Clinical practice guideline: Benign paroxysmal positional vertigo Journal Club 12/05/2014 Clinical practice guideline: Benign paroxysmal positional vertigo Dr. Loay Alekri

Key Terms Dizziness: A nonspecific term which includes sense of imbalance (disequilibrium), blacking out (presyncope), lightheadedness, floating sensation or vertigo. Vertigo: A hallucination of movement (rotatory). It is a cardinal symptom of a disorder in the vestibular system; (peripheral or central) Nystagmus: An involuntary movement of the eyes due to a disturbance in vestibulo-ocular reflex (VOR); a sign of peripheral or central vestibular disorder

Causes of Dizziness

Peripheral Vestibular System Vestibular apparatus consists of the ‘otolithic organs’ and the semicircular canals Sensory neuroepithelium is called the crista in SCCs and the macula in otolithic organs 3 pairs of semicircular canals; the anterior (superior), posterior and lateral (horizontal) Ducts of the SCCs terminate into the ampula. Crista within the ampula consists of hair cells embedded in a gelatinous substance ‘cupula’. The semicircular canals determine rotational velocity in three dimensions

Cont… Otolithic organs consist of utricle and saccule. They contain hair-cells coupled to calcium carbonate crystals (otoconia or otoliths). Sense gravity and linear accelerations. Utricle: accelerations in horizontal plane Saccule: accelerations in vertical plane

Central Vestibular System Maintenance of balance: vestibulospinal tract ‘VST’ Maintenance of eye position during head movement: vestibulo-ocular reflex ‘VOR’

BPPV 17-42% of pts. with vertigo receive a diagnosis of benign paroxysmal positional vertigo (BPPV). What is BPPV? Positional vertigo: a spinning sensation produced by changes in head position relative to gravity. BPPV: a disorder of the inner ear characterized by repeated episodes of positional vertigo.

Cont… Benign and paroxysmal used to characterize this particular form of positional vertigo Benign historically implies that this vertigo is not due to serious CNS disorder; and overall prognosis for recovery was favorable. Paroxysmal describes the rapid and sudden onset of the vertigo

Cont… It is due to dislodgement of calcium carbonate crystals (otoliths) from the utricle into the SCCs If free floating in SSC “canalithiasis”, if attached to cupula, “cupulolithiasis” debris in the SSC becomes “trapped” causes inertial changes in the canal, When stimulated by head movement: The Input difference from both vestibules results in episodic vertigo/nystagmus

Cont… Lasts from a few seconds up to a minute. Common complaints: dizziness when turning to one side while in bed, looking up to take something from above, bending down to pick something up or praying Types: BPPV of the posterior SCC (85-95%) BPPV of the lateral SCC (5-15%) BPPV of the anterior SCC (rare) Mixed-canal type BPPV (rare)

Clinical practice guideline: Benign paroxysmal positional vertigo Otolaryngology–Head and Neck Surgery (2008) 139, S47-S81 American Academy of Otolaryngology–Head and Neck Surgery Foundation Clinical practice guideline: Benign paroxysmal positional vertigo Purpose: to improve quality of care and outcomes for BPPV by: improving accurate and efficient diagnosis of BPPV, reducing inappropriate use of vestibular suppressant medications, decreasing inappropriate use of imaging and vestibular testing, to promote use of effective repositioning maneuvers for treatment.

Cont… Goal: create multidisciplinary guideline specific set of focused recommendations established and transparent process that considers levels of evidence, harm-benefit balance, and expert consensus

Statement 1a Clinicians should diagnose posterior SSC BPPV when vertigo associated with nystagmus is provoked by the Dix-Hallpike maneuver. Strong recommendation based on diagnostic studies with minor limitations and a preponderance of benefit over harm.

Diagnosis of PC-BPPV

Performing Dix-Hallpike Maneuver Performed by moving pt. through a set of specified head-positioning maneuvers to elicit the expected characteristic nystagmus of PC-BPPV Counsel the pt. regarding the upcoming movements May cause sudden onset of intense vertigo, and nausea (subside in a min)

Cont… Begins with pt. in the upright seated position with the examiner standing at one side (e.g. Rt side). Examiner rotates the head 45 to the Rt, and maintains (45 head turn) during the next steps. Quickly moves the pt. from seated to supine Rt-ear down position (keep eyes open) Extends the neck slightly (20 below the horizontal plane; chin is pointed slightly upward), with the head hanging off the edge of the table and supported

