Rapid Systematic Review

Rapid Systematic Review of Normal

Audiometry Results as a Predictor for
Benign Paroxysmal Positional Vertigo

Otolaryngology
Head and Neck Surgery
2014, Vol. 150(6) 919924
American Academy of
OtolaryngologyHead and Neck
Surgery Foundation 2014
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599814527233
http://otojournal.org

Paul M. Dorresteijn, MSc1,2*, Norbertus A. Ipenburg1,2*,

Kathryn J. Murphy1,2*, Michelle Smit1,2*, Jonna K.
van Vulpen1,2*, Inge Wegner, MD1,3, Inge Stegeman, PhD1,3, and
Wilko Grolman, MD, PhD1,3

No sponsorships or competing interests have been disclosed for this article.

Abstract
Objective. To evaluate whether absence of hearing loss on
pure-tone audiometry (PTA) is reliable as a diagnostic test
for predicting benign paroxysmal positional vertigo (BPPV)
in adult patients with vertigo.
Data Sources. PubMed, Embase, and the Cochrane Library.
Methods. A systematic literature search was conducted on
December 10, 2013. Relevant publications were selected
based on title, abstract, and full text. Selected articles were
assessed for relevance and risk of bias using predetermined
criteria. Prevalence and the positive and negative predictive
value (PPV and NPV) were extracted.
Results. Of 603 retrieved publications, 1 article with high
relevance and moderate risk of bias was included. In this
study, the prevalence of BPPV was 28%. The PPV of hearing
loss assessed by PTA was 31% (95% CI, 17-49) and the NPV
was 73% (95% CI, 61-83). The absence of hearing loss on
PTA decreased the risk of BPPV by 1%.
Conclusion and Recommendation. There is insufficient highquality evidence regarding the diagnostic value of the
absence of hearing loss, assessed by PTA, for predicting
BPPV in adult patients with vertigo.

BPPV is higher in older patients.5 Vertiginous episodes in

BPPV are induced by head movements and are accompanied by a characteristic paroxysmal positional nystagmus.1
These episodes can be provoked by the Dix-Hallpike maneuver. This is also the reference test for diagnosing BPPV.6
Unlike other vestibular disorders, BPPV does not entail
additional hearing loss in patients.7 However, many BPPV
patients show signs of presbycusis or other forms of preexisting hearing loss.8 The prevalence of hearing loss in
BPPV patients ranges from 18% to 95%.8-13 According to
the American Academy of OtolaryngologyHead and
Neck Surgery Foundations 2008 BPPV Clinical Practice
Guideline,7 audiometry is not required to diagnose BPPV.
Nonetheless, pure-tone audiometry (PTA) is frequently
obtained in patients with vertigo.14
The aim of this rapid systematic review is therefore to
evaluate whether absence of hearing loss on PTA is reliable
as a diagnostic test for predicting BPPV in adult patients
with vertigo.

Methods
A rapid systematic review of the available evidence was
performed. Whereas traditional systematic reviews typically
take a minimum of 6 months to 1 year to complete, a rapid
review accelerates the process while maintaining a systematic approach.

Keywords
BPPV, benign paroxysmal positional vertigo, vertigo, puretone audiometry, hearing loss, systematic review
Received January 17, 2014; revised January 27, 2014; accepted
February 18, 2014.

Background
Benign paroxysmal positional vertigo (BPPV) is the most
common cause of vertigo.1 Of all patients with vertigo, 17%
to 42% are diagnosed with BPPV.2-4 The prevalence of

1
Department of OtorhinolaryngologyHead and Neck Surgery, University
Medical Center, Utrecht, The Netherlands
2
Julius Center for Health Sciences and Primary Care, University Medical
Center Utrecht, The Netherlands
3
Brain Center Rudolf Magnus, University Medical Center Utrecht, The
Netherlands
*
These authors contributed equally to this article.

Corresponding Author:
Inge Wegner, MD, Department of OtorhinolaryngologyHead and Neck
Surgery, University Medical Center Utrecht, G05.129, Heidelberglaan 100,
3584 CX Utrecht, The Netherlands.
Email: ENT-research@umcutrecht.nl

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OtolaryngologyHead and Neck Surgery 150(6)

Table 1. Search for Studies on the Diagnostic Value of Hearing Loss, Assessed by PTA, in Diagnosing BPPV in Patients with Vertigo (Date
of Search: December 10, 2013).
Database

Search

Hits

PubMed

((vertigo[tiab] AND positional[tiab]) OR (recurrent[tiab] AND dizziness[tiab] AND benign[tiab])

