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

2. 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

3. Causes of Dizziness

4. 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

5. 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

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

7. 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.

8. 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

9. 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

10. 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)

11. 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.

12. 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

13. 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.

14. Diagnosis of PC-BPPV

15. 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)

16. 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

17. 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

18. 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

19. 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.

20. 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)

21. 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

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

23. 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

24. 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

25. 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%

26. 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

27. 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.

28. 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

29. 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

30. 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

31. 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

32. 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

33. Performing CRP

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

35. 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

36. Cont…

37. 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

38. Cont…

39. 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

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

41. 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

42. 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

43. 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

44. 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)

45. 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

46. 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

47. Summary

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