BURUN

LAK BO
KU ĞA
R
Şİ

Z
Kulak Burun Bogaz Ihtis Derg 2014;24(3):159-163 doi: 10.5606/kbbihtisas.2014.00018 159
AN

HA
EV

ST
B EH B UT C

AL IK
LARI
. .
Original Article / Çalışma - Araştırma
İ
VE

EĞ

Ş R
BA

BO E
YU İD
N C E R R A Hİ S

An investigation of atherosclerotic markers in patients with

posterior semi-circular canal benign paroxysmal
positional vertigo

Arka yarı dairesel kanal benign paroksismal pozisyonel vertigolu hastalarda

aterosklerotik belirteçlerin araştırılması

Murat Baykara, MD.,1 Cahit Polat, MD.,2 Cansu Öztürk, MD.,1 Turgut Karlıdağ, MD.3

Department of Radiology, Elazığ Training and Research Hospital, Elazığ, Turkey

1

2
Department of Otolaryngology, Elazığ Training and Research Hospital, Elazığ, Turkey
3
Department of Otolaryngology, Medical Faculty of Fırat University, Elazığ, Turkey

Objectives: This study aims to investigate the presence and incidence of arteriosclerosis in patients with benign
paroxysmal positional vertigo (BPPV).
Patients and Methods: A total of 89 patients who were admitted to the ear, nose, throat outpatient clinic with complaint of
vertigo and were diagnosed with BPPV based on the positive Dix-Hallpike test results were included (BPPV group) between
January 2010 and July 2010. Data from otological asymptomatic controls (n=129) who were referred to the radiology
department from other clinics for ultrasound examination were obtained. Intima-media thickness and arteriosclerosis
measurements were carried out. Arteriosclerosis measurement was performed through a Doppler ultrasound.
Results: No statistically significant difference in carotid, femoral intima-media thicknesses and elastic modulus
measurements between the controls and BPPV group. In the BPPV group, carotid artery cross-sectional compliance,
cross-sectional distensibility, femoral artery cross-sectional compliance and cross-sectional distensibility were statistically
significantly lower.
Conclusion: Our study results suggest that atherosclerotic changes may play a role in the underlying etiology of BPPV.
Key Words: Arteriosclerosis; benign paroxysmal positional vertigo; intima-media thickness.

Amaç: Bu çalışmada benign paroksismal pozisyonel vertigo (BBPV) olan hastalarda arteriyoskleroz varlığı ve insidansı
araştırıldı.
Hastalar ve Yöntemler: Ocak 2010 ve Temmuz 2010 tarihleri arasında vertigo yakınması ile kulak, burun, boğaz polikli-
niğine başvuran ve pozitif Dix-Hallpike test sonucuna göre BPPV tanısı konan toplam 89 hasta (BPPV grubu) çalışmaya
alındı. Diğer kliniklerden ultrason incelemesi için radyoloji kliniğine sevk edilen otolojik asemptomatik kontrollerin verileri
elde edildi. İntima-media kalınlığı ve arteriyoskleroz ölçümleri yapıldı. Arteriyoskleroz ölçümü Doppler ultrason ile yapıldı.
Bulgular: Karotis, femoral intima-media kalınlığı ve elastik modülüs ölçümleri açısından kontroller ve BPPV grubu arasın-
da istatistiksel olarak anlamlı bir fark yoktu. Karotis arter çapraz kesitsel uyum, çapraz kesitsel distansibilite, femoral arter
çapraz kesitsel uyum ve çapraz kesitsel distansibilite BPPV grubunda istatistiksel anlamlı olarak daha düşüktü.
Sonuç: Çalışma bulgularımız, aterosklerotik değişikliklerin BPPV’nin altta yatan etyolojisinde bir rolü olabileceğini göster-
mektedir.
Anahtar Sözcükler: Arteriyoskleroz; benign paroksismal pozisyonel vertigo; intima-media kalınlığı.