OR (benign[tiab] AND Paroxysmal[tiab] AND positional[tiab]) OR (benign[tiab] AND
paroxysmal[tiab] AND vertigo[tiab]) OR (recurrent[tiab] AND vertigo[tiab] AND benign[tiab])
OR (vertigo[tiab] AND paroxysmal[tiab] AND positional[tiab]) OR (benign[tiab] AND
paroxysmal[tiab] AND dizziness[tiab]) OR Familial Vestibulopathy[tiab] OR postural
vertigo[tiab] OR BPPV[tiab] OR Benign paroxysmal positional vertigo [Supplementary
Concept] OR paroxysmal vertigo[tiab] OR episodic vertigo[tiab] OR BPPN[tiab] OR
cupulolithiasis[tiab] OR canalolithiasis[tiab] OR canalithiasis[tiab]) AND (hearing
examination[tiab] OR hearing test[tiab] OR hearing tests[tiab] OR Hearing Tests[Mesh]
OR PTA[tiab] OR audio*[tiab] OR auditory test[tiab] OR auditory tests[tiab] OR hearing
loss[tiab])
((vertigo:ab,ti AND positional:ab,ti) OR (recurrent:ab,ti AND dizziness:ab,ti AND benign:ab,ti)
OR (benign:ab,ti AND paroxysmal:ab,ti AND positional:ab,ti) OR (benign:ab,ti AND
paroxysmal:ab,ti AND vertigo:ab,ti) OR (recurrent:ab,ti AND vertigo:ab,ti AND benign:ab,ti)
OR (vertigo:ab,ti AND paroxysmal:ab,ti AND positional:ab,ti) OR (benign:ab,ti AND
paroxysmal:ab,ti AND dizziness:ab,ti) OR Familial Vestibulopathy:ab,ti OR postural
vertigo:ab,ti OR BPPV:ab,ti OR benign paroxysmal positional vertigo/exp OR episodic
vertigo/exp OR positional vertigo/exp OR paroxysmal vertigo:ab,ti OR episodic vertigo:ab,ti
OR BPPN:ab,ti OR cupulolithiasis:ab,ti OR canalolithiasis:ab,ti OR canalithiasis:ab,ti) AND
(hearing examination:ab,ti OR hearing test:ab,ti OR hearing tests:ab,ti OR PTA:ab,ti OR
audio*:ab,ti OR auditory test:ab,ti OR auditory tests:ab,ti OR hearing loss:ab,ti OR hearing
test/exp)
((vertigo AND positional) OR (recurrent AND dizziness AND benign) OR (benign AND
paroxysmal AND positional) OR (benign AND paroxysmal AND vertigo) OR (recurrent AND
vertigo AND benign) OR (vertigo AND paroxysmal AND positional) OR (benign AND
paroxysmal AND dizziness) OR Familial Vestibulopathy OR postural vertigo OR BPPV OR
paroxysmal vertigo OR episodic vertigo OR BPPN OR cupulolithiasis OR canalolithiasis OR
canalithiasis) AND (hearing examination OR hearing test OR hearing tests OR PTA OR
auditory test OR auditory tests OR hearing loss OR audiometry OR audiometric OR
audiogram OR audiograms OR audiology)

406

Embase

The Cochrane Library

531

17

Search and Selection

Study Assessment

A systematic literature search in PubMed, Embase, and the

Cochrane Library was conducted. Relevant synonyms for
the search terms PTA and BPPV were used (Table 1).
Two authors (K.J.M. and J.K.V.) excluded duplicate titles
and independently screened titles and abstracts of the
retrieved records for inclusion. Studies reporting original
data on the diagnostic value of PTA in adult patients with
BPPV were included. Only reports of original study data
were included; systematic reviews, opinion papers, animal
studies, and case reports were excluded (see Figure 1 for
selection criteria). Five independent reviewers (P.M.D.,
N.A.I., K.J.M., M.S., and J.K.V.) screened full texts of eligible articles using the same criteria. Additionally,
PubMed and Web of Science were searched for related
articles, and references of the selected articles were handsearched for titles not identified by our initial search.
Initial disagreements were solved by discussion; hence,
selection is based on full consensus.

Remaining records were assessed for their relevance and

risk of bias by 5 of the authors (P.M.D., N.A.I., K.J.M.,
M.S., and J.K.V.) using predefined criteria (see Table 2 for
assessment criteria). Relevance concerned the applicability
of the study findings for answering the research question
and involved the evaluation of (1) patients, (2) the index
test, and (3) outcomes. Studies were classified as having a
high relevance if they complied with all 3 criteria and moderate if they satisfied 2 of the criteria; the remainder were
classified as low relevance. Assessment of risk of bias
involved evaluation of the extent of selection and information bias, using the Cochrane Collaborations tool for assessing risk of bias.15 Assessment of risk of bias involved
evaluation of (1) the reference test, (2) blinding, standardization of both (3) the index test and (4) the evaluation of
outcomes, (5) selective reporting, and (6) completeness of
reported data. If studies complied with all of these criteria,
they were classified as having a low risk of bias. Studies

