Apogeotropic Horizontal Canal Benign Paroxysmal Positional Vertigo: Zuma e Maia Maneuver versus Appiani Variant of Gufoni

Round 1

Reviewer 1 Report

In the title, Zuma e Maia maneuver should be brought up front.

Appiani is mentioned more than Gufoni in the manuscript which would be very confusing to readers. I think Appiani should be mentioned for one time at first. There are many 'Appiani' in figures and tables.

Abstract should be revised considering the current format, maybe subtitles (introduction, objective, etc) should be removed.

In the introduction, there are too many descriptions about diagnostic positioning test which should be minimized. Instead, difference of two therapeutic maneuver should be discussed more. I do acknowledge that there are some descriptions in methods part, but again should be discussed briefly in introduction as well (do not change the methods).

What is VPPB? It is found in two places in the beginning of methods and result.

Figure 3 itself it not enough to understand the categorization of groups. Figure legend should be included.

Groups should be named in same fashion in table 1, Group A or A / Group A/N or A/N.

Figure 4 and 5 are redundant.

I think regardless of the recurrence successful treatment rate of two therapeutic maneuver should be provided. This should be included in revised manuscript.

Since there are only 54 subjects, authors can formulate the survival graph considering the time and the maneuvers. In addition authors can provide the whole table of subjects and discuss how many times that therapeutic maneuver has beed used in each subjects. Please include both in revised manuscript.

 

Author Response

Reviewer 1:

In the title, Zuma e Maia maneuver should be brought up front.

We appreciate your comment. We have modified the title, as you suggest.

Appiani is mentioned more than Gufoni in the manuscript which would be very confusing to readers. I think Appiani should be mentioned for one time at first. There are many 'Appiani' in figures and tables.

We agree with your comment. We made some modifications in the introduction section, in order to introduce better the Appiani maneuver.

Abstract should be revised considering the current format, maybe subtitles (introduction, objective, etc) should be removed.

We appreciate you comment. We have made those changes in the abstract.

In the introduction, there are too many descriptions about diagnostic positioning test which should be minimized. Instead, difference of two therapeutic maneuver should be discussed more. I do acknowledge that there are some descriptions in methods part, but again should be discussed briefly in introduction as well (do not change the methods).

We agree with your comment. As previously explained, and in order to make both changes you suggest, we have changed the Introduction.

What is VPPB? It is found in two places in the beginning of methods and result.

We appreciate you comment. We made a mistake. We meant BPPV. Changes are already done (see lines 80 and 173).

Figure 3 itself it not enough to understand the categorization of groups. Figure legend should be included.

We appreciate you comment. We had included a Figure legend for that image.

Groups should be named in same fashion in table 1, Group A or A / Group A/N or A/N.

We agree with you comment. They were changed to: “A”, “A/N+” and “S”.

Figure 4 and 5 are redundant.

We appreciate your comment. We considered that those images are a visual summary of the main results obtained. From our point of view, figure 4 is sufficient to graphically summarize results. Thus, we removed figure 5 as you suggested.

I think regardless of the recurrence successful treatment rate of two therapeutic maneuver should be provided. This should be included in revised manuscript.

We appreciate your comment. We have add the successful treatment rate for each maneuver, regardless of the recurrence (see lines 180-181).

Since there are only 54 subjects, authors can formulate the survival graph considering the time and the maneuvers. In addition authors can provide the whole table of subjects and discuss how many times that therapeutic maneuver has beed used in each subjects. Please include both in revised manuscript.

We appreciate your comment. Unfortunately, survival graph is not reliable in this study considering the variable time laps between each revision. Thus, we included this as a limitation in our study (see lines 313-314). In addition, a summary of how many times the therapeutic maneuver has been used has been included as a Figure (see Figure 5).

Reviewer 2 Report

The revised version of this manuscript is really improved and can are accepted for the publication in Audiology Research.

Only one question: the exact title of the manuscript is the one reported in this form or the one reported in the manuscript?

I took that the exact title would be "Apogeotropic Horizontal Canal Benign Paroxysmal Positional Vertigo: Appiani versus Zuma e Maia Maneuver" or in alternative "Apogeotropic Horizontal Canal Benign Paroxysmal Positional Vertigo: the Appiani variant of Gufoni versus Zuma e Maia Maneuver"

Author Response

The exact title of the manuscript is the one reported in this form or the one reported in the manuscript?I took that the exact title would be "Apogeotropic Horizontal Canal Benign Paroxysmal Positional Vertigo: Appiani versus Zuma e Maia Maneuver" or in alternative "Apogeotropic Horizontal Canal Benign Paroxysmal Positional Vertigo: the Appiani variant of Gufoni versus Zuma e Maia Maneuver"

We appreciate your comment. We made a mistake. The title of the manuscript has been changed to: “Apogeotropic Horizontal Canal Benign Paroxysmal Positional Vertigo: Zuma e Maia Maneuver versus Appiani variant of Gufoni”. We also would like to clarify that we have placed Zuma e Maia in front, in order to be in accordance with other comments from reviewers.