Available online at Received / Geliş tarihi: December 18, 2013 Accepted / Kabul tarihi: February 20, 2014
www.kbbihtisas.org Correspondence / İletişim adresi: Murat Baykara, M.D. Elazığ Eğitim ve Araştırma
doi: 10.5606/kbbihtisas.2014.00018 Hastanesi Radyoloji Kliniği, 23100 Elazığ, Turkey.
QR (Quick Response) Code Tel: +90 532 - 771 20 88 e-mail (e-posta): [email protected]
160 Kulak Burun Bogaz Ihtis Derg

Vertigo is a disruption of vertical orientation with BPPV with normal results during routine
or an illusion of movement. Benign paroxysmal audiological, biochemical, and imagining tests
positional vertigo (BPPV) is a common entity and positive Dix-Hallpike tests were included
and is a component of peripheral vestibular in this study. Otological asymptomatic control
disorders, which are especially encountered group data was obtained by getting permission
with an older patient.[1] Since the underlying from cases referred to the radiology department
pathophysiological mechanism of vertigo cannot for ultrasound (US) examination who did
be explained precisely,[2] the intended success not demonstrate any pathology in their US
of patient treatment is sometimes not achieved. examinations.
Sunami[3] claim that there may be a relationship
Body mass index (BMI) and waist hip ratio
between BPPV recurrence and diseases such
(WHR) were assessed in all cases. Intima-media
as hypertension and hyperlipidemia which are
thickness was measured in all the cases. Arterial
associated with certain life styles. Wada et al.[4]
stiffness measurements were taken as follows:
report that there is a significant correlation
between BPPV, which requires long-term Measurements were carried out 2 cm before the
treatment, and diseases such as hypertension right carotid artery bifurcation and 2 cm after the
and hyperlipidemia. Results of the recent studies deep branch division of the right femoral artery.
suggest that there may be a relationship between
All non-invasive measurements were made by
arteriosclerosis, which accompanies diseases
the same investigator, who used and a US imager
associated with certain life styles, and BPPV.
[SSA-660A (Xario), PLT-704AT Prob, (Toshiba
Numerous methods have been developed in Medical Systems Corporation, Tochigi, Japan)].
order to determine the existence and prevalence Intima-media thickness, lumen diastolic (dD) and
of arteriosclerosis. Noninvasive intima- systolic (sD) diameters were measured at the
media thickness (IMT) and arterial stiffness common carotid and femoral arteries according to
measurements are among the most common the previously described procedure.[7]
methods.[5,6] The factor that causes mechanical
The lumen cross-sectional area was calculated
stress in the physiology of arterial structures
as πdD2/4 and the wall cross-sectional area
is called pressure. While the changes in the
as π(dD/2+IMT)2-π(dD/2)2 . Cross-sectional
diameter due to pressure are called strain. The
compliance and distensibility of the common
relationship between these two physiological
carotid artery were calculated from diameter
conditions reflects arterial elasticity or stiffness.
changes during systole and from simultaneously
Quantitative counterparts of elasticity and
measured pulse pressures (ΔP) according to the
stiffness are compliance and distensibility.
following formulae:
Distensibility implies proportional changes due
to an increase in pressure while compliance Cross-sectional compliance= π[(sD2-dD2)]/4ΔP;
implies the absolute changes in diameter due to
Cross-sectional distensibility= (sD2-dD2)/(dD2.ΔP)
the increase in pressure.
Diastolic wall stress was calculated using the
This study aims to investigate the existence
mean arterial pressure multiplied by dD/2IMT.
or frequency of arteriosclerosis through non-
Whereas compliance provides information on
invasive methods on patients who were referred
the elasticity of the artery as a hollow structure,
to ear nose and throat (ENT) clinics with BPPV by
the incremental elastic modulus provides
measuring IMT and arterial stiffness in carotid
information on the properties of the wall material
and femoral arteries.
independently from the arterial geometry. This
PATIENTS AND METHODS variable was calculated as 3/(1+lumen cross-
sectional area/wall cross-sectional area) divided
Ethical approval was obtained from the Ethics
by cross-sectional distensibility.
Committee of our institution and patient consents
were obtained. Statistical analysis
Patients that were referred to ENT clinics Data was expressed as mean ± standard
with vertigo were compiled in the first half deviation (SD). The differences between data
of 2010. Patients that were clinically diagnosed were studied using the Student t test and the
Atherosclerotic markers in benign paroxysmal positional vertigo 161

