Effect of Vitamin D Injection in Recurrent Benign Paroxysmal Positional Vertigo with Vitamin D Deficiency

THIEME Original Research Effect of Vitamin D Injection in Recurrent Benign Paroxysmal Positional Vertigo with Vitamin D Deficiency Gu Il Rhim1 1 The One Otorhinolaryngology Clinic, Paju, South Korea Int Arch Otorhinolaryngol 2020;24(4):e423–e428. Abstract Keywords ► benign paroxysmal positional vertigo ► vitamin D deficiency ► recurrence Introduction There have been reports indicating that patients with frequently recurring benign paroxysmal positional vertigo (BPPV) had vitamin D deficiency, and some studies indicated that the treatment of severe vitamin D deficiency is effective in the reduction of the recurrence of BPPV. Objective The purpose of the present study was to examine the effects of Vitamin D3 injection on recurrence among patients with a 10 ng/mL or lower 25-hydroxyvitamin D blood concentration diagnosed with BPPV. Methods Among 99 patients with idiopathic BPPV with vitamin D deficiency, 25 patients (case group) were submitted to 3 to 4 injections of 200,000 IU of vitamin D3 in the first year. In total, 50 patients in the control group were selected through frequency matching, with 25 patients in the case group. Age, gender, and type of BPPV are used in matching variables with 1:2 matched data. The subjects of the study group were followed up for 24 months. Results The differences in relapse rates between the case and the control groups were examined using the non-parametric Kruskal-Wallis test for k independent samples. With regard to the relapse rates of the entire case and control groups by period, from 0 to 6 months (p < 0.531), from 7 to 12 months (p < 1.000), and from 13 to 24 months (p < 0.711), and in the entire study period (p < 0.883) there were no statistically significant differences. Conclusion The present case-control study indicated that vitamin D3 injection had no significant effect on the recurrence of BPPV patients with vitamin D deficiency when age, gender, and type of BPPV were homogeneous between the two groups. Introduction Benign paroxysmal positional vertigo (BPPV) is a disorder arising in the inner ear, in which otoconia enter the semicircular canal or adhere to the cupula and cause clinical symptoms due to changes in position. The particle repositioning maneuver is known to be the standard treatment, but the 1-year recurrence rate is
20%, and recurrence rates within 4 to 5 years are of
40% to 50%.1–3 received November 10, 2018 accepted October 10, 2019 Address for correspondence Gu Il Rhim, MD, PhD, The One Otorhinolaryngology Clinic, 2 sicheong-ro, Paju 10924, Korea (e-mail: ). DOI https://doi.org/ 10.1055/s-0039-3402431. ISSN 1809-9777. Some studies indicated that vitamin D is involved in the metabolic process of calcium in the vestibular organ, and vitamin D deficiency affects the development of BPPV.4,5 Otoconia are biocrystals that couple mechanic forces to the sensory hair cells of the vestibular system. Otoconia are composed of calcium carbonate (CaCO3) crystals and glycoproteins, and are connected with protein fibers on hair cells.4 Little has been done on issues related to otoconia regeneration and degeneration in humans. But the generation, growth, and Copyright © 2020 by Thieme Revinter Publicações Ltda, Rio de Janeiro, Brazil 423 424 Effect of Vitamin D Injection in Recurrent Benign Paroxysmal Positional Vertigo degeneration processes of otoconia are known to be regulated by the calcium metabolic process of the vestibular organ in animal studies.6 Some study results indicated that vitamin D-related epithelial calcium channel proteins as players for otoconia formation are involved in determining the crystalline morphology, growth, and stability of otoconia.7 Recent studies8–10 indicated that osteoporosis, which is an example of calcium metabolic disease, is associated with the development and recurrence of BPPV. There have also been reports indicating that patients with frequently recurring BPPV had vitamin D deficiency, along with study results indicating that low levels of vitamin D were related to the development of BPPV, while very low levels were associated with the recurrence of BPPV.11–13 Moreover, a study14 indicated that the treatment of severe vitamin D deficiency is effective to reduce the recurrence of BPPV. The present study was conducted to examine the effect of vitamin D3 injection on BPPV recurrence in vitamin D-deficient patients diagnosed with idiopathic BPPV who had 25-hydroxyvitamin D (25-OH vitamin D) blood concentrations < 10 ng/mL. Materials and Methods The present study was conducted at a primary otorhinolaryngology clinic. The subjects of present study were selected from among 299 patients diagnosed with idiopathic BPPV with vitamin D deficiency from June 2014 to February 2016 at our outpatient clinic, and, among those, 99 individuals (23 males, 76 females; age range: 15–67 years) were recruited. In accordance with the Declaration of Helsinki, oral and written informed consent about the design, aim, and clinical implication of our study was obtained from all of the participants. A total of 299 subjects with BPPV were examined to select the study group. Patients with renal disease, Ménière disease, or any ear disease, such as chronic otitis media, vestibular neuritis, and otitis media on the same side accompanying BPPV from the beginning, as well as patients with secondary BPPV were excluded. Patient information on age, gender, comorbidities (diabetes, hypertension, and Fig. 1 Study design. International Archives of Otorhinolaryngology Vol. 24 No. 4/2020 Rhim hyperlipidemia), 25-OH vitamin D concentrations and the type and location of the semicircular canals involved in the initial BPPV attacks were reviewed retrospectively. The subjects were instructed to return to the clinic immediately if they suspected BPPV recurrence, and direct patient telephone calls were made to ensure the accuracy of the recurrence data. The entire observation period was of 26 months; The first 2 months were the period of waiting for 25-OH vitamin D levels in the blood to be normal, and the remaining 24 months were follow-up periods (►Fig. 1). Blood samples were collected on the first visit to the hospital and sent for tests on the same day. The 25-OH vitamin D concentrations of the patients were measured using a chemiluminescence immunoassay (CIA; Centaur, Siemens, Munich, Germany) as a serum test. Levels lower than 10 ng/mL were accepted as vitamin D deficient. In the case group, the 25-OH vitamin D concentration was re-evaluated 12 months after the initial diagnosis. Among the 99 patients with idiopathic BPPV with vitamin D deficiency, 25 were enrolled in the present study. During the follow-up period of 2 years, 25 patients (the case group) were injected with 200,000 IU of vitamin D3 through an intramuscular injection into the buttocks within 2 weeks after the initial diagnosis. Twenty patients were submitted to 200,000 IU of vitamin D3 every 3 months after that, and 5 patients were submitted to 200,000 IU (...truncated)