This study was conducted in the Otorhinolaryngology Department, Zagazig University, Egypt, and Alazhar University, Egypt, in collaboration with the Audiovestibular Department, Menoufia University, Egypt.

This is a prospective study which involved 114 patients in the period from January 2019 to March 2021. The institutional review board (IRB) approved the study methods, and detailed consents were gained prior to inclusion in the research.

All the patients were subjected to a full and detailed history, general and clinical ENT examination, position provocation tests (Dix-Hallpike and supine roll test), and audiological assessment (tympanometry and pure tone audiometry). Patients with congenital ear anomalies or ear malignancies are excluded from the study.

The symptoms were clearly documented using the same criteria of Brevern et al. [1] to diagnose the vestibular vertigo and BPPV.

In vestibular vertigo (one criterion must be fulfilled):

  1. (1)

    Self-generated rotational vertigo.

  2. (2)

    Positional vertigo.

  3. (3)

    Repeated dizziness with nausea and either imbalance or oscillopsia.

In Benign paroxysmal positional vertigo (A–D has to be fulfilled):

  1. (A)

    Recurrent vestibular vertigo.

  2. (B)

    Duration of the attack is less than 1 min.

  3. (C)

    Symptoms always evoked by change of head position as turning over in the supine position, lying down, recline the head, rising from supine position, or leaning forward.

  4. (D)

    Not another disorder.

BPPV in all patients was diagnosed by the above symptoms plus at least one positive test of Dix–Hallpike test, supine roll test, and deep midline head-hang test.

The test was considered positive when subjective vertigo was reported by the patient, and objective nystagmus was observed by the examiner. Nystagmus observed with the aid of videonystagmography (Visual Eyes by Micromedical Technologies, Chatham, IL) or Frenzel goggles (ICS-FL15, Otometrics, Denmark) in most of the cases.

Posterior semicircular canal BPPV (PSC-BPPV) was diagnosed by Dix–Hallpike test when a geotropic, torsional, upbeat nystagmus was observed associated with subjective vertigo while the affected ear down. Horizontal semicircular canal BPPV (HSC-0BPPV) was diagnosed by supine roll test when horizontal nystagmus was observed associated with subjective vertigo. It was considered geotropic if nystagmus beat toward the ground while the affected ear down and apogeotropic if nystagmus beat away from the ground while the affected ear up. Laterality was decided based on which side elicited more robust nystagmus and vertigo symptoms in cases where nystagmus and vertigo were present while either ear down. Anterior semicircular canal BPPV (ASC-BPPV) was diagnosed if apogeotropic, torsional, downbeat nystagmus was noticed while the affected ear up during the Dix–Hallpike test and/or downbeat nystagmus was noticed in the deep midline head-hang position.

Secondary BPPV was identified when a patient informs a history of acute unilateral vestibular loss or trauma to the head or surgery to the ear within 6 months of the onset of BPPV or intubation for general anesthesia within 3 days earlier.

All the patients are subjected to repositioning maneuver (Epley maneuver in cases of PSC-BPPV, barbeque maneuver in HSC-BPPV, and deep midline head-hang maneuver in ASC-BPPV) according to the affected canal.

After 2 weeks, if any of these patients is still complaining from vertigo, the patient subjected to the 2nd repositioning maneuver while using the oscillation on the mastoid. There are fixed instructions which are instructed to the patients to be followed in the first week after doing the repositioning maneuver either in the first or in the second attempt.

The patient has to avoid any trigger action which can allocate the otoconia again to any canal:

  1. a)

    Avoid head shaking movement.

  2. b)

    Avoid any exercises or any daily practice associated with angular head movement.

  3. c)

    In daytime, try to stay with your head in a vertical position.

  4. d)

    In sleep time, sleep with the upper half of the body in semi-upright position.

  5. e)

    Avoid sleep in the affected ear.

The patient is considered not responding to the rehabilitation if after 6 weeks the patient is still having vertigo as well as a positive provocation test with the characteristic nystagmus (the same inclusion criteria).

All data were shown as means and standard deviation (SD). All statistical data were analyzed with the SPSS program version 25 (Chicago, Illinois, USA). When the P value < 0.05, it was reported as statistically significant.

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