Is the vitamin D deficiency a cause of intractable BPPV?

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Dastan Temirbekov, Elif Sari This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5753749/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background This study investigated the association between treatment resistance in benign paroxysmal positional vertigo (BPPV) and various risk factors, including vitamin D deficiency, age, gender, and comorbidities. Methods A retrospective review of medical records was conducted on 122 patients diagnosed with BPPV at a tertiary care hospital between January 2020 and January 2023. The diagnosis of BPPV was confirmed using clinical history and positional tests, while serum 25-OH vitamin D levels were measured using chemiluminescence immunoassay. Patients who required three or more canalith repositioning maneuvers were considered treatment-resistant. Logistic regression analysis was employed to assess the impact of demographic and clinical factors on BPPV treatment resistance, and recurrence rates were evaluated over a one-year follow-up period. Results. Logistic regression revealed that male gender, comorbidities, and betahistine use were significantly associated with BPPV resistance (p 0.05). Recurrence was observed in 22.1% of patients during the follow-up period, though this was not significantly related to vitamin D status. Conclusions While previous studies suggested a potential link between vitamin D deficiency and BPPV recurrence, this study found no significant association between vitamin D deficiency and intractability along with the recurrence of BPPV. Instead, male gender, comorbidities (notably hypertension), and betahistine use were identified as risk factors for requiring multiple maneuvers. The study raises questions about the role of vitamin D in BPPV pathophysiology and suggests that other clinical factors may have a greater influence on treatment outcomes. Benign Paroxysmal Positional Vertigo intractable BPPV recurrent BPPV Vitamin D deficiency Figures Figure 1 Background Benign Paroxysmal Positional Vertigo (BPPV), being one of the most common causes of peripheral vertigo, is characterized by short, recurrent episodes of vertigo triggered by certain head positions [ 1 ]. The underlying pathophysiology of BPPV is attributed to the displacement of otoconia from the utricle into the semicircular canals, leading to abnormal vestibular responses to head movements [ 1 ]. BPPV has been associated with various risk factors, including age, gender, head trauma, and comorbidities such as migraine and Meniere's disease, vascular diseases, diabetes, vitamin D deficiency, and osteoporosis [ 2 , 3 ]. Vitamin D, a fat-soluble nutrient, is essential for several physiological functions, including maintaining calcium and phosphorus balance, supporting bone health, and regulating immune function [ 4 ]. Vitamin D deficiency is a global health issue that affects a significant proportion of the population [ 4 ]. Emerging evidence suggests that vitamin D deficiency may contribute to the pathogenesis of several neurological disorders, including multiple sclerosis, Parkinson's disease, and Alzheimer's disease [ 5 – 7 ]. Recent studies have also explored the potential association between vitamin D deficiency and BPPV [ 8 ]. It has been hypothesized that vitamin D deficiency may contribute to the development of BPPV by affecting the calcium metabolism in the vestibular system, leading to otoconia degeneration and displacement [ 9 ]. Some studies have reported a higher prevalence of vitamin D deficiency among BPPV patients compared to healthy controls [ 8 – 10 ]. Moreover, a few clinical trials have demonstrated that vitamin D supplementation may reduce the recurrence rate of BPPV [ 11 ]. However, the relationship between vitamin D deficiency and the resistance to treatment of BPPV remains inconclusive. Most of the previous studies have focused on the effects of vitamin D supplementation on BPPV recurrence, and few have investigated the treatment course of BPPV in patients with vitamin D deficiency. In this study, we aimed to investigate the association between treatment resistance of BPPV and several risk factors, including vitamin D deficiency, age, gender, and comorbidities. Methods Study design We retrospectively reviewed the medical records of the adult patients who underwent treatment in our tertiary care hospital with the diagnosis of BPPV between January 2020 and January 2023. The inclusion criteria for the study were patients aged 18 to 65 diagnosed with BPPV based on their clinical history and positive Dix-Hallpike or Roll test results and measured serum vitamin D levels. The blood tests must be done within one month of BPPV diagnosis. The 25-OH vitamin D concentration was measured using chemiluminescence immunoassay (Centaur; Siemens Healthineers, Erlangen, Germany) as a serum test. The exclusion criteria were a history or clinical findings of any metabolic disorders. Patients with a history of head trauma, otologic surgery, or those who received vitamin D supplementation during the study period were also excluded from the study. Ethical Approval and Informed Consent This retrospective study received approval from the Institutional Ethics Committee and followed the principles outlined in the Declaration of Helsinki. Data Collecting and Recording The patients’ files deemed suitable for the study were reviewed, and demographic data and all the comorbidities were recorded. Since all patients who started treatment in our clinic routinely fill out Dizziness handicap inventory (DHI) and Visual Analog Scale (VAS) questionnaires, we were able to record the results of our patients' questionnaires. Vitamin D status was categorized according to serum 25(OH)D levels in the following manner: deficiency was defined as less than 20 ng/mL, insufficiency as 20–29 ng/mL, and sufficiency as 30 ng/mL or greater. In this study, individuals with serum 25(OH)D levels below 20 ng/mL were regarded as having vitamin D deficiency. BPPV Diagnosis and Treatment BPPV diagnosis was based on the presence of a history of positional vertigo and a positive Dix-Hallpike test for posterior canal BPPV or a positive Roll test for horizontal canal BPPV. The involved semicircular canal was determined based on the direction of nystagmus during the diagnostic maneuvers. All participants received canalith repositioning maneuvers, such as the Epley maneuver for posterior canal BPPV or the Lempert maneuver (Barbecue roll) for horizontal canal BPPV, as the initial treatment. Patients were called for a control examination at 3–4 day intervals, and canalith repositioning maneuvers were repeated until positioning tests were negative. Patients who required three or more maneuvers were considered intractable to treatment. Participants were considered successfully treated if they had no positional nystagmus or vertigo during the follow-up visit within one week of the initial treatment. After the treatment, the patients were asked to fill out the DHI and VAS questionnaire forms again. Follow-up and Assessment of Recurrence Participants were