Journal Reading

Osteoporosis as a Risk Factor for the Recurrence of

Benign Paroxysmal Positional Vertigo

Presentan : Dewi Yuri Lestari, MD
Day/Date : Wednesday / August 27
th
, 2014
Time : 07.30 AM
Place : Conference Room Department of
Otorhinolaryngology Dr. M. Djamil Hospital
Note Person : Ferdy Azman, MD
Moderator : Dolly Irfandy, MD ORL-HNS
Tutor : Jacky Munilson, MD ORL-HNS (C)






Otorhinolaryngology Head and Neck Surgery Department
Faculty of Medicine of Andalas University
Dr. M. Djamil Hospital Padang
2014
The Laryngoscope
VC
2013 The American Laryngological,
Rhinological and Otological Society, Inc.
Osteoporosis as a Risk Factor for the Recurrence of Benign
Paroxysmal Positional Vertigo
Toshiaki Yamanaka, MD; Shiho Shirota, MD; Yachiyo Sawai, MD; Takayuki Murai, MD;
Nobuya Fujita, MD; Hiroshi Hosoi, MD
Objectives/Hypothesis: Benign paroxysmal positional vertigo (BPPV) frequently occurs in females over 50 years old,
suggesting that a postmenopausal decrease in estrogen secretion might be involved in its onset. An estrogen deficiency is
generally known to cause osteoporosis through a reduction in bone mass. This study was designed to investigate a clinical
association between idiopathic BPPV and osteoporosis.
Study Design: Case-control study.
Methods: We measured the bone mineral density (BMD) at the lumbar vertebrae in 61 patients with idiopathic BPPV
who were postmenopausal women over 50 years old using dual-energy x-ray absorptiometry. After being treated with the
canalith repositioning maneuver, the patients were followed up for at least 1 year.
Results: Our results showed that the incidence of osteoporosis in patients with BPPV was 26.2%, which was similar to
those observed in epidemiological surveys conducted in Japan. However, we found that in BPPV patients with osteoporosis,
the incidence of recurrence was 56.3%, which was significantly higher than that observed in patients with normal bone min-
eral density (16.1%). Furthermore, the frequency of BPPV recurrence increased as BMD decreased.
Conclusions: These results suggest that osteoporosis is a risk factor for BPPV recurrence. The prognosis of BPPV might
be clinically predicted by BMD reduction.
Key Words: Benign paroxysmal positional vertigo, osteoporosis, bone mineral density, recurrence, otolith.
Level of Evidence: 3b
Laryngoscope, 123:28132816, 2013
INTRODUCTION
Benign paroxysmal positional vertigo (BPPV) is fre-
quent in females aged 50 years old.
1
A menopause-
related decrease in the secretion of female hormones
may be involved in the etiology of BPPV.
24
A decrease
in estrogen secretion influences calcium/bone metabo-
lism, causing osteoporosis through a reduction in bone
mass.
5
Calcium metabolism also plays a primary role in
the synthesis/absorption of otoconia made of calcium car-
bonate, and so might be an etiological factor in the onset
of BPPV.
68
Thus, BPPV and osteoporosis might be
caused by similar pathophysiological mechanisms involv-
ing calcium/bone metabolism disorders caused by
decreased estrogen secretion. Previous studies have
investigated the bone mass of BPPV patients, and the
results suggested that a relationship exists between
BPPV and osteoporosis.
13
Osteoporosis is determined by
the percentage of bone mineral density (BMD) value rel-
ative to young adult mean. In this study, we assessed
the BMD of idiopathic BPPV patients to determine
whether bone mass reductions were involved in the
onset/recurrence of BPPV. In addition, we also investi-
gated whether BPPV prognosis (recurrence) can be
predicted.
MATERIALS AND METHODS
This study was approved by the clinical research ethics
board of Nara Medical University Hospital. The subjects were
61 postmenopausal females 50 years old or older (mean,
63.767.40 years; range, 5088 years), who were diagnosed as
idiopathic BPPV without a history of vestibular diseases or
head trauma, based on the presence of vertigo and direction-
changing vertical rotatory nystagmus in the Dix-Hallpike test.
