Benign Paroxysmal Positional Vertigo (BPPV)

Summary: Clinical Guidelines on Benign Paroxysmal Positional Vertigo (BPPV):

Otolaryngology–Head and Neck Surgery2017, Vol. 156(3S) S1–S47© American Academy ofOtolaryngology—Head and NeckSurgery Foundation 2017

Pathophysiology of BPPV

Mechanism

BPPV is characterized by episodic vertigo caused by abnormal movement of dislodged otoconia (calcium carbonate crystals) within the semicircular canals. These particles, originating from the utricle, typically migrate into the posterior semicircular canal, where they disturb endolymph flow, causing inappropriate stimulation of the vestibular nerve.

Types of BPPV

Clinical Assessment and Diagnosis of BPPV

  • Primary Diagnostic Tool: Dix-Hallpike Maneuver: The Dix-Hallpike maneuver is the gold standard for diagnosing posterior canal BPPV. When the patient’s head is quickly repositioned, it may provoke vertigo with characteristic torsional and upbeating nystagmus. The latency period before the onset and the duration of symptoms are important for a positive diagnosis.
  • Supine Roll Test for Lateral Canal BPPV: When the Dix-Hallpike maneuver shows horizontal or no nystagmus, a supine roll test is recommended. This maneuver can diagnose lateral canal BPPV by observing horizontal nystagmus that changes direction depending on the head’s position.
  • Differentiating BPPV from Other Vestibular Disorders: Accurate differentiation is essential as other conditions, such as vestibular neuritis, Meniere’s disease, and CNS-related vertigo, may present similarly. A careful history and physical exam, along with targeted maneuvers, are critical for differential diagnosis.
  • Factors Modifying Management: Clinicians should assess for factors like impaired mobility, CNS disorders, home support availability, and fall risk, which may affect both diagnosis and treatment choices.

Treatment of BPPV: Repositioning Techniques

  • Canalith Repositioning Procedures (CRP):
    • Posterior Canal BPPV: The Epley maneuver, the most commonly used CRP, involves sequential head positioning to guide otoconia out of the semicircular canal. The Semont maneuver is an alternative for posterior canal cases.
    • Lateral Canal BPPV: The Gufoni maneuver is useful, especially for cases where nystagmus is observed as geotropic or apogeotropic, indicating the orientation of otoconia within the canal.
  • Benefits of CRP: CRP is associated with high efficacy, immediate symptom relief, and minimal side effects. Patients treated with CRP often experience a substantial reduction in symptom recurrence.
  • Vestibular Rehabilitation Therapy (VRT): For patients with persistent symptoms, VRT can help through habituation exercises and balance training. This may be recommended as an option for patients experiencing recurrent BPPV or prolonged dizziness.
  • Observation: Observation with regular follow-up is suggested as an option, especially if the diagnosis is uncertain or if the patient has a history of spontaneous symptom resolution.

Medications for BPPV: Use and Limitations

  • Guideline Recommendation: Strongly advises AGAINST routine pharmacological treatment for BPPV.
  • Vestibular Suppressants:
    • Although medications such as antihistamines (e.g., meclizine) and benzodiazepines may be used for symptomatic relief, they are not recommended as they do not address the underlying cause (otoconia dislocation) and may delay recovery by suppressing central compensation.
  • Alternative Scenarios for Medication Use: Short-term use of vestibular suppressants may be considered for managing severe vertigo during diagnostic or repositioning procedures, but clinicians should be cautious with their use.
  • Avoidance of Long-Term Use: Long-term medication use is discouraged due to the potential for side effects, sedation, dependency (especially with benzodiazepines), and interference with natural vestibular compensation mechanisms.

Follow-Up and Education

  • Patient Reassessment: Patients should be reassessed within a month post-treatment to confirm resolution or persistence of symptoms. Persistent or recurrent symptoms may necessitate repeat CRP or further evaluation for potential underlying vestibular or neurological disorders.
  • Patient Education: Educating patients about BPPV, its recurrence potential, and safe management techniques is critical. Patients should be informed of the non-benign impact of untreated BPPV, which can increase fall risk and impair daily function, especially in elderly individuals.

Additional Recommendations

  • Avoidance of Unnecessary Imaging: Routine imaging (e.g., MRI, CT) is generally unnecessary unless the presentation suggests an alternative diagnosis or atypical features.
  • Role of Shared Decision-Making: The guideline emphasizes the importance of involving patients in treatment decisions, especially when symptoms persist or when considering treatments beyond CRP.

Conclusion

This updated guideline provides clear evidence-based practices for diagnosing, treating, and managing BPPV. Repositioning maneuvers are the mainstay of treatment and demonstrate high effectiveness with minimal side effects. Routine medication use is not indicated for BPPV, as it does not treat the root cause and can impede natural recovery.

Regular follow-up and patient education are essential for optimal outcomes and prevention of complications associated with BPPV.

Reference: https://journals.sagepub.com/doi/full/10.1177/0194599816689667