Cont… Observes for latency, duration, and direction of the nystagmus Nystagmus in PC-BPPV: mixed torsional and vertical movement with upper pole of the eye beating toward the dependent ear After it subsides, pt. slowly returned to upright position; nystagmus may be observed and allowed to resolve This test should be repeated for the opposite side to complete the examination

Dix-Hallpike maneuver is considered the gold standard test for the diagnosis of PC-BPPV Its accuracy differ between clinicians Reported sensitivity 82% and specificity 71% Negative Dix-Hallpike maneuver does not necessarily rule out posterior canal BPPV May need to be repeated at a separate visit to confirm the diagnosis and avoid a false-negative result

Statement 1b If the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, the clinician should perform a supine roll test to assess for lateral semicircular canal BPPV.

Diagnosis of Lateral Canal BPPV Lateral (horizontal) canal BPPV is the second most common type of BPPV Clinicians may be relatively unaware of its existence and the appropriate diagnostic maneuvers for it It may occur following performance of Epleys for an initial diagnosis and treatment of PC-BPPV. Transition from PC to HC-BPPV: thought to occur as free-floating otoliths migrate from the posterior to the lateral canal (canal switch)

Supine Roll Test (Pagnini-McClure) The preferred maneuver Position the pt. supine with head in neutral position followed by quickly rotating the head 90 to one side (observing for nystagmus) If no nystagmus, the head is returned to the neutral position. Then head is quickly turned 90 to the opposite side

Diagnosis of HC-BPPV Two potential nystagmus may occur with vertigo: (horizontal and changes direction) Geotropic Apogeotropic

Cont… Geotropic type: (most cases) Rolling to the affected ear causes stronger horizontal nystagmus beating toward the ground If rolled to unaffected ear, less intense horizontal nystagmus, again beating toward the ground Apogeotropic type: (less common) Horizontal nystagmus stronger toward the uppermost ear (affected one) Rolling to opposite side, nystagmus changes direction, beating again toward uppermosr ear, less intense

Cont… Canalithiasis; nystagmus is geotropic and stronger when affected ear is down; otoconia moves toward the cupula (same way of endolymph), increases firing rate from H-SCC Cupulolithiasis, if affected ear is down, cupula bends down by weight of otoconia, decreases firing rate from H-SCC (inhibitory); apogeotropic nystagmus but less intense; becomes stronger when affected ear is upward; because cupula is deflected in excitatory direction if positive; this test is most consistent diagnostic criteria for therapeutic trials of HC-BPPV

Statement 2a Clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo BPPV is often under or misdiagnosed: Diseases confused with BPPV, can be divided into otological, neurological, and other entities BPPV found to account for 42% of vertigo, followed by vestibular neuritis 41%, Ménière’s disease 10%, vascular causes 3%, and other causes 3%

Statement 2b Clinicians should question patients with BPPV for factors that modify management including impaired mobility or balance, CNS disorders, a lack of home support, and increased risk for falling Pts. with BPPV often suffer from comorbidities, limitations, and risks that may affect the diagnosis and treatment outcome Assessment for factors that modify management is essential for improved outcomes and ensuring pt. safety

Statement 3a Clinicians should not obtain radiographic imaging, vestibular testing, or either in a patient diagnosed with BPPV, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to BPPV that warrant testing.

Radiographic and Vestibular Testing Routine radiographic imaging or vestibular testing is unnecessary in pts. who already meet clinical criteria for the diagnosis of BPPV Further testing may have a role if: clinical presentation felt to be atypical, Dix-Hallpike elicits equivocal or unusual nystagmus findings, or additional symptoms are present, suggesting an accompanying CNS or other otological disorder failed response to treatment, or frequent recurrences

Statement 3b No recommendation is made concerning audiometric testing in patients diagnosed with BPPV. No recommendation based on insufficient evidence for the diagnostic or prognostic value of audiometry in the evaluation of BPPV

Audiometric Testing Recent data indicates that 9% of audiograms annually are ordered in association with diagnostic categories related to vertigo Specialty clinicians with access to audiometry frequently obtain PTA as part of the vertigo evaluation However, limited diagnostic and cost-effectiveness studies supporting this practice are available. Audiometry is not required to diagnose BPPV It may offer some diagnostic benefit for whom the clinical diagnosis of BPPV is unclear