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Dorresteijn et al

921
Determinant
Audiogram
406
PubMed
Inclusion criteria:
Original data
Determinant: audiogram
Outcome: BPPV
Exclusion criteria:
Children
Systematic reviews
Animal studies
Laboratory studies
Opinion papers
Case reports

Exclusion (n = 18)
based on:
No original study (n = 5)
Domain (n = 9)
Determinant (n = 1)
No data (n = 3)

Outcome

AND

BPPV

531
Embase

17
Cochrane

954
Removal of duplicates
603
Screening on title and abstract
19
Screening on full-text
1
Study assessment
Cross references (n = 0)
Web of Science (n = 0)

Figure 1. Flowchart for selection of studies on the diagnostic value of hearing loss, assessed by pure-tone audiometry, in diagnosing benign
paroxysmal positional vertigo (BPPV) in patients with vertigo (date of search: December 10, 2013).

were classified as having a moderate risk of bias if they satisfied at least 3 criteria, and the remainder were classified as
high risk of bias. When an item of the study assessment was
reported, it was classified as either satisfactory or unsatisfactory. When an item was not reported, it was rated
unclear. Initial discrepancies between independent reviewers
were resolved by discussion and reported results are based on
full consensus. Studies with either or both low relevance and
high risk of bias were excluded from further review.

Data Extraction
Five authors (P.M.D., N.A.I., K.J.M., M.S., and J.K.V.)
independently extracted descriptive data considering the
study population, the index test, and the reference test from
the included studies. The true-positive, false-positive, truenegative, and false-negative test results were extracted to
enable calculation of the prevalence, the positive and negative predictive values (PPV and NPV respectively), and the
added diagnostic values.

Results
Search and Selection
A total of 954 titles were retrieved. Titles and abstracts of 603
unique studies were screened (Figure 1). After screening the
full text of 19 articles, 1 article16 was selected for study assessment. Cross-reference checking revealed no additional relevant
articles. The results of the assessment of the relevance and risk
of bias evaluation criteria are presented in Table 2.

Study Assessment
The included article by Somefun et al16 scored high on relevance. In this prospective cross-sectional study, consecutive

patients with vertigo were included. Selective reporting was

an issue because included patients with incomplete diagnostic
workup were excluded from further analysis. The DixHallpike maneuver was used as the reference test in all
patients. It was not mentioned at what frequencies PTA was
performed. Blinding of patients and investigators for results
of PTA was also not mentioned. The extracted data of this
study are described in Table 3 and Table 4.

Data Extraction
In the assessed study, 102 patients (aged 21-90 years) were
included. The prior probability, or prevalence, of BPPV
was 28% in this study (95% CI, 20-38). Eleven of these
patients had mild sensorineural hearing loss on PTA
(38%). The PPV of sensorineural hearing loss assessed by
PTA was 31% (95% CI, 17-49), and the NPV was 73%
(95% CI, 61-83). The presence of mild sensorineural hearing loss increases the risk of BPPV by 3% (risk difference
for ruling in BPPV: PPV minus prevalence). In its absence,
the risk of BPPV decreases by 1% (risk difference for
ruling out BPPV: NPV minus 1-prevalence).

Discussion
Although absence of hearing loss in vertiginous patients,
assessed by PTA, is generally considered a useful finding in
diagnosing BPPV, this rapid systematic review shows that
evidence supporting this believe is lacking. In the study by
Somefun et al,16 a negative PTA decreased the diagnostic
certainty for diagnosing BPPV by 1%. This is contrary to
the hypothesis that the absence of hearing loss increases a
patients probability of having BPPV. The small effect size
leads to a marginal clinical applicability. Also the

922

102

No. of
Patients

Cross-sectional

Study
Design


Patientsa


Index
Testb


Outcomec


Reference
Testd
?

Blindinge
?

Standardization (I)f

Standardization (R)g

Risk of Bias

Selective
Reportingh

Complete
Datai

Patients:  = adult patients with vertigo; s = patients diagnosed with BPPV, other.
Index test:  = PTA; s = other.
c
Outcome:  = BPPV as determined by Dix-Hallpike maneuver; s = other.
d
Reference test:  = Dix-Hallpike maneuver performed in all patients; s = Dix-Hallpike maneuver not performed in all patients, reference test other than Dix-Hallpike maneuver; ? = unclear, no information
provided.
e
Blinding:  = adequate blinding of both patients and outcome assessor for results of PTA and Dix-Hallpike maneuver; s = only patients blinded or no blinding; ? = unclear, no information provided.
f
Standardization (I) of index test (PTA):  = yes; s = no; ? = unclear, no information provided.
g
Standardization (R) of reference test (Dix-Hallpike maneuver):  = yes; s = no; ? = unclear, no information provided.
h
Selective reporting:  = adequate sample selection; s = inadequate sample selection; ? = unclear, no information provided.
i
Completeness of outcome data:  = below 10% missing data; s = 10% or more missing data; ? = unclear, no information provided.