followed up for at least one year after the diagnosis of BPPV. Recurrence was defined as the reappearance of vertigo symptoms and a positive Dix-Hallpike or Roll test during the follow-up period after a successful initial treatment. Participants were instructed for follow-up visits every year or whenever they experienced recurrent vertigo symptoms. The follow-up visits included a detailed clinical history, otoscopic examination, and vestibular function tests, as needed. Statistical Analysis The data were examined for normal distribution using the Shapiro-Wilk test, and the difference between initial and final measurements that did not have a normal distribution was examined using the Wilcoxon signed rank test. Associations among variables measured quantitatively were assessed using Spearman's Correlation Coefficient. A coefficient value between 0.8 and 1 signifies a very strong association, values from 0.6 to 0.8 indicate a strong association, values from 0.4 to 0.6 suggest a moderate association, and values between 0.2 and 0.4 represent a weak association [ 12 ]. The effects of age, gender, some clinical characteristics, and laboratory characteristics of the cases on the increase in the number of maneuvers were first analyzed using the Univariate LR (Logistic Regression) method. For descriptive statistics, numerical variables were reported as Median [IQR: Interquartile Range, Q1 – Q3], while categorical variables were presented as frequencies and percentages. Statistical analyses were performed using SPSS version 25.0 (IBM Corporation, Armonk, NY, USA), with a significance level set at p < 0.05. Results A total of 122 patients diagnosed with BPPV were included in the study. The mean age of the participants was 54 ± 11.3 years, and gender distribution was 63.9% female and 36.9% male patients. The distribution of demographic and clinical features of the cases is demonstrated in Table 1 . Based on the serum 25(OH) D levels, 47.5% of the patients had vitamin D deficiency (less than 20ng/ml), and 52.5% of patients had normal or insufficient vitamin D levels. The baseline characteristics of the participants, including age, gender, and comorbidities, were comparable between the vitamin D-deficient and non-deficient groups (p > 0.05). The most common comorbid diseases were: hypertension, vestibular migraine, diabetes mellitus, and vestibular insufficiency. Hypertension was seen in 25 cases (36.8%), vestibular migraine in 8 cases (11.8%), diabetes in 7 cases (10.3%), and vestibular insufficiency in 6 cases (8.8%) (Fig. 1 ). Table 1 Demographic and clinical feature distribution of the patients Features n(%) / M[Q1-Q3] Sex Male 44 (36,1) Female 78 (63,9) Age 54 [40,5–64] Comorbidity Yes 53 (43,4) No 69 (56,6) vıtamın D level 19 [13,35 − 30,25] Duration of the disease [month] 1 [0,25 − 12] number of maneuvers 3 [ 2 – 4 ] Affected canal Posterıor 87 (71,3) Lateral 23 (18,9) Multıple 12 (9,8) Posterıor canal L + R 4 (4) Left 50 (50,5) Right 45 (45,5) Lateral canal Left 21 (72,4) Right 8 (27,6) Multıple canal Yes 12 (9,8) no 110 (90,2) Cupulolıttiasis yes 7 (5,7) no 115 (94,3) Betahistine use yes 49 (40,2) no 73 (59,8) Reccurence Yes 27 (28,7) no 95 (71,3) Intactable to treatment No (1–2) 68 (55,7) yes ( > = 3) 54 (44,3) M:Median, Q1:Quartile 1, Q3:Quartile 3 Logistic regression analysis determined the factors requiring three or more maneuvers in the cases (Table 2 ). It was determined that gender, presence of comorbid diseases, and Betahistine use were factors affecting the increase in the number of maneuvers (p = 0.005 & p = 0.017 & p = 0.020 & p = 0.002, respectively). It was determined that males had a (95% CI: 1.395–6.450) higher risk of having more maneuvers than females. Individuals with comorbid diseases had a 2.446-fold (95% CI: 1.172–5.101) higher risk of having more maneuvers. Patients who took betahistine (95% CI: 1.163–5.866) had more maneuvers than patients who did not (Table 3 ). No significant relationship was found between the increase in the number of maneuvers and variables such as age, involved semicircular canal, vitamin D level, and duration of symptoms before treatment (p > 0.05). Table 2 Potential risk factors associated with increased numbers of maneuver (3 or more) in the logistic regression equation. Variable n Prevelance (%) Exp (β) 95% CI for Exp(β) p-value Sex Female 78 63,9 1 Male 44 36,1 3 1,395-6,450 0,005 Age < 40 30 25,0 1 40–49 21 17,5 0,905 0,297-2,762 0,861 50–59 25 20,8 1,027 0,352-2,996 0,960 60–69 24 20,0 1,107 0,376-3,258 0,854 70–79 16 13,3 1,017 0,299-3,457 0,978 80+ 4 3,3 1,308 0,162 − 10,559 0,801 Canal Lateral canal 23 18,9 1 Posterior canal 87 71,3 1,098 0,429-2,810 0,845 Multiple canal 12 9,8 4,667 0,989 − 22,030 0,052 Duration of symptoms 20 19 47,5 2,383 0,655-8,675 0,188 Comorbidity No 69 43,4 1 Yes 53 56,6 2,446 1,172-5,101 0,017 Hypertension No 97 79,5 1 Yes 25 20,5 2,211 0,504-9,699 0,293 Vestibular Migrane No 114 93,4 1 Yes 8 6,6 1,814 0,747-4,404 0,188 Betahistine No 73 40,2 1 Yes 49 59,8 3,744 1,747-8,024 0,001 Reccurence No 95 28,7 1 Yes 27 71,3 1,906 0,769-4,721 0,163 Exp(β):Odds Ratio, CI: Confidence Interval Table 3 The relationship between numbers of the maneuvers and characteristic features of the cases Number of maneuvers 1 (n = 44) 2 (n = 24) 3 (n = 18) 4 (n = 11) ≥ 5 (n = 25) n(%) n(%) n(%) n(%) n(%) p Sex Man 6 (13,6) 11 (45,8) 10 (55,6) 6 (54,5) 11 (44) 0,003 Woman 38 (86,4) 13 (54,2) 8 (44,4) 5 (45,5) 14 (56) Age < 40 10 (22,7) 7 (29,2) 5 (27,8) 0 (0) 8 (32) 0,457 40–49 6 (13,6) 7 (29,2) 2 (11,1) 1 (10) 6 (24) 50–59 9 (20,5) 5 (20,8) 2 (11,1) 4 (40) 5 (20) 60–69 10 (22,7) 3 (12,5) 4 (22,2) 3 (30) 4 (16) 70–79 8 (18,2) 1 (4,2) 5 (27,8) 1 (10) 1 (4) 80+ 1 (2,3) 1 (4,2) 0 (0) 1 (10) 1 (4) Comorbidity Yes 10 (22,7) 13 (54,2) 10 (55,6) 7 (63,6) 13 (52) 0,014 No 34 (77,3) 11 (45,8) 8 (44,4) 4 (36,4) 12 (48) Affected canal Lateral canal 10 (22,7) 4 (16,7) 2 (11,1) 2 (18,2) 5 (20) 0,397 Posterior canal 32 (72,7) 19 (79,2) 14 (77,8) 6 (54,5) 16 (64) Multiple canal 2 (4,5) 1 (4,2) 2 (11,1) 3 (27,3) 4 (16) Recurrences ın at least 1 year Yes 3 (11,1) 8 (36,4) 5 (31,3) 4 (40) 7 (36,8) 0,199 no 41 (88,9) 16 (63,6) 13 (68,8) 7 (60) 18 (63,2) p value was obtained from Pearson Chi Square test During the at least one-year follow-up period, 27 (22.1%) patients experienced a recurrence of BPPV. The recurrence rate was not significantly higher in the vitamin D-deficient group (p = 0.188) compared to the non-deficient group. The Kaplan-Meier survival analysis showed that the recurrence-free survival rate was lower in the vitamin D-deficient group than in the non-deficient group. Still, this difference was not statistically significant (P > 0.05) (Table 4 ). Table 4 The relationship between vitamin D deficiency and the need for increased maneuvers Not intractable (1–2 maneuvers) Intractabe (≥ 3 maneuvers) n(%) n(%) p vitamin D level ≤ 19 8 (66,7) 10 (43,5) 0,193 > 20 4 (33,3) 13 (56,5) Discussion The pathophysiology of BPPV is primarily attributed to the displacement of otoconia from the utricle into the semicircular canals, leading to abnormal vestibular responses to head movements [ 13 ]. Otoconia are calcium carbonate