Round 2

Reviewer 1 Report

Clearly this manuscript has been improved compared to initial submission. Though there are some limitations and weaknesses in present form, this publication would help readers to develop better therapeutics for BPPV. I agree with the publication in current form. 

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

In this manuscript the Authors compare the results of two different maneuvers for the treatment of the apogeotropic form of BPPV involving the horizontal semicircular canal. The work has many points that need to be deepened and clarified better.

In the present form I do not think it can be accepted for publication in Audiology Research.

 

Major Concerns

               The authors did not perform the Gufoni maneuver (with the head turned downwards when the patient is lying down), but a variant. They clearly say this in the text, citing Appiani. For this reason, the Authors needs to change the title: "Appiani versus Zuma ...", because, if they want to do a job with such a title, they must do the maneuver as Dr. Gufoni have described it. Perhaps it is no coincidence that Gufoni maneuver is not even mentioned in the bibliography (Casani, A. P., et al. (2011). "Horizontal semicircular canal benign paroxysmal positional vertigo: effectiveness of two different methods of treatment." Audiol Neurootol 16(3): 175-184. In this paper a video clip is included with the Gufoni maneuver performed directly by the Author.Mandala M, Pepponi E, Santoro G. P., Cambi J., Casani A, Faralli M, Giannoni B, Gufoni M, Marcelli V., Trabalzini F., Vannucchi P., Nuti D. (2013). "Double-blind randomized trial on the efficacy of the Gufoni maneuver for treatment of lateral canal BPPV." Laryngoscope 123(7): 1782-1786.Gufoni M, Mastrosimone L, Di Nasso F. Trattamento con manovra di riposizionamento per la canalolitiasi orizzontale. Acta Otorhinolaryngol Ital 1998;18:363-7.) 

How does the study be cross-sectional if each patient is in control of himself? And also, how do patients get randomized if the study is retrospective?

Let me explain when they visited the patients and performed the maneuver, the study had not yet begun. The cases were placed there, and the study was done afterwards. So how is it possible that cases are randomized? A randomization is made in the case of a prospective study.

 

Cases from 2014 to 2019 are considered, but Zuma published its maneuver in 2016: if cases were randomly assigned to one maneuver or the other, how did they assign cases to the Zuma maneuver group before 2016?

 

In my experience, I have never met patients with paroxysmal positional nystagmus from lateral canalolithiasis without vertigo (group A / N + "). Furthermore, in these cases a differential diagnosis against a central nervous system involvement should be considered. Instead, I have often found patients still with instability but without nystagmus (these however have not been taken into consideration).

 

Finally, the cases used for the comparison between the two treatments are eight patients treated with Gufoni and eleven cases treated with Zuma: they are very few indeed! I am not an expert in statistics, but I believe that there are not even enough numbers to apply Chiquadro which instead has been done.

  

The Authors affirm that Guf does not work in the case of patients who had already had a BPPV. When? How is possible that a previous episode of a posterior canal PPV (30 years earlier; this is possible because the average age of the population is 69) could affect the outcome of a maneuver for a lateral canal BPPV performed in the same patient thirty years later? And how do you realize that the previous episode was really a VPP? The criterion is only anamnestic!

 

 

According to the Authors, Guf would not work because we are faced with cases of cupulolithiasis of the utricular side: they say that the recurrent forms are cupulolithiasis of the utricular side. This is a supposition not supported by any evidence. On the other hand, in my experience, I have found that PERSISTENT forms are more prone to be considered as cupulolithiasis. However, if there are otolithic fragments attached to the cupula on the utricular side, probably the only maneuver that could

work, in my opinion, would be a modified Gufoni performed on the healthy side with the head rotated upwards.

 

In my opinion, in lateral canal BPPV, the check must be done immediately after the maneuver, otherwise how do you know if for example there is a conversion to a geotropic (and the maneuver must be done on the opposite side) or in the posterior channel?

The Authors don't do it "... in order not to modify the results given a new supine to lateral testing." And I just don't understand what they mean.

 

Minor Concerns

 

The English language must be improved (for example in the Abstract, line 15 “affectation” probably would mean involvement)

Page 2 line 47: “There can be a small  torsional component in which the upper pole of the eye also beats towards the uppermost ear”. In my experience this is not a common occurrence. A reference about it should be added.

Page 2, line 51-52: In my experience, in cupulolithiasis no latency could be observed. However, in the cited paper no observations about it are reported. Please use a more adequate reference.

Page 7, line 207: in the cited paper Guf maneuver is not made as described in the original papers: they rotated the head up instead of down.Page 7, line 212: “Some studies suggest that U-Cup may be more frequent than C-Cup and canalithiasis in the anterior arm of the HC:”: which studies?    

   

 

 

 

 

 

 

 

Reviewer 2 Report

Reading the manuscript as I have been depicted in the grades that I made, I felt this manuscript is good enough to be published in scientific journals to increase the interest of clinicians facing the intractable BPPV.
Such a new strategies would strengthen the vestibular clinicians therapeutic options and would eventually lead to more favorable outcomes.

Reading the manuscript, illustrations of new maneuver was not enough to exactly understand the posture of the patients during the exercise.
I would recommend the authors to include the movie clip of actual therapy and ease the understanding of the reader clinicians.