Somefun et al (2010)16

Study (Year)

Relevance

Table 2. Assessment of Studies on the Diagnostic Value of Hearing Loss, Assessed by Pure-Tone Audiometry (PTA), in Diagnosing Benign Paroxysmal Positional Vertigo (BPPV) in
Patients with Vertigo.

Dorresteijn et al

923

Table 3. Study Descriptives on the Diagnostic Value of Hearing Loss, Assessed by Pure-Tone Audiometry (PTA), in Diagnosing Benign
Paroxysmal Positional Vertigo in Patients with Vertigo.
Study (Year)
Somefun et al (2010)16

No. of
Patients

Patients

Reference
Test

Definition of Hearing
Loss on PTA

Timing of PTA

102

Adult patients with vertigo

Dix-Hallpike test

Unknown

Unknown

Table 4. Results of Studies on the Diagnostic Value of Hearing Loss, Assessed by Pure-Tone Audiometry (PTA), in Diagnosing Benign
Paroxysmal Positional Vertigo in Patients with Vertigo.
Added Diagnostic Value
Study (Year)
Somefun et al (2010)16

No. of Patients

Prevalencea

Positive Predictive Valuea

Negative Predictive Valuea

To Rule In

To Rule Out

102

28 (20-38)

31 (17-49)

73 (61-83)

3%

1%

Percentage (95% confidence interval).

confidence intervals are broad, leading to an uncertainty

of the effect for the research question. This study has
some major limitations. First, all initially included
patients who did not complete the full diagnostic workup
were excluded from further analysis. This may have led
to selective dropout of patients. One explanation might be
that patients who did not experience hearing loss did not
see the point of undergoing a PTA. Assuming that these
patients did indeed not have hearing loss, this would have led
to an overestimation of the percentage of patients with hearing loss. However, individuals with hearing loss might be
afraid to see the diagnosis confirmed, leading to an underestimation of the number of patients with hearing loss. Second,
the article did not state how the PTA was performed in every
subject. It is unclear whether this led to information bias. In
the article, an extended specification of several types of hearing loss was given. However, the degree of sensorineural
hearing loss was not stated. It was also not mentioned
whether the investigators of the Dix-Hallpike maneuver were
blinded for the results of PTA. This might have influenced
the assessment of the maneuver. The generalizability of the
study could also be a point of discussion. It is unclear
whether the results of this Nigerian study can be generalized
to other populations.
To our knowledge, this is the first publication reviewing
the diagnostic value of hearing loss, assessed by PTA, in
diagnosing BPPV in adult patients with vertigo. Strengths of
this rapid systematic review include the comprehensive and
extensive search for evidence and the independent quality
assessment. Furthermore, this topic is clinically relevant,
because of the high prevalence of BPPV and the fact that
PTA is frequently performed in patients with vertigo.1-4
Unfortunately, we could only use 1 article to answer our
research question. Most research in this field has a follow-up
design,10,11,17-19 including patients with BPPV instead of
undiagnosed patients with vertigo.8,9,12,20 Their audiogram
data could therefore not be used to calculate predictive values.

Conclusion and Recommendation

Although absence of hearing loss, assessed by PTA, is in
general considered to be an indicator for BPPV, there is
insufficient evidence to support this statement. Our literature
review yielded 1 article, with a moderate risk of bias, to
answer our research question. The findings of this article
suggest that the absence of hearing loss on PTA slightly
decreases the probability of BPPV. However, this article
had a small effect size with broad confidence intervals and
therefore unsubstantial statistical power to answer our
research question. More research is therefore needed. We
suggest a large prospective cross-sectional study to investigate the use of PTA in diagnosing BPPV among adults with
vertigo. Researchers should be blinded for the outcome of
PTA, and diagnostic workup should be completed in all
patients.
Author Contributions
Paul M. Dorresteijn, writing, data collection, data analysis, interpretation, drafting and revision, approval final version;
Norbertus A. Ipenburg, writing, data collection, data analysis,
interpretation, drafting and revision, approval final version;
Kathryn J. Murphy, writing, data collection, data analysis, interpretation, drafting and revision, approval final version; Michelle
Smit, writing, data collection, data analysis, interpretation, drafting and revision, approval final version; Jonna K. van Vulpen,
data analysis and interpretation, drafting and revision, approval
final version; Inge Wegner, data analysis, interpretation, drafting
and revision, approval final version; Inge Stegeman, data analysis, interpretation, drafting and revision, approval final version;
Wilko Grolman, design, drafting and revision, approval final
version, supervision.

Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.

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OtolaryngologyHead and Neck Surgery 150(6)

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