In advance, we excluded females who had received long-term
steroid therapy/osteoporosis treatment, those with a history of
endocrine diseases and surgery influencing female hormones,
and those with vertebral diseases such as spondylosis defor-
mans and compression vertebral fracture, which influence
BMD. The BMD of the second to fourth lumbar vertebrae was
measured in all subjects using dual-energy x-ray absorptiome-
try (DPX-NT; GE Medical Systems, Milwaukee, WI). According
to the diagnostic criteria for primary osteoporosis established by
the Japanese Society for Bone and Mineral Research,
9
the sub-
jects were divided into three types based on their percentage
BMD values relative to the young adult mean (%YAM); patients
with a %YAM of 69% or less were regarded as having osteoporo-
sis, those with a %YAM of 70% to 79% as showing osteopenia,
and those with a %YAM of 80% or more as normal.
From the Department of OtolaryngologyHead and Neck Surgery
(T.Y., S.S, Y.S., T.M., H.H.), Nara Medical University School of Medicine,
Nara, Japan; and the Department of Otorhinolaryngology (N.F.), Nara
Prefectural Hospital, Nara, Japan.
Editors Note: This Manuscript was accepted for publication
February 21, 2013.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Toshiaki Yamanaka, MD, Department of
OtolaryngologyHead and Neck Surgery, Nara Medical University
School of Medicine, 840 Shijo, Kashihara Nara, 634-8522, Japan.
E-mail: toshya@naramed-u.ac.jp
DOI: 10.1002/lary.24099
Laryngoscope 123: November 2013 Yamanaka et al.: Osteoporosis and BPPV
2813
The subjects were treated with the canalith repositioning
maneuver (Epleys method)
10
and then followed up for at least a
year. Recurrence was defined as confirmed vertigo and nystag-
mus according to the Dix-Hallpike test during the follow-up
period. There were 39 recurrence-free BPPV patients (mean
age, 63.868.60 years; range, 5081 years) and 22 recurrent-
BPPV patients (mean age, 65.364.70 years; range, 5388
years). Among the recurrent-BPPV patients, recurrence
occurred once in nine patients (mean age, 65.764.80 years;
range, 5488 years) and twice or more in 13 patients (mean
age, 64.964.60 years; range, 5382 years). There were no sig-
nificant differences in the age distributions of the recurrence-
free and recurrent-BPPV patients or between the single- and
multiple-recurrence patients. We examined the associations
between the onset/recurrence of idiopathic BPPV and osteoporo-
sis. The Mann-Whitney test or v
2
test was used for statistical
analyses in this study.
RESULTS
The mean BMD value of all the BPPV patients
examined in this study was 0.88960.158 g/cm
2
. The
mean BMD value of the recurrence-free patients was
0.94360.155 g/cm
2
, whereas that of the recurrent
patients was 0.79360.113 g/cm
2
. The mean BMD value
of the recurrent-BPPV patients was significantly lower
than that of the recurrence-free patients. Moreover, the
mean BMD of the single and multiple recurrence
patients was 0.84960.081 g/cm
2
and 0.754 60.118 g/
cm
2
, respectively. Accordingly, the mean BMD of the
multiple-recurrence patients was significantly lower
than that of the single-recurrence patients (Table I).
The mean %YAM of the study subjects was
80.2 614.0%, which was considered to be indicative of
the lower limit of the normal range. The %YAM of the
recurrence-free patients was 84.8 614.2%, whereas that
of the recurrent-BPPV patients was 72.2 69.6%, which
was within the reference range for osteopenia. The
%YAM of the recurrent-BPPV patients was significantly
lower than that of the recurrence-free patients. Further-
more, the %YAM of the single- and multiple-recurrence
patients was 76.967.2% and 69.0 69.9%, respectively,
which was within the range for osteoporosis. The %YAM
of the multiple-recurrence patients was significantly
lower than that of the recurrence-free patients or that of
the single-recurrence patients (Table I).