crystals that play a crucial role in the mechanical transduction of gravitational forces and head movements into electrical signals within the vestibular system [ 14 ]. The integrity and function of otoconia are maintained by a delicate balance of calcium and phosphorus homeostasis, which is regulated by various factors. Seemingly, vitamin D also plays a certain role in the regulation of calcium metabolism, including calcium carbonate of the otoconia [ 10 , 15 ]. The link between vitamin D deficiency and BPPV has gained considerable attention in recent years. Numerous studies have shown that vitamin D deficiency is more common in patients with BPPV than in healthy individuals [ 16 – 18 ]. Although most studies suggest that vitamin D deficiency affects the pathogenesis of BPPV, some authors are skeptical about this issue [ 19 ]. A possible explanation for this association is that vitamin D deficiency may affect calcium metabolism in the vestibular system, leading to the degeneration and displacement of otoconia [ 17 ]. Otoconia degeneration has been observed in animal models of vitamin D deficiency, suggesting a potential role of vitamin D in maintaining the structural integrity of otoconia [ 18 ]. While numerous studies have explored the connection between vitamin D deficiency and recurrent BPPV, only a limited number have investigated the association between vitamin D deficiency and treatment-resistant BPPV. In our study, we examined the vitamin D levels of both intractable BPPV cases and patients who had recurrences with at least one year of follow-up. However, we could not find any relationship between recurrence, intractable status, and vitamin D deficiency. Although there is no consensus in the literature on the concept of maneuver-resistant BPPV, we have seen that cases requiring three or more repeated maneuvers are mostly evaluated as intractable or resistant BPPV [ 20 , 21 ]. When we tried to determine the risk factors of our cases requiring three or more maneuvers with logistic regression analysis, we found that, unlike vitamin D deficiency, the presence of comorbidities, male gender, and betahistine use were risk factors for multiple maneuvers. Interestingly, among comorbidities, hypertension rather than vestibular migraine or vestibular insufficiency seems to increase BPPV resistance. The study by Korkmaz et al. also argued that hypertension is a risk factor that increases BPPV resistance [ 20 ]. We speculate that there is a relationship between betahistine use and BPPV resistance not because of betahistine use directly but because most patients with more severe diseases have used betahistine. We found that patients with higher DHI and VAS scores at the time of application had longer treatment. The recurrence of BPPV is a common clinical problem, with reported recurrence rates ranging from 15–50% within one year of the initial diagnosis [ 2 , 10 ]. The exact mechanisms underlying the recurrence of BPPV remain unclear, but several risk factors have been identified, including age, comorbidities, and the involvement of multiple semicircular canals [ 9 , 22 ]. Our study revealed that resistant BPPV may not be associated with vitamin D deficiency. This study has several limitations that should be noted. First, the relatively small sample size may have restricted the statistical power to identify significant associations between vitamin D deficiency and BPPV recurrence. Second, the absence of a control group of healthy individuals limits our ability to compare the prevalence of vitamin D deficiency between BPPV patients and the general population. Third, serum 25(OH)D levels were used to assess vitamin D status, which may not fully represent vitamin D bioavailability in the vestibular system [ 23 ]. Despite these limitations, our findings contribute valuable data regarding the potential role of vitamin D in BPPV pathophysiology. Our study reveals that the pathophysiology of BPPV may be more complex than thought before and further deeper researches are needed. Conclusion In this study, we examined the relationship between treatment-resistant BPPV and vitamin D deficiency, considering additional risk factors such as age, gender, and comorbidities. Unlike prior research that suggested a potential connection between vitamin D deficiency and persistent BPPV, as well as its recurrence, our findings did not reveal a significant association between vitamin D levels and the intractability of BPPV. Instead, factors such as male gender and the presence of comorbidities emerged as predictors of resistance to canalith repositioning maneuvers. These findings suggest that the pathogenesis of treatment-resistant BPPV may be influenced by a broader set of clinical factors rather than vitamin D deficiency alone. Our study underscores the necessity for additional research to gain a deeper understanding of the intricate mechanisms that contribute to BPPV resistance and recurrence, and the potential role of comorbidities like hypertension in these processes. While vitamin D deficiency has been implicated in otoconia degeneration and vestibular dysfunction, our results suggest that its impact on BPPV may be less significant than previously thought, particularly in cases of treatment resistance. Declarations Ethics approval was received from our institutipnal Ethics Committee (approval number:105/2024; date:23.10.2024) Funding and conflict of interest The authors have no funding, financial relationships, or conflict of interest to disclose. Author Contribution D.T concepted this study. D.T. and E.S. collected data. E.S. contributed to the writing of the manuscript. D.T. critically reviewed the manuscript. References Sayin I, Koç RH, Temirbekov D, Gunes S, Cirak M, Yazici ZM (2022) Betahistine add-on therapy for treatment of subjects with posterior benign paroxysmal positional vertigo: a randomized controlled trial. Braz J Otorhinolaryngol 88(3):421–426. https://doi.org/10.1016/j.bjorl.2020.07.011 Chen J, Zhang S, Cui K, Liu C (2021) Risk factors for benign paroxysmal positional vertigo recurrence: a systematic review and meta-analysis. 