Statement 4a Clinicians should treat patients with posterior canal BPPV with a particle repositioning maneuver. Although pts. with BPPV are likely to spontaneously remit in the subsequent months, recent high-quality evidence supports active treatment with a particle repositioning maneuver (PRM). Advantage: consistently eliminates vertigo, improves quality of life, and reduces the risks of falling

Repositioning Maneuvers as Initial Therapy PRMs found effective for PC-BPPV: canalith repositioning procedure (CRP); Epley’s liberatory maneuver (Semont) CRP moves canaliths from posterior SCC to vestibule; relieving the stimulus that had been producing vertigo Most commonly performed Cochrane review: a statistically significant effect in favor of CRP compared with controls Several meta-analyses reported that CRP is significantly more effective than placebo

Performing CRP

Liberatory (Semont’s) maneuver Clinical trials concerning the effectiveness of liberatory maneuver are limited Most concluded: Semont maneuver is more effective than no treatment

Treatment of HC-BPPV HC-BPPV may respond to other maneuvers intended to move canaliths into the vestibule Roll maneuver (Lempert or barbecue roll) are the most commonly employed; Involves rolling the patient 360 in a series of steps to effect particle repositioning But, limited data exist with respect to the effectiveness of this treatment; reported response vary widely From 50 to almost 100% Currently, no sufficient evidence to recommend a preferred maneuver for HC-BPPV treatment

Cont…

Statement 4b The clinician may offer vestibular rehabilitation, either self-administered or with a clinician, for the initial treatment of BPPV Vestibular rehabilitation: a form of physical therapy designed to promote habituation, adaptation, and compensation for deficits related to balance disorders, with or without direct clinician supervision Includes: CRP (Brandt-Daroff) exercises, gaze/postural control, fall prevention, relaxation, and education Vestibular rehabilitation: may decrease recurrence rates for BPPV is thought to improve long-term outcomes

Cont…

Statement 4c Clinicians may offer observation as initial management for pts. with assurance of follow-up. Observation: defined as a “watchful waiting” or the withholding of therapeutic interventions for a given time Often considered when the disease course is self-limited and/or felt to be benign with limited sequelae Pts. are instructed to avoid provocative positions and activities where risk of injury (falls) may be increased until symptoms resolve spontaneously or until they are reassessed again

Observation as Initial Therapy Spontaneous rate of symptomatic resolution ranges from 15-86% The natural history of PC-BPPV varies widely

Statement 5 Clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines Clinicians may prescribe drugs as initial management: (vestibular suppressant medications) to: Reduce spinning sensations of vertigo Reduce accompanying motion sickness symptoms no evidence to suggest that any of these medications are effective as a definitive, primary treatment for BPPV

Statement 6a Clinicians should reassess patients within 1 month after an initial period of observation or treatment to confirm symptom resolution One of major goals of reassessment is to ensure the accuracy of diagnosis; failure of initial therapy may question the diagnosis Patients with BPPV, regardless of initial treatment, will have variable responses to therapy Persistence of symptoms requires clinicians to reassess and reevaluate for other etiologies of vertigo

Statement 6b Clinicians should reevaluate patients with BPPV who failed the initial treatment, for persistent symptoms or underlying peripheral vestibular or CNS disorders Pts. with persistent symptoms at time of reassessment are classified as treatment failures They require reevaluation: persistent BPPV may be present; needs additional maneuvers coexisting vestibular conditions; can be identified and treated serious CNS disorders may simulate BPPV

Statement 7 Clinicians should counsel patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up There is a significant rate of recurrence after initial resolution or clinical cure 5-13.5% at 6 months 10-18% at 1 year may reach 37-50% at 5 years Should counsel pts. and families regarding the risk of falls (elderly)

Recommendations Clinicians should diagnose posterior SCC BPPV when vertigo associated with nystagmus is provoked by the Dix-Hallpike maneuver. Recommendations against: Using imaging and/or vestibular testing in patients diagnosed with BPPV, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to BPPV; Routinely treating BPPV with vestibular suppressant medications

Cont… If the history is compatible with BPPV, but Dix-Hallpike is negative, clinicians should perform a supine roll test to assess for HC-BPPV; Treat patients with PC-BPPV with a particle repositioning maneuver (PRM); Reassess patients within 1 month after an initial period of observation or treatment to confirm symptom resolution; Counsel patients regarding the impact of BPPV on their safety, the potential for recurrence, and the importance of follow-up

Summary

It’s Enough to Make Your Head Spin! Thank you