine semicircular canals back to the utricle to provide relief of vertigo
West China Hospital, Sichuan University symptoms. BPPV is still under diagnosed or misdiagnosed by
Sichuan, PR China clinicians [8].
E-mail address: dr.yu.cao@gmail.com There are tremendous costs associated with managing BPPV
mainly due to delayed diagnosis. In the United States, it costs
approximately US $2000 to diagnose this condition in one patient,
and 86% of patients experience signicant disruption in their daily
http://dx.doi.org/10.1016/j.ajem.2013.10.009 activities [1,9].
The physical maneuvers used for treating BPPV are also
called particle repositioning maneuvers and include Epley,
References modied Epley, Semont, and Brandt Daroff exercises. All
[1] Schultz CH, Koenig KL, Noji EK. A medical disaster response to reduce immediate physical maneuvers help in improving the symptoms of BPPV
mortality after an earthquake. N Engl J Med 1996;334:43844. patients. However, the modied Epley maneuver is the most
[2] Noji EK. Evaluation of the efcacy of disaster response: research at the Johns effective [10].
Hopkins University. UNDRO News;1987:113.
[3] Thiel CC, Schneider JE, Hiatt D, et al. 911 EMS process in the Loma Prieta Medications are commonly given to vertigo sufferers to improve
earthquake. Prehosp Disaster Med 1992;7:34858. the spinning sensation and to control nausea and vomiting. There is
[4] Super G, Groth S, Hook R, et al. START: simple triage and rapid treatment plan. no evidence to suggest that these medications are effective or
Newport Beach, CA: Hoag Memorial Presbyterian Hospital, 1994.
[5] Waeckerle JF. Disaster planning and response. N Engl J Med 1991;324: provide alternative treatment to particle repositioning maneuvers
81521. [11-14].
[6] Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med 2011;364: Anecdotally, it appeared that most emergency doctors were
74957.
[7] Ma OJ, Norvell JG, Subramanian S. Ultrasound applications in mass casualties and
not applying an evidence-based approach to treatment. The
extreme environments. Crit Care Med 2007;35:S2759. aim of this survey was to assess present knowledge and
[8] Bhoi S, Sinha TP, Ramchandani R, et al. To determine the accuracy of focused approach to BPPV patients by emergency doctors at Hamad
assessment with sonography for trauma done by nonradiologists and its
comparative analysis with radiologists in emergency department of a level 1
General Hospital.
trauma center of India. J Emerg Trauma Shock 2013;6:426. Between February and April 2013 a cross-sectional interview-
[9] Zhou J, Huang J, Wu H, et al. Screening ultrasonography of 2,204 patients with based questionnaire survey was conducted among emergency
blunt abdominal trauma in the Wenchuan earthquake. J Trauma Acute Care Surg
physicians at Hamad general hospital, Doha, Qatar. A simple 4-item
2012;73:8904.
[10] Shorter M, Macias DJ. Portable handheld ultrasound in austere environments: use questionnaire was designed based on existing literature and clinical
in the Haiti disaster. Prehosp Disaster Med 2012;27:1727. experience.
[11] Sarkisian AE, Khondkarian RA, Amirbekian NM, et al. Sonographic screening of The questionnaire included the following 4 questions:
mass casualties for abdominal and renal injuries following the 1988 Armenian
earthquake. J Trauma 1991;31:24750.
1. Approximately how many patients have you seen with BPPV in
the last 3 months?
2. Did you offer BPPV patients, particle repositioning maneuver
such as Epley and others?
Physical maneuvers: effective but underutilized treatment of
3. Have you been trained in particle re-positioning maneuvers in
benign paroxysmal positional vertigo in the ED,
treating BPPV?
4. Did you treat BPPV patients with medications?
To the Editor,
A total of 80 forms were distributed and 73 completed forms were
Benign paroxysmal positional vertigo (BPPV) is a common returned (response rate, 91.25%).
clinical condition. Most patients experience short episodes of Out of 73 emergency department (ED) physicians, 51 were
vertigo associated with certain positions such as looking up, males and 22 were females. In our study, 62 physicians (85%) said
changing position in the bed, bending down and straightening up they would offer medications only, 8 (11%) physicians stated that
from bending down. Its incidence varies between 11 and 64 per they would offer maneuvers along with medications and only 3
100,000 and lifetime prevalence in general practice is 2.4%. [1]. (4%) physicians stated that they would offer a physical maneuver as
The most common age group is 50 to 55 years in the idiopathic primary treatment (Table). There was no difference according to
group [2] and is uncommon in children [3]. seniority of the doctor.
