Clinical Practice Guideline
Benign Paroxysmal Positional Vertigo Steven A. Harvey, MD, FACS Associate Professor Dept. of Otolaryngology & Communication Sciences Medical College of Wisconsin
Panelists David R. Friedland, MD, PhD Professor and Vice-Chairman Dept. of Otolaryngology & Communication Sciences Medical College of Wisconsin Alexia Miles, MPT Director, Vestibular Rehabilitation Program Froedtert and Medical College of Wisconsin
Clinical practice guideline: benign paroxysmal positional vertigo Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, Chalian AA, Desmond AL, Earll JM, Fife TD, Fuller DC, Judge JO, Mann NR, Rosenfeld RM, Schuring LT, Steiner RW, Whitney SL, Haidari J; American Academy of Otolaryngology-Head and Neck Surgery Foundation.
Otolaryngol Head Neck Surg. 2008;139:S47-81.
57 yo female with c/o dizziness • Started 3 months prior • Episodic attacks of intense vertigo • Triggers: checks bedside clock in morning; puts things away in the kitchen • Severe for 5-10 minutes • Feels dizzy for hours afterward • Notes lighter sense of dizziness daily
Clinical Practice Guideline: Recommendation to differentiate BPPV from other causes of dizziness Panelists What other history or information do you wish to ask this patient?
What test would you perform next? A. B. C. D.
CT or MRI VNG/ENG Audiogram Dix-Hallpike 0% A.
0%
0%
B.
C.
0% D.
Clinical Practice Guideline: Recommend against radiographic/vestibular testing unless diagnosis uncertain or additional signs/symptoms
Clinical Practice Guideline: No recommendation for/against audiometric testing in patients diagnosed with BPPV
Clinical Practice Guideline: Strong recommendation to diagnosis posterior canal BPPV when vertigo associated with nystagmus provoked by Dix-Hallpike maneuver
OHNS CPG, 2008
Friedland, 2009
Panelists • How do you position the physically challenging patient? • Given this history would you be surprised if the Dix-Hallpike were negative? • What would be your next steps?
Clinical Practice Guideline: Recommendation to perform supine roll test if history compatible with BPPV and Dix-Hallpike negative (sensitivity/specificity/PPV/NPV have not been determined)
Supine Roll Test • Assess for horizontal canal BPPV • Represents 5-15% of cases of BPPV • Two types (both direction-changing): 1. Geotropic: nystagmus beats toward undermost ear 2. Apogeotropic: nystagmus beats away from undermost ear
• Shorter latency, longer duration, poor fatigability, greater vertigo intensity, emesis
OHNS, CPG 2008
The Dix-Hallpike was positive to the left. What would be your recommendation? A. Perform Epley maneuver in clinic B. Refer to vestibular therapy C. Observe D. Vestibular suppressants 0% A.
0%
0%
B.
C.
0% D.
Clinical Practice Guideline: Recommendation to treat patients with posterior canal BPPV with a repositioning maneuver (no comment regarding lateral/superior canal variant)
Repositioning Maneuvers for Posterior Canal BPPV • Two main options: 1. Canalith repositioning procedure (CRP)/ Epley maneuver 2. Liberatory/Semont maneuver
Clinical Practice Guideline: Option to offer vestibular rehabilitation as initial treatment
Clinical Practice Guideline: Option to offer observation as initial treatment for BPPV
Clinical Practice Guideline: Recommend against vestibular suppressant medications
Medical Therapy • No evidence in the literature to suggest vestibular suppressant medication are effective as primary treatment or substitution for repositioning maneuvers • May increase the risks of falls in the elderly • Consider only short-term for vegetative symptoms in severely symptomatic patients
Summary of Guidelines
Strong Recommendation • Diagnose posterior canal BPPV if positive DixHallpike
Recommendation • Treat posterior canal BPPV with CRP/Epley maneuver • Differentiate BPPV from other causes of dizziness • Perform supine roll test if Dix-Hallpike negative • Factors that may modify treatment for BPPV • Reassessment within 1 month of treatment • Reevaluate initial treatment failures for persistent BPPV or other causes
Option • Offer vestibular rehabilitation • Offer observation
Recommendation Against • Radiographic or vestibular testing unless diagnosis is uncertain or are additional signs and symptoms • Routinely treating with vestibular suppressant medications