Of 61 patients with BPPV, the bone mass was nor-
mal in 31 (50.8 %), osteopenia was noted in 14 (23.0 %),
and osteoporosis was observed in 16 (26.2 %). There was
a reduction in the bone mass in 30 (49.2 %) of the 61
patients (Fig. 1).
BPPV recurred in five (16.2 %) of 31 BPPV patients
with normal bone mass (Fig. 2A), in eight (57.2 %) of 14
BPPV patients with osteopenia, and in nine (56.3 %) of
16 BPPV patients with osteoporosis (Fig. 2B,C). The
recurrence rate was significantly higher in the patients
with osteopenia and osteoporosis than in those with nor-
mal bone mass. In addition, multiple recurrences were
found in two (6.5 %) of 31 patients with a normal bone
mass, four (28.6 %) of 14 patients with osteopenia, and
seven (43.8 %) of 16 patients with osteoporosis, and the
frequency of multiple recurrences was greater in the
patients with osteoporosis than in those with osteopenia
(Fig. 2).
Fig. 1. The decrease in bone mineral density in patients with idio-
pathic benign paroxysmal positional vertigo (BPPV). Thirty-one
BPPV patients displayed normal bone mass values. Fourteen and
16 patients were regarded as osteopenia and osteoporosis,
respectively. A reduction in the bone mass was observed in
49.2% (30 patients) of the 61 BPPV patients. Numerical values
depict the number of patients.
TABLE I.
Bone Mineral Density and Percentage Young Adult Mean Values in
Benign Paroxysmal Positional Vertigo Patients.
Patients n
Bone Mineral
Density (g/cm
2
)
Percent of Young
Adult Mean
All 61 0.88960.158 80.2614.0
Recurrence free 39 0.94360.155 84.8614.2
Recurrent 22 0.79360.113
*
72.269.6
*
Single recurrence 9 0.84960.081 76.967.2
Multiple recurrence 13 0.75460.118
*
69.069.9
*
*P<.05 vs. recurrence-free patients.

P<.05 vs. single recurrence patients.

Fig. 2. The influence of bone mineral density (BMD) on the inci-
dence of benign paroxysmal positional vertigo (BPPV) recurrence.
The BPPV recurrence rate was significantly higher in the patients
with osteopenia or osteoporosis than in those with normal bone
mass values. Numerical values in parenthesis depict the number
of patients.
Laryngoscope 123: November 2013 Yamanaka et al.: Osteoporosis and BPPV
2814
The relationship between the %YAM and frequency
of BPPV recurrence was plotted, as shown in Figure 3.
Pearson correlation coefficient was 20.46, and there was
a negative correlation between the %YAM and BPPV
recurrence. The frequency of the recurrence increased
with a decrease in BMD. All patients with BPPV recur-
ring four times or more had osteoporosis.
DISCUSSION
Idiopathic BPPV was frequent in females over 50
years old, suggesting that decreases in the levels of
female hormones after menopause are involved in the
etiology of BPPV.
24
It is known that a decrease in the
estrogen level influences calcium/bone metabolism,
reducing the bone mass and causing osteoporosis.
5
Cal-
cium metabolism involved in the synthesis/absorption of
otoliths may also be affected in the presence of osteopo-
rosis with systemic calcium/bone metabolism disorder.
7
Therefore, this similar pathogenesis may contribute to
the occurrence of BPPV.
Previously, some studies investigated BMD in
patients with BPPV. Osteopenia was noted in 34% of
BPPV females over 50 years old and osteoporosis in
47%; there was a bone mass reduction in approximately
80% of patients with BPPV.
2
In another study, osteope-
nia and osteoporosis were also observed in 47.2% and
25.3% of adult females with BPPV, including young
females, respectively; 72.5% of these females showed a
decrease in BMD.
3
The results suggested the relation-
ship between the onset of BPPV and osteoporosis.
2,3
In this study, osteopenia or osteoporosis was noted
in approximately 50% of postmenopausal patients with
idiopathic BPPV; the proportion of BPPV patients with a
reduction in bone mass was not high, which is not con-
sistent with other previous studies.