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Otolaryngol Head Neck Surg 156(3suppl):S1–S47. https://doi.org/10.1177/0194599816689667 Sreenivas V, Sima NH, Philip S (2021) The Role of Comorbidities in Benign Paroxysmal Positional Vertigo. Ear Nose Troat J 100(5):NP225–NP230. https://doi.org/10.1177/0145561319878546 Hanel A, Carlberg C (2020) Vitamin D and evolution: Pharmacologic implications. Biochem Pharmacol 173:113595. https://doi.org/10.1016/j.bcp.2019.07.024 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5753749","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":399961629,"identity":"861dc258-36e3-434e-b501-c8d8b69ad209","order_by":0,"name":"Dastan Temirbekov","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYDCCAwwMjA0gBjuINLAgRQvPAZAWCVK0SCSAScI6+I4ff/hwRoWNHL/k86sbfhRIMPC3dyfg1SJ5JsfYcMOZNGPJ2TllN3uADpM4c3YDXi0GB3LYJB+2HU7ccDsn7QYPUIuBRC4BLeefP//58N//+v03z6Td/EOUlhsJZowbGw4kGEiwH7tNlC2SN94YS844lmw440wO220ZAwkegn7hO5/+8GNPjZ08f/vxZzff/AEGXXsvfi1IgMcATBKrHATYH5CiehSMglEwCkYQAACSIE6WShIcHwAAAABJRU5ErkJggg==","orcid":"","institution":"Istanbul Aydın University, Faculty of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Dastan","middleName":"","lastName":"Temirbekov","suffix":""},{"id":399961632,"identity":"ec9d72eb-8511-4d51-b410-35f9e7809ecb","order_by":1,"name":"Elif Sari","email":"","orcid":"","institution":"Istanbul Aydın University, Faculty of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Elif","middleName":"","lastName":"Sari","suffix":""}],"badges":[],"createdAt":"2025-01-02 19:08:13","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5753749/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5753749/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73866823,"identity":"a4c4bcb5-4ec5-4a22-8d4a-31ca50f72e9b","added_by":"auto","created_at":"2025-01-15 11:53:48","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":73260,"visible":true,"origin":"","legend":"\u003cp\u003eDistribution of comorbidities\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5753749/v1/4714020616fe78b95dda54b0.jpg"},{"id":77829179,"identity":"d2a9f5f5-a766-480a-a556-fdac15fcc07c","added_by":"auto","created_at":"2025-03-06 01:16:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1030352,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5753749/v1/b0f8a5a9-351a-4ed7-8f42-a13b6efef567.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Is the vitamin D deficiency a cause of intractable BPPV?","fulltext":[{"header":"Background","content":"\u003cp\u003eBenign Paroxysmal Positional Vertigo (BPPV), being one of the most common causes of peripheral vertigo, is characterized by short, recurrent episodes of vertigo triggered by certain head positions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The underlying pathophysiology of BPPV is attributed to the displacement of otoconia from the utricle into the semicircular canals, leading to abnormal vestibular responses to head movements [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. BPPV has been associated with various risk factors, including age, gender, head trauma, and comorbidities such as migraine and Meniere's disease, vascular diseases, diabetes, vitamin D deficiency, and osteoporosis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eVitamin D, a fat-soluble nutrient, is essential for several physiological functions, including maintaining calcium and phosphorus balance, supporting bone health, and regulating immune function [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Vitamin D deficiency is a global health issue that affects a significant proportion of the population [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Emerging evidence suggests that vitamin D deficiency may contribute to the pathogenesis of several neurological disorders, including multiple sclerosis, Parkinson's disease, and Alzheimer's disease [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRecent studies have also explored the potential association between vitamin D deficiency and BPPV [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. It has been hypothesized that vitamin D deficiency may contribute to the development of BPPV by affecting the calcium metabolism in the vestibular system, leading to otoconia degeneration and displacement [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Some studies have reported a higher prevalence of vitamin D deficiency among BPPV patients compared to healthy controls [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Moreover, a few clinical trials have demonstrated that vitamin D supplementation may reduce the recurrence rate of BPPV [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, the relationship between vitamin D deficiency and the resistance to treatment of BPPV remains inconclusive. Most of the previous studies have focused on the effects of vitamin D supplementation on BPPV recurrence, and few have investigated the treatment course of BPPV in patients with vitamin D deficiency.\u003c/p\u003e \u003cp\u003eIn this study, we aimed to investigate the association between treatment resistance of BPPV and several risk factors, including vitamin D deficiency, age, gender, and comorbidities.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design\u003c/h2\u003e \u003cp\u003e We retrospectively reviewed the medical records of the adult patients who underwent treatment in our tertiary care hospital with the diagnosis of BPPV between January 2020 and January 2023. The inclusion criteria for the study were patients aged 18 to 65 diagnosed with BPPV based on their clinical history and positive Dix-Hallpike or Roll test results and measured serum vitamin D levels. The blood tests must be done within one month of BPPV diagnosis. The 25-OH vitamin D concentration was measured using chemiluminescence immunoassay (Centaur; Siemens Healthineers, Erlangen, Germany) as a serum test.\u003c/p\u003e \u003cp\u003eThe exclusion criteria were a history or clinical findings of any metabolic disorders. Patients with a history of head trauma, otologic surgery, or those who received vitamin D supplementation during the study period were also excluded from the study.\u003c/p\u003e \u003cp\u003e \u003cb\u003eEthical Approval and Informed Consent\u003c/b\u003e \u003c/p\u003e\u003cp\u003e This retrospective study received approval from the Institutional Ethics Committee and followed the principles outlined in the Declaration of Helsinki.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collecting and Recording\u003c/h3\u003e\n\u003cp\u003eThe patients\u0026rsquo; files deemed suitable for the study were reviewed, and demographic data and all the comorbidities were recorded. Since all patients who started treatment in our clinic routinely fill out Dizziness handicap inventory (DHI) and Visual Analog Scale (VAS) questionnaires, we were able to record the results of our patients' questionnaires.\u003c/p\u003e \u003cp\u003eVitamin D status was categorized according to serum 25(OH)D levels in the following manner: deficiency was defined as less than 20 ng/mL, insufficiency as 20\u0026ndash;29 ng/mL, and sufficiency as 30 ng/mL or greater. In this study, individuals with serum 25(OH)D levels below 20 ng/mL were regarded as having vitamin D deficiency.\u003c/p\u003e\n\u003ch3\u003eBPPV Diagnosis and Treatment\u003c/h3\u003e\n\u003cp\u003eBPPV diagnosis was based on the presence of a history of positional vertigo and a positive Dix-Hallpike test for posterior canal BPPV or a positive Roll test for horizontal canal BPPV. The involved semicircular canal was determined based on the direction of nystagmus during the diagnostic maneuvers.\u003c/p\u003e \u003cp\u003e All participants received canalith repositioning maneuvers, such as the Epley maneuver for posterior canal BPPV or the Lempert maneuver (Barbecue roll) for horizontal canal BPPV, as the initial treatment. Patients were called for a control examination at 3\u0026ndash;4 day intervals, and canalith repositioning maneuvers were repeated until positioning tests were negative. Patients who required three or more maneuvers were considered intractable to treatment. Participants were considered successfully treated if they had no positional nystagmus or vertigo during the follow-up visit within one week of the initial treatment.