Table 1. Ages, body mass index, waist hip ratio values of In the BPPV group, carotid artery cross-
the investigated groups sectional compliance and cross-sectional
Controls BPPV distensibility were found to be low in statistically
significance (p<0.001) (Table 2).
Mean±SD Mean±SD p
DISCUSSION
Age 48.93±19.65 46.52±17.44 0.352
Body mass index (kg/m2) 28.55±5.38 27.94±5.35 0.410 Vertigo is the illusion of motion.[8] Cases referred
Waist/hip ratio 0.82±0.06 0.81±0.08 0.293 with vertigo complaints should be considered
BPPV: Benign paroxysmal positional vertigo; SD: Standard deviation.
with medical, neurological, and otological
reasons.[9] It is especially important to distinguish
the peripheral (otologic) and central (neurologic)
Mann-Whitney U test. The level of statistical reasons for vertigo. Benign paroxysmal positional
significance was taken as p<0.05. Data was vertigo, Meniere's disease, and vestibular neuritis
analyzed using SPSS for Windows version 15.0 can be considered among the otologic reasons.
software program (SPSS Inc., Chicago, IL, USA). Benign paroxysmal positional vertigo is the most
common vestibular disorder. Epidemiological
RESULTS studies show that the average age of the onset
There was no significant difference between the of vertigo is 54. However, they may occur in
demographic characteristics of individuals in both some people between the ages of 11 to 84.[10]
groups, such as a history of arterial hypertension, Recently peripheral vestibular disorders have
been reported to be related to arteriosclerosis and
diabetes, high cholesterol, smoking, previous
other diseases associated with the certain life
stroke, etc.
styles.[11]
There were 89 BPPV patients (57 males and
Sonographic investigation of carotid and
32 females) with an average age of 46 (range
femoral arteries is quite important for noninvasive
15-85). There were 129 controls (73 males and 56 assessment of arteriosclerosis. Arterial stiffness
females), with average age of 48 (range 13-78), is a term, which implies stiffness of the
(Table 1). vessel walls while arterials tend to lose their
The distribution of sexes between the control elasticity and is considered a component of
and BPPV groups was proportional. There was arteriosclerosis. Numerous parameters were
no statistically significant difference between the shown as a marker of arterial stiffness and
ages (p=0.352), BMI (p=0.410) and WHR (p=0.293) these parameters have no superiority over one
of these groups. another. Changes of vessel walls at an early
arteriosclerosis stage, which generally occur
There were no statistically significant before having a clinical symptom, were mainly
differences observed between carotid and femoral investigated in the aorta, brachial, and femoral
IMT and elastic modulus measurements between arteries.[12] Arterial stiffness measurements in
the control and BPPV groups. carotid arteries were noted in previous studies

Table 2. Carotid and femoral arteries intima-media thickness and arterial stiffness measures
of investigated groups
Controls BPPV
Mean±SD Mean±SD p

Carotid intima-media thickness (mm) 0.39±0.13 0.42±0.15 0.117

Carotid cross-sectional compliance 0.201±0.006 0.156±0.006 0.001
Carotid cross-sectional distensibility 0.0082±0.0003 0.0067±0.0003 0.001
Femoral intima-media thickness (mm) 0.39±0.15 0.42±0.9 0.710
Femoral cross-sectional compliance 0.18±0.01 0.14±0.04 0.001
Femoral cross-sectional distensibility 0.0079±0.0004 0.0074±0.0003 0.001
BPPV: Benign paroxysmal positional vertigo; SD: Standard deviation.
162 Kulak Burun Bogaz Ihtis Derg