Dix and Hallpike, in 1952, explained this condition in detail It is important to differentiate central from peripheral cause of
and called this Benign paroxysmal positional vertigo [4]. vertigo. Some patients will need a referral to a neurologist or an
About 18% of patients seen in Dizziness clinics [5], and 25% ENT surgeon if there are atypical symptoms and if physical
of patients undergoing vestibular tests for balance problems [6] maneuvers do not improve the symptoms, to rule out any
suffer from BPPV. intracranial pathology.
The underlying cause is believed to be the presence of
calcium carbonate crystals in the semicircular canals, in particular
the posterior semicircular canal [7]. These crystals are understood
Table
to have migrated from the utricle. The movement of these
Use of particle repositioning physical maneuvers or medications by physicians in ED
crystals in the semicircular canals causes abnormal ring of the (n = 73)

Variable n %

Offer BPPV patients, physical maneuver only 3 4.1%

Declaration of interest: No conict of interests declared. Offer BPPV patients, physical maneuver and medications both 8 10.9%
Financial Support: No nancial support declared. Offer BPPV patients, medications only 62 84.9%
96 Correspondence / American Journal of Emergency Medicine 32 (2014) 86106

BPPV sufferers commonly present to EDs for help and in most [14] Fujino A, Tokumasu K, Yosio S, et al. Vestibular training for benign paroxysmal
positional vertigo. Its efcacy in comparison with antivertigo drugs. Arch
cases do not get the appropriate treatment. In a study comprising Otolaryngol Head Neck Surg 1994;120:497504.
3522 dizzy patients attending the ED only 0.2% were offered a [15] Kerber KA, Burke JF, Skolarus LE, Meurer WJ, et al. Use of BPPV processes in
physical maneuver, and even with a conrmed diagnosis of BPPV emergency department dizziness presentations: a population-based study.
Otolaryngol Head Neck Surg 2013;148(3):42530.
by Dix-Hallpike maneuver only 3.9% were offered a physical
maneuver [15]. These results are comparable to our study with
only 4% of our study ED physicians offering a physical maneuver
only to manage BPPV.
Does chest radiograph conrm tracheal intubation?
Until now the exact pathophysiology of BPPV was not well
understood. BPPV symptoms can resolve spontaneously and in some
patients it can last for weeks, months, and even years. There may be To the Editor,
other reasons both central and peripheral that contribute to the
success of the treatments. Physical maneuvers appear to provide the The article by Hossain Nejad et al is encouraging in view of
quickest relief of symptoms. There is a need for prospective, their conclusion that in more than 85% cases, emergency
randomized controlled studies that include long term follow-up of physicians are putting the endotracheal tube (ETT) in the
BPPV patients as recurrence of symptoms and prolonged disability appropriate position [1]. The study was based on clinical
appear to be common. examination and chest radiography to ascertain the proper
BPPV sufferers commonly present to EDs, most physicians do position of the endotracheal tube. According to studies clinical
not apply this evidence based approach. It is thus recommended examination and chest radiography are not reliable methods to
that dizziness, in particular BPPV management should be included conrm tracheal intubation. Their sensitivity to detect esophageal
in the induction for physicians coming to work in ED. intubation is also low [2].