\u003c/p\u003e \u003cp\u003eAfter the treatment, the patients were asked to fill out the DHI and VAS questionnaire forms again.\u003c/p\u003e\n\u003ch3\u003eFollow-up and Assessment of Recurrence\u003c/h3\u003e\n\u003cp\u003eParticipants were followed up for at least one year after the diagnosis of BPPV. Recurrence was defined as the reappearance of vertigo symptoms and a positive Dix-Hallpike or Roll test during the follow-up period after a successful initial treatment. Participants were instructed for follow-up visits every year or whenever they experienced recurrent vertigo symptoms. The follow-up visits included a detailed clinical history, otoscopic examination, and vestibular function tests, as needed.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eThe data were examined for normal distribution using the Shapiro-Wilk test, and the difference between initial and final measurements that did not have a normal distribution was examined using the Wilcoxon signed rank test. Associations among variables measured quantitatively were assessed using Spearman's Correlation Coefficient. A coefficient value between 0.8 and 1 signifies a very strong association, values from 0.6 to 0.8 indicate a strong association, values from 0.4 to 0.6 suggest a moderate association, and values between 0.2 and 0.4 represent a weak association [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The effects of age, gender, some clinical characteristics, and laboratory characteristics of the cases on the increase in the number of maneuvers were first analyzed using the Univariate LR (Logistic Regression) method. For descriptive statistics, numerical variables were reported as Median [IQR: Interquartile Range, Q1 \u0026ndash; Q3], while categorical variables were presented as frequencies and percentages. Statistical analyses were performed using SPSS version 25.0 (IBM Corporation, Armonk, NY, USA), with a significance level set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 122 patients diagnosed with BPPV were included in the study. The mean age of the participants was 54\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3 years, and gender distribution was 63.9% female and 36.9% male patients. The distribution of demographic and clinical features of the cases is demonstrated in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Based on the serum 25(OH) D levels, 47.5% of the patients had vitamin D deficiency (less than 20ng/ml), and 52.5% of patients had normal or insufficient vitamin D levels. The baseline characteristics of the participants, including age, gender, and comorbidities, were comparable between the vitamin D-deficient and non-deficient groups (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The most common comorbid diseases were: hypertension, vestibular migraine, diabetes mellitus, and vestibular insufficiency. Hypertension was seen in 25 cases (36.8%), vestibular migraine in 8 cases (11.8%), diabetes in 7 cases (10.3%), and vestibular insufficiency in 6 cases (8.8%) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and clinical feature distribution of the patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeatures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en(%) / M[Q1-Q3]\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (36,1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (63,9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 [40,5\u0026ndash;64]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (43,4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (56,6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003evıtamın D level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 [13,35\u0026thinsp;\u0026minus;\u0026thinsp;30,25]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of the disease [month]\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 [0,25\u0026thinsp;\u0026minus;\u0026thinsp;12]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003enumber of maneuvers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAffected canal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterıor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (71,3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (18,9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultıple\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (9,8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePosterıor canal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eL\u0026thinsp;+\u0026thinsp;R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (50,5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45 (45,5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLateral canal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (72,4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (27,6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMultıple canal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (9,8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110 (90,2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCupulolıttiasis\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (5,7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115 (94,3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBetahistine use\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (40,2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e73 (59,8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReccurence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (28,7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95 (71,3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIntactable to treatment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo (1\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (55,7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eyes (\u0026thinsp;\u0026gt;\u0026thinsp;=\u0026thinsp;3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54 (44,3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003cem\u003eM:Median, Q1:Quartile 1, Q3:Quartile 3\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eLogistic regression analysis determined the factors requiring three or more maneuvers in the cases (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). It was determined that gender, presence of comorbid diseases, and Betahistine use were factors affecting the increase in the number of maneuvers (p\u0026thinsp;=\u0026thinsp;0.005 \u0026amp; p\u0026thinsp;=\u0026thinsp;0.017 \u0026amp; p\u0026thinsp;=\u0026thinsp;0.020 \u0026amp; p\u0026thinsp;=\u0026thinsp;0.002, respectively). It was determined that males had a (95% CI: 1.395\u0026ndash;6.450) higher risk of having more maneuvers than females. Individuals with comorbid diseases had a 2.446-fold (95% CI: 1.172\u0026ndash;5.101) higher risk of having more maneuvers. Patients who took betahistine (95% CI: 1.163\u0026ndash;5.866) had more maneuvers than patients who did not (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). No significant relationship was found between the increase in the number of maneuvers and variables such as age, involved semicircular canal, vitamin D level, and duration of symptoms before treatment (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePotential risk factors associated with increased numbers of maneuver (3 or more) in the logistic regression equation.