such as ARIC and SMART. They are now accepted Funding

as a new risk factor for arteriosclerosis.[13-15]
The authors received no financial support for
In addition, IMT measurements in the carotid
the research and/or authorship of this article.
artery have shown to be a noninvasive and
reliable marker in order to show the existence REFERENCES
and prevalence of arteriosclerosis. 1. Cloutier JF, Saliba I. Isolated vertigo and dizziness
of vascular origin. J Otolaryngol Head Neck Surg
In the study carried out by Cruz et al. it is
[11]
2008;37:331-9.
claimed that arteriosclerotic risk factors such as 2. Wada M, Naganuma H, Tokumasu K, Okamoto M.
smoking, alcohol drinking, and hypertension Correlation between arteriosclerotic changes and
together with emotional stress are all independent prognosis in patients with peripheral vestibular
factors which increase the prevalence of balance disorders. Int Tinnitus J 2009;15:193-5.
3. Sunami K. Factors associated with recurrence BPPV.
disorders in young adults. These are all associated Equilib Res 2005;64:64-70.
with the arteriosclerotic process. In some 4. Wada M, Naganuma H, Tokumasu K, Ito A, Okamoto
epidemiological studies it is reported that older M. Inner-ear function test in cases of posterior canal-
women with low high-density lipoprotein (HDL) type benign paroxysmal positional vertigo. Int
Tinnitus J 2009;15:91-3.
values and abdominal obesity tend to show more
5. Arnett DK, Evans GW, Riley WA. Arterial stiffness:
balance disorders.[16] a new cardiovascular risk factor? Am J Epidemiol
1994;140:669-82.
The study on the relationship between
6. Hodes RJ, Lakatta EG, McNeil CT. Another
prognosis and arteriosclerosis in BPPV cases, modifiable risk factor for cardiovascular disease?
which was carried out by Wada et al.,[2] carotid Some evidence points to arterial stiffness. J Am
IMT was found to be higher in the BPPV group Geriatr Soc 1995;43:581-2.
compared to the control group. No statistically 7. Baykara M, Öztürk C, Elbüken F. The relationship
between bone mineral density and arterial stiffness in
significant differences were noted between women. Diagn Interv Radiol 2012;18:441-5.
the carotid and femoral IMT measurements of 8. Halmagyi GMA, Akdal G. Vertigo and imbalance. J
the BPPV and the control groups in our study. Neurol Sci 2005;22:123-41.
However, in the study of arterial distensibility and 9. Furman JM, Cass SP. Benign paroxysmal positional
compliance, which are markers of arteriosclerotic vertigo. N Engl J Med 1999;341:1590-6.
10. Baloh RW, Honrubia V, Jacobson K. Benign positional
process in carotid and femoral arteries, the vertigo: clinical and oculographic features in 240
vertigo group was found to be lower compared cases. Neurology 1987;37:371-8.
to the control group. Hemenway and Lindsay[17] 11. Cruz IB, Barreto DC, Fronza AB, Jung IE, Krewer
reported that the etiology of BPPV, which is based CC, Rocha MI, et al. Dinamic balance, lifestyle
on the degeneration due to the obstruction of and emotional states in young adults. Braz J
Otorhinolaryngol 2010;76:392-8.
vestibular artery, is a circulatory impairment. 12. Godia EC, Madhok R, Pittman J, Trocio S, Ramas
Microcirculation disorders that may occur in R, Cabral D, et al. Carotid artery distensibility: a
the inner ear will result in more mobile otolith reliability study. J Ultrasound Med 2007;26:1157-65.
development and BPPV.[18] Results show that 13. Liao D, Arnett DK, Tyroler HA, Riley WA,
increases in arterial stiffness and arteriosclerosis Chambless LE, Szklo M, et al. Arterial stiffness and
the development of hypertension. The ARIC study.
are more common in cases with BPPV. Hypertension 1999;34:201-6.
This trial suggests that atherosclerotic changes 14. Dijk JM, Algra A, van der Graaf Y, Grobbee DE, Bots
ML; SMART study group. Carotid stiffness and the
are more commonly observed in BPPV cases and risk of new vascular events in patients with manifest
should be assessed as a factor, which may have cardiovascular disease. The SMART study. Eur Heart J
a role in BPPV etiology. Diagnosis and treatment 2005;26:1213-20.
of underlying arteriosclerosis in these patients 15. Dijk JM, van der Graaf Y, Grobbee DE, Bots ML;
SMART Study Group. Carotid stiffness indicates risk
can decrease the symptoms of BPPV along with of ischemic stroke and TIA in patients with internal
the risk of cerebrovascular and cardiovascular carotid artery stenosis: the SMART study. Stroke
events. 2004;35:2258-62.
16. Okoro CA, Zhong Y, Ford ES, Balluz LS, Strine TW,
Declaration of conflicting interests Mokdad AH. Association between the metabolic
syndrome and its components and gait speed among
The authors declared no conflicts of interest U.S. adults aged 50 years and older: a cross-sectional
with respect to the authorship and/or publication analysis. BMC Public Health 2006;6:282.
of this article. 17. Hemenway WG, Lindsay JR. Postural vertigo due to
Atherosclerotic markers in benign paroxysmal positional vertigo 163

unilateral sudden partial loss of vestibular function. S, Ito A, Okamoto M. Arteriosclerotic changes as
Ann Otol Rhinol Laryngol 1956;65:692-706. background factors in patients with peripheral
18. Wada M, Naganuma H, Tokumasu K, Hashimoto vestibular disorders. Int Tinnitus J 2008;14:131-4.