According to the American College of Emergency Physicians
(ACEP) 2009 and American Heart Association (AHA) 2010
guidelines the most accurate and widely accepted method to
Khalid Bashir FCEM, FRCS Ed, FRCS Glas, DIMC Ed, Dip in Sports med
know the correct position of the ETT is estimation of end tidal
Galal S. Alessai MBChB, CABMS-EM
CO2 (ETCO2) detection. The end tidal CO2 estimation is quite
Waleed Awad Salem MBBS, CABMS-EM
accurate in adequately tissue perfused condition [3]. Esophageal
Furqan B. Irfan MBBS
detector device can also be used to know ETT position, but they
Emergency Department, Hamad General Hospital
are not as reliable as ETCO2 [4]. Ultrasonography imaging and
Doha, Qatar
transthoracic impedance methods are proven useful adjuncts to
E-mail addresses: khalidbashir1@btinternet.com, jsa501@gmail.com,
monitor the proper location of the endotracheal tube. Proper
waleed1423@hotmail.com, FUddin@hmc.org.qa
position of ETT under ultrasonography imaging is dened as
single A-M interface with Comet-tail artefact [5]. Electric imped-
Peter A. Cameron MBBS, MD, FACEM
ance tomography is also emerging as a technique to know the
Hamad Medical Corporation
position of the endotracheal tube [6]. This technique is based on
Doha, Qatar
the assumption that a ventilated lung will have increased
E-mail address: PCameron@hmc.org.qa
impedance. Therefore, by measuring the impedance over the
chest cavity, a discrimination between esophageal and tracheal
http://dx.doi.org/10.1016/j.ajem.2013.10.012 intubation can be made.
Correct position of the endotracheal tube tip is 5 2 cm from
carina, when the head and neck are in neutral position. When the
References carina is not visible, then it can be assumed that the endotracheal tube
tip positioned at the level of the T2-T4 level is safe and effective [7].
[1] von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal
positional vertigo: a population based study. J Neurol Neurosurg Psychiatry Optimal depth of ET placement can be estimated by the formula:
2007;78:7105. (height in cm/7) 2.5.
[2] Hilton M, Pinder D. The Epley manoeuvre for benign paroxysmal positional vertigo Despite the fact that there are several methods to verify the ETT
a systematic review. Clin Otolaryngol Allied Sci 2002;27(6):4405.
[3] Baloh RW, Honrubia V. Childhood onset of benign positional vertigo. Neurology placement, visualization of vocal cords during laryngoscopy and
1998;50(5):14946. capnography to estimate ETCO2 is the gold standard for it. Chest
[4] Dix M, Hallpike C. The pathology, symptomatology and diagnosis of certain radiography is not useful for detecting esophageal intubation as the
common disorders of the vestibular system. Proc R Soc Med 1952;45(6):341.
[5] Nedzelski JM, Barber HO, McIlmoyl L. Diagnoses in a dizziness unit. J Otolaryngol esophagus lies posterior to the trachea. Furthermore, it is not full
1986;15:101. proof, for instance, an ETT misplacement rate of 14% with the use of
[6] Hughes CA, Proctor L. Benign paroxysmal positional vertigo. Laryngoscope chest radiography has also been reported [8]. So to conclude it
1997;107:607.
[7] Hall SF, Ruby RR, Mclure JA. The mechanism of benign paroxysmal vertigo.
could have been a much better study if the author had ruled out
J Otolaryngol 1979;8:151. esophageal intubation.
[8] von Brevern M, Lezius F, Tiel-Wilck K, et al. Benign paroxysmal positional
vertigo: current status of medical management. Otolaryngol Head Neck Surg
2004;130:3812. Nayer Jamshed MD
[9] Li JC, Li CJ, Epley J, et al. Cost-effective management of benign positional vertigo Department of Emergency Medicine
using canalith repositioning. Otolaryngol Head Neck Surg 2000;122:334. All India Institute of Medical Sciences, Ansari Nagar
[10] Comparison of three types of self-treatments for posterior canal benign
paroxysmal positional vertigo: modied Epley maneuver, modied Semont New Delhi, India
maneuver and Brandt-Daroff maneuver. Zhang YX, Wu CL, Xiao GR, et al. Er Bi E-mail address: jamshednayer@gmail.com
Yan Hou Tou Jing Wai Ke Za Zhi. 2012 Oct; 47(10):799803.
[11] Frohman EM, Kramer PD, Dewey RB, et al. Benign paroxysmal positioning vertigo
in multiple sclerosis: diagnosis, pathophysiology and therapeutic techniques.
Fouzia F. Ozair MBBS, DO
Mult Scler 2003;9:2505. Department of Forensic Medicine
[12] Hain TC, Uddin M. Pharmacological treatment of vertigo. CNS Drugs 2003;17: Hamdard Institute of Medical Sciences and Research, Hamdard Nagar
85100.
[13] Hain TC, Yacovino D. Pharmacologic treatment of persons with dizziness. Neurol
New Delhi, India
Clin 2005;23:83153, vii. E-mail address: cutesidoc@gmail.com
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