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrevelance (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExp (β)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e95% CI for Exp(β)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,395-6,450\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0,005\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0,905\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,297-2,762\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0,861\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,027\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,352-2,996\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0,960\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,107\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,376-3,258\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0,854\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e70\u0026ndash;79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,299-3,457\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0,978\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e80+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,308\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,162\u0026thinsp;\u0026minus;\u0026thinsp;10,559\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0,801\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCanal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral canal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior canal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,429-2,810\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0,845\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple canal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4,667\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,989\u0026thinsp;\u0026minus;\u0026thinsp;22,030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0,052\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDuration of symptoms\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;1month\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,235\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,530-2,879\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0,625\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVitamin D\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2,383\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,655-8,675\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0,188\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e56,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2,446\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,172-5,101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0,017\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHypertension\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e79,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2,211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,504-9,699\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0,293\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVestibular Migrane\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e114\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e93,4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6,6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,814\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,747-4,404\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0,188\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBetahistine\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59,8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3,744\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1,747-8,024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0,001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReccurence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71,3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1,906\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0,769-4,721\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0,163\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eExp(β):Odds Ratio, CI: Confidence Interval\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe relationship between numbers of the maneuvers and characteristic features of the cases\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eNumber of maneuvers\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (n\u0026thinsp;=\u0026thinsp;44)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 (n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;5 (n\u0026thinsp;=\u0026thinsp;25)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003en(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003en(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003en(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (13,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (45,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (55,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (54,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11 (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0,003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (86,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (54,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (44,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5 (45,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e14 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (22,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (29,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (27,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8 (32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0,457\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (13,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (29,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (11,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e6 (24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e50\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (20,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (20,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (11,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e60\u0026ndash;69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (22,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (12,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4 (22,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e70\u0026ndash;79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (18,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (27,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e80+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eComorbidity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (22,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (54,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10 (55,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (63,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13 (52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0,014\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (77,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (45,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 (44,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (36,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e12 (48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAffected canal\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLateral canal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (22,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (16,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (11,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (18,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5 (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0,397\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePosterior canal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (72,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (79,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14 (77,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 (54,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16 (64)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple canal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (11,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3 (27,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4 (16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRecurrences ın at least 1 year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (11,1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (36,4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (31,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7 (36,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0,199\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (88,9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (63,6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 (68,8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7 (60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e18 (63,2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003ep value was obtained from Pearson Chi Square test\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDuring the at least one-year follow-up period, 27 (22.1%) patients experienced a recurrence of BPPV. The recurrence rate was not significantly higher in the vitamin D-deficient group (p\u0026thinsp;=\u0026thinsp;0.188) compared to the non-deficient group. The Kaplan-Meier survival analysis showed that the recurrence-free survival rate was lower in the vitamin D-deficient group than in the non-deficient group. Still, this difference was not statistically significant (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe relationship between vitamin D deficiency and the need for increased maneuvers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot intractable (1\u0026ndash;2 maneuvers)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntractabe (\u0026ge;\u0026thinsp;3 maneuvers)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003en(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003en(%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003evitamin D level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026le;\u0026thinsp;19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (66,7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (43,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0,193\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (33,3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (56,5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe pathophysiology of BPPV is primarily attributed to the displacement of otoconia from the utricle into the semicircular canals, leading to abnormal vestibular responses to head movements [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Otoconia are calcium carbonate crystals that play a crucial role in the mechanical transduction of gravitational forces and head movements into electrical signals within the vestibular system [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The integrity and function of otoconia are maintained by a delicate balance of calcium and phosphorus homeostasis, which is regulated by various factors. Seemingly, vitamin D also plays a certain role in the regulation of calcium metabolism, including calcium carbonate of the otoconia [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe link between vitamin D deficiency and BPPV has gained considerable attention in recent years. Numerous studies have shown that vitamin D deficiency is more common in patients with BPPV than in healthy individuals [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Although most studies suggest that vitamin D deficiency affects the pathogenesis of BPPV, some authors are skeptical about this issue [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. A possible explanation for this association is that vitamin D deficiency may affect calcium metabolism in the vestibular system, leading to the degeneration and displacement of otoconia [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Otoconia degeneration has been observed in animal models of vitamin D deficiency, suggesting a potential role of vitamin D in maintaining the structural integrity of otoconia [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. While numerous studies have explored the connection between vitamin D deficiency and recurrent BPPV, only a limited number have investigated the association between vitamin D deficiency and treatment-resistant BPPV. In our study, we examined the vitamin D levels of both intractable BPPV cases and patients who had recurrences with at least one year of follow-up. However, we could not find any relationship between recurrence, intractable status, and vitamin D deficiency. Although there is no consensus in the literature on the concept of maneuver-resistant BPPV, we have seen that cases requiring three or more repeated maneuvers are mostly evaluated as intractable or resistant BPPV [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. When we tried to determine the risk factors of our cases requiring three or more maneuvers with logistic regression analysis, we found that, unlike vitamin D deficiency, the presence of comorbidities, male gender, and betahistine use were risk factors for multiple maneuvers. Interestingly, among comorbidities, hypertension rather than vestibular migraine or vestibular insufficiency seems to increase BPPV resistance. The study by Korkmaz et al. also argued that hypertension is a risk factor that increases BPPV resistance [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. We speculate that there is a relationship between betahistine use and BPPV resistance not because of betahistine use directly but because most patients with more severe diseases have used betahistine. We found that patients with higher DHI and VAS scores at the time of application had longer treatment.