Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)
Otolaryngology—Head and Neck Surgery
Bhattacharyya, N., Gubbels, S. P., et al. (2017).
Otolaryngology—Head and Neck Surgery, 156(3 Suppl), S1-S47.
This is a guideline update to the 2008 American Academy of Otolaryngology—Head and Neck Surgery Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo. This current guideline provides recommendations for diagnosing and managing benign paroxysmal positional vertigo (BPPV) in adult patients with suspected or potential BPPV diagnosis.
American Academy of Otolaryngology—Head and Neck Surgery Foundation
<p>This guideline was reviewed with the following supplemental document:</p>
<ul>
<li>Bhattacharyya, N., Gubbels, S. P., et al. (2017). Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update) Executive Summary. <i>Otolaryngology--Head and Neck Surgery, 156</i>(3): 403-416. doi:10.1177/0194599816689660</li>
</ul>
<p>Differential diagnosis recommendations include:</p>
<ul>
<li>"Clinicians should differentiate, or refer to a clinician who can differentiate, [benign paroxysmal positional vertigo] BPPV from other causes of imbalance, dizziness, and vertigo" (Recommendation; p. S13).</li>
<li>"Clinicians should assess patients with BPPV for factors that modify management, including impaired mobility or balance, [central nervous system] CNS disorders, a lack of home support, and/or increased risk for falling" (Recommendation; p. S16).</li>
</ul>
<p>Outcome assessment recommendations include:</p>
<ul>
<li>"Clinicians should reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms" (Recommendation; p. S31).</li>
<li>"Clinicians should evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved [benign paroxysmal positional vertigo] BPPV and/or underlying peripheral vestibular or [central nervous system] CNS disorders" (Recommendation; p. S32).</li>
</ul>
<p>Additional testing recommendations include:</p>
<ul>
<li>Regarding radiographic testing, "clinicians should not obtain radiographic imaging in a patient who meets diagnostic criteria for [benign paroxysmal positional vertigo] BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging" (Recommendation Against; p. S18).</li>
<li>Regarding vestibular testing, "clinicians should not order vestibular testing in a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing" (Recommendation Against; p. S19).</li>
</ul>
Regarding education, "clinicians should educate patients regarding the impact of [benign paroxysmal positional vertigo] BPPV on their safety, the potential for disease recurrence, and the importance of follow-up" (Recommendation; p. S33).
<p>Diagnosis recommendations include:</p>
<ul>
<li>Regarding Posterior Semicircular Canal [benign paroxysmal positional vertigo] BPPV, "clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down. The maneuver should be repeated with the opposite ear down if the initial maneuver is negative" (Strong Recommendation; pp. S8-S9).</li>
<li>Regarding Lateral (Horizontal) Semicircular Canal BPPV, "if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus, the clinician should perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV" (Recommendation, p. S12).</li>
</ul>
Regarding vestibular rehabilitation, "the clinician may offer [vestibular rehabilitation] VR in the treatment of [benign paroxysmal positional vertigo] BPPV" (Option; p. S27).
<p>Treatment recommendations include:</p>
<ul>
<li>Regarding repositioning procedures as initial therapy, "clinicians should treat, or refer to a clinician who can treat, patients with posterior canal [benign paroxysmal positional vertigo] BPPV with a [canalith repositioning procedure] CRP" (Strong Recommendation; p. S20).</li>
<li>Regarding post-procedural restrictions, "clinicians should not recommend post-procedural postural restrictions after CRP for posterior canal BPPV" (Strong Recommendation Against; p. S25).</li>
<li>Regarding observation as initial therapy, "clinicians may offer observation with follow-up as initial management for patients with BPPV" (Option; p. S26).</li>
</ul>