2,3
The incidence of
BPPV with osteoporosis was 26.2% in this study. This
percentage was similar to those estimated in females 50
years old or older in two epidemiological surveys in
Japan (approximately 24% and 31%).
11,12
We did not
find that BPPV patients had significantly lower BMD
values than healthy adults. This suggests that there is
no clinical association between BPPV and osteoporosis.
However, when we examined the frequency of BPPV
recurrence, we found that it was 16.1% in
BPPV patients with normal bone mass, 57.2% in BPPV
patients with osteopenia, and 56.3% in BPPV patients
with osteoporosis. In addition, the proportion of patients
who suffered multiple recurrent episodes was higher
among the patients with osteoporosis than among those
with osteopenia. These results suggest that a condition
with a reduction in bone mass may be closely involved
in the mechanism of BPPV recurrence.
Bones are formed and maintained through calcium
uptake. However, reductions in an individuals estrogen
level can induce calcium insufficiency, which in turn
leads to reduced calcium uptake by bones, causing osteo-
penia/osteoporosis.
5
On the other hand, otoliths made of
calcium carbonate are present on the otolithic mem-
branes of the vestibular maculae of the otolithic organs
and mature by taking up the calcium.
68
Thus, calcium
is also essential for the synthesis of otoliths; therefore,
calcium supply to otoliths may become insufficient in the
presence of a condition with a reduction in bone mass,
resulting in its incomplete maturation.
Furthermore, osteopontin, a bone matrix protein,
has been demonstrated to be present in otoliths. Osteo-
pontin is considered to form a complex with calcium car-
bonate crystals at the otolith margin, thereby
contributing to otolith synthesis.
13
Because osteopontin
is considered to be involved in bone formation/absorp-
tion,
14,15
otolith formation might be impaired due to
osteopontin deficiency in patients with osteoporosis.
In addition, the otolith plays a role as a calcium res-
ervoir that maintains calcium homeostasis,
16,17
as
reported for bones. To maintain calcium homeostasis,
the otolith is reportedly absorbed, depending on the cal-
cium ion concentration.
17
As the lymph level of calcium
is decreased in postmenopausal women with osteoporo-
sis, calcium may be eluted from the otolith, accelerating
otolith calcium insufficiency.
Thus, in patients with BPPV and osteoporosis, cal-
cium metabolism failure may be present as a common
pathogenesis, leading to the synthesis of atrophic, fragile
otoliths related to calcium insufficiency, as described for
bones. In fact, an experiment with a rat osteoporosis
model also demonstrated that the size of otoliths was
reduced, showing atrophy.
18
This is a condition in which
the otolith is fragile, that is, otolithoporosis. In such con-
ditions, some otoliths might be exfoliated from the macu-
lae of the otolithic organs, and therefore a BPPV episode
could frequently recur.
No study has investigated the association between
the bone mass and prognosis (recurrence) of BPPV. How-
ever, the results of this study showed that recurrence
was frequent when bone mass was reduced, and that the
frequency of the recurrence in patients with BPPV
increased with a decrease in the bone mass. Therefore,
in BPPV patients with osteopenia or osteoporosis, the
risk of recurrence may be clinically predicted. The
results suggest that it is clinically significant to investi-
gate bone mass in BPPV patients to make a prognosis.
Fig. 3. The relationships between the percentage young adult
mean values and the frequency of benign paroxysmal positional
vertigo (BPPV) recurrence. Values are mean6standard error. The
frequency of BPPV recurrence increased as bone mineral density
decreased.
Laryngoscope 123: November 2013 Yamanaka et al.: Osteoporosis and BPPV
2815
In the future, it may be important to prevent the onset/
recurrence of BPPV by osteoporosis treatment.
CONCLUSION
Our results from this study suggest that BMD
reductions are involved in the onset/recurrence of idio-
pathic BPPV, and osteoporosis is a possible risk factor
for BPPV recurrence in postmenopausal females. The
prognosis of BPPV might be predicted clinically by bone
mass reduction.
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