Benign paroxysmal positional vertigo (ECPG)

- Annexes

Editorial Independence:

▪️ This guideline was developed without any external funding.

▪️ All the guideline development group members have declared that they do not have any competing interests.

Annex 1: Guideline Flowchart

Annex 2: Tables of appraisal of selected guidelines: Currency (table 1), Content (table 2) and Quality (table 3) of the selected guidelines.

Table 1: Currency

Table 2: Content

CRITERIA	American Academy ORL-HNS	Bárány Society	Spanish ORL-HNS Consensus	Japan Society for Equilibrium Research
Credibility	9/9	5.4/9	7.2/9	3.6/9
Observability	9/9	7.2/9	3.6/9	3.6/9
Relevance	9/9	7.2/9	7.2/9	5.4/9
Relative advantage	7.2/9	7.2/9	7.2/9	7.2/9
Easy to install and understand	9/9	9/9	7.2/9	5.4/9
Compatibility	*9/9*	*9/9*	*9/9*	*9/9*
Testability	9/9	9/9	9/9	9/9
Total	61.2	54	50.4	43.2

Table 3: Quality

Domain	AAO-HNS	Bárány Society	Spanish ORL- HNS Consensus	Japan Society for Equilibrium Research
1. Transparency	A	A	C	C
2. Conflict of interest	A	A	B	B
3. Development group	A	C	C	C
4. Systematic review	A	B	A	B
5. Grading of evidence	A	B	B	B
6. Recommendations	A	C	C	C
7. External review	A	A	NR	B
8. Updating	B	B	B	B

Annex 3: The risks and benefits of added and/or modified statements

Statement topic	Original statement	The statement action to be adapted	Benefits	Risk/Harm
Vestibular testing	Clinicians should not order laboratory 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.	Clinicians should not order laboratory 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. Vestibular testing may be ordered in case of recurrence, persistence of complaint after repositioning maneuver or in the presence of atypical nystagmus	Diagnosis and treatment of possible causes of positional vertigo other than BPPV	Cost of vestibular testing
Repositioning procedures as initial therapy for posterior canal (a)	Clinicians should treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure	Clinicians should treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. Epley or Semont are equivocally effective for post.canal BPPV	High value ascribed to prompt resolution of symptoms and the ease with which the CRP may be performed	No serious adverse events reported in controlled randomized trials
Repositioning procedures as initial therapy for lateral canal (b)	Not reported	the barbecue roll maneuver or Gufoni maneuver appear moderately effective for the geotropic form of lateral semicircular canal BPPV	Helps in resolution of patients symptoms	None
Post procedural restrictions	Clinicians may not routinely recommend post procedural postural restrictions after canalith repositioning procedure for posterior canal BPPV.	Clinicians may not routinely recommend post procedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. Post procedural postrural restriction might be recommended in selected cases as in failure (or repeated failure) of the repositioning maneuvers, recurrent cases, or cases associated with other vestibular pathology as MD or vestibular Migraine.	Help patients to tolerate symptoms till complete recovery	Possible musculoskeletal discomfort and cost of cervical collars
Number of CRP repetitions	Not reported	1-2 sessions would resolve the condition in 87-100% of patients. A minority would require a 3ed trial. Otherwise persistent BPPV is suspected.	Help the clinician to search for causes of resolution failure	Cost of investigations
If there is difficulty in performing successful maneuver	Not reported	Clinicians should start with CRP (or modified) even in those patients who are very obese; have severe cervical or lumber discs; or upon patient’s preference. In the latter case patients should be instructed to avoid activities that may increase the risk of falls until symptoms resolve.	Faster recovery and resolution of BPPV	Patient discomfort and difficulty of performing the maneuver
Observation as initial therapy	Clinicians may offer observation with follow up as initial management for patients with BPPV	Clinicians may offer observation with follow up only if there is difficulty in performing successful maneuver after trials in some patients as : very obese; severe cervical or lumber discs; or upon patient's preference not to repeat the maneuver	Avoidance of increased risks of falls; the use of vestibular suppressants with their known side effects	Prolonged symptoms compared with other interventions that may expose patients to increased risks for falls or lost days of work; indirect costs of delayed resolution compared with other measures
Vestibular rehabilitation	The clinician may offer VR in the treatment of BPPV	VR should be considered an option in the treatment of BPPV rather than a recommended first-line treatment modality. Home based Brandt-Daroff exercises is indicated in patients with persistent dizziness or imbalance after successful CRP or patients who refuse CRP.A more comprehensive customized VR program is indicated in patients with other vestibular pathology or with comorbid impairments that require balance rehabilitation specially in elderly.	Reduce patient symptom in the mentioned cases	None for home-based exercise. Cost if formal VR program is recommended
Medical therapy	Clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines	Clinicians should not treat BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. Exceptions: Severely symptomatic patients refusing other treatment options and patients requiring prophylaxis for CRP	Avoidance of adverse effects from, or medication interactions with, these medications; prevention of decreased diagnostic sensitivity from vestibular suppression during performance of the Dix-Hallpike maneuvers	None
Outcome assessment	Clinicians should reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms	Clinicians should reassess patients within time frame of 3 weeks following the canalith repositioning procedure to document resolution, need for repetition of CRP session or persistence of symptoms	Confirming the success of the maneuver; avoidance of missing other versions of BPPV as multiple canals or central causes	None