\u003c/p\u003e \u003cp\u003eThe recurrence of BPPV is a common clinical problem, with reported recurrence rates ranging from 15\u0026ndash;50% within one year of the initial diagnosis [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The exact mechanisms underlying the recurrence of BPPV remain unclear, but several risk factors have been identified, including age, comorbidities, and the involvement of multiple semicircular canals [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Our study revealed that resistant BPPV may not be associated with vitamin D deficiency.\u003c/p\u003e \u003cp\u003eThis study has several limitations that should be noted. First, the relatively small sample size may have restricted the statistical power to identify significant associations between vitamin D deficiency and BPPV recurrence. Second, the absence of a control group of healthy individuals limits our ability to compare the prevalence of vitamin D deficiency between BPPV patients and the general population. Third, serum 25(OH)D levels were used to assess vitamin D status, which may not fully represent vitamin D bioavailability in the vestibular system [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Despite these limitations, our findings contribute valuable data regarding the potential role of vitamin D in BPPV pathophysiology.\u003c/p\u003e \u003cp\u003eOur study reveals that the pathophysiology of BPPV may be more complex than thought before and further deeper researches are needed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this study, we examined the relationship between treatment-resistant BPPV and vitamin D deficiency, considering additional risk factors such as age, gender, and comorbidities. Unlike prior research that suggested a potential connection between vitamin D deficiency and persistent BPPV, as well as its recurrence, our findings did not reveal a significant association between vitamin D levels and the intractability of BPPV. Instead, factors such as male gender and the presence of comorbidities emerged as predictors of resistance to canalith repositioning maneuvers.\u003c/p\u003e \u003cp\u003eThese findings suggest that the pathogenesis of treatment-resistant BPPV may be influenced by a broader set of clinical factors rather than vitamin D deficiency alone. Our study underscores the necessity for additional research to gain a deeper understanding of the intricate mechanisms that contribute to BPPV resistance and recurrence, and the potential role of comorbidities like hypertension in these processes. While vitamin D deficiency has been implicated in otoconia degeneration and vestibular dysfunction, our results suggest that its impact on BPPV may be less significant than previously thought, particularly in cases of treatment resistance.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval\u003c/strong\u003e \u003cp\u003e was received from our institutipnal Ethics Committee (approval number:105/2024; date:23.10.2024)\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eFunding and conflict of interest\u003c/strong\u003e \u003cp\u003eThe authors have no funding, financial relationships, or conflict of interest to disclose.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eD.T concepted this study. D.T. and E.S. collected data. E.S. contributed to the writing of the manuscript. D.T. critically reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSayin I, Ko\u0026ccedil; RH, Temirbekov D, Gunes S, Cirak M, Yazici ZM (2022) Betahistine add-on therapy for treatment of subjects with posterior benign paroxysmal positional vertigo: a randomized controlled trial. Braz J Otorhinolaryngol 88(3):421\u0026ndash;426. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.bjorl.2020.07.011\u003c/span\u003e\u003cspan address=\"10.1016/j.bjorl.2020.07.011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen J, Zhang S, Cui K, Liu C (2021) Risk factors for benign paroxysmal positional vertigo recurrence: a systematic review and meta-analysis. 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Biochem Pharmacol 173:113595. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.bcp.2019.07.024\u003c/span\u003e\u003cspan address=\"10.1016/j.bcp.2019.07.024\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Benign Paroxysmal Positional Vertigo, intractable BPPV, recurrent BPPV, Vitamin D deficiency","lastPublishedDoi":"10.21203/rs.3.rs-5753749/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5753749/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThis study investigated the association between treatment resistance in benign paroxysmal positional vertigo (BPPV) and various risk factors, including vitamin D deficiency, age, gender, and comorbidities.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective review of medical records was conducted on 122 patients diagnosed with BPPV at a tertiary care hospital between January 2020 and January 2023. The diagnosis of BPPV was confirmed using clinical history and positional tests, while serum 25-OH vitamin D levels were measured using chemiluminescence immunoassay. Patients who required three or more canalith repositioning maneuvers were considered treatment-resistant. Logistic regression analysis was employed to assess the impact of demographic and clinical factors on BPPV treatment resistance, and recurrence rates were evaluated over a one-year follow-up period.\u003c/p\u003e\u003ch2\u003eResults.\u003c/h2\u003e \u003cp\u003eLogistic regression revealed that male gender, comorbidities, and betahistine use were significantly associated with BPPV resistance (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05), while no significant relationship was found between vitamin D levels and treatment resistance or recurrence (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). Recurrence was observed in 22.1% of patients during the follow-up period, though this was not significantly related to vitamin D status.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWhile previous studies suggested a potential link between vitamin D deficiency and BPPV recurrence, this study found no significant association between vitamin D deficiency and intractability along with the recurrence of BPPV. Instead, male gender, comorbidities (notably hypertension), and betahistine use were identified as risk factors for requiring multiple maneuvers. The study raises questions about the role of vitamin D in BPPV pathophysiology and suggests that other clinical factors may have a greater influence on treatment outcomes.\u003c/p\u003e","manuscriptTitle":"Is the vitamin D deficiency a cause of intractable BPPV?","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-15 11:45:44","doi":"10.21203/rs.3.rs-5753749/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"efe947db-86ac-423b-90f3-20596856b49d","owner":[],"postedDate":"January 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-03-06T01:08:20+00:00","versionOfRecord":[],"versionCreatedAt":"2025-01-15 11:45:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5753749","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5753749","identity":"rs-5753749","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}