Benign paroxysmal positional vertigo (ECPG)

 Statement topic

 Egyptian Recommendation

 Evidence Quality

 Strength of

Recommendations

Study type

Reference

1.Diagnosis of posterior semicircular canal BPPV

Clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with torsional, up beating nystagmus is   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.

Moderate

Strong Recommendation

Diagnostic study

with minor limitation

Honrubia V, Baloh RW, Harris MR, et al. Paroxysmal positional

vertigo syndrome. Am J Otol. 1999;20:465-470.

2.Diagnosis of 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.

Moderate

Strong Recommendation

Diagnostic study with minor limitation

Baloh RW, Jacobson K, Honrubia V. Horizontal semicircular

canal variant of benign positional vertigo. Neurology.

1993;43:2542-2549.

3.Differential diagnosis

Clinicians should differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo.

Low

Strong Recommendation

Observational study

Kentala E, Rauch SD. A practical assessment algorithm

for diagnosis of dizziness. Otolaryngol Head Neck Surg.

2003;128:54-59.

4.Modifying factors

Clinicians should assess patients with BPPV for factors that modify management ,by the recommended repositioning maneuvers, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling.

Low

Conditional Recommendation

Observational study

Lawson J, Johnson I, Bamiou DE, et al. Benign paroxysmal positional

vertigo: clinical characteristics of dizzy patients referred to

a Falls and Syncope Unit. QJM. 2005;98:357-364.

5.Radiographic testing

Clinicians should not obtain radiographic imaging in a patient who meets diagnostic criteria for BPPV.

Low

Strong Recommendation

(against)

Observational study

Turski P, Seidenwurm D, Davis P; American College of Radiology.

Expert Panel on Neuroimaging: Vertigo and Hearing Loss. Reston, VA: American College of Radiology; 2006.

6.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.   Vestibular testing may be ordered in case of recurrence, persistence of complaint after repositioning manoeuvre or in the presence of atypical nystagmus .

Low

Conditional Recommendation (against)

Observational study

Baloh RW, Honrubia V, Jacobson K. Benign positional vertigo:

clinical and oculographic features in 240 cases. Neurology.

1987;37:371-378

7.Repositioning procedures as initial therapy (a)

Clinicians should treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. Epley’s or Semont’s are equivocally effective for posterior canal BPPV. Semont’s is recommended in cupulolithiasis than Epley’s.

 High

 Strong Recommendation

Well designed RCT  and systemic review with meta-analysis

Hilton MP, Pinder DK. The Epley (canalith repositioning)

manoeuvre for benign paroxysmal positional vertigo. Cochrane

Database Syst Rev. 2014;(12):CD003162.

Prim-Espada MP, De Diego-Sastre JI, Pérez-Fernández E.

Meta-analysis on the efficacy of Epley’s manoeuvre in benign

paroxysmal positional vertigo. Neurologia. 2010;25:295-299.

8.Repositioning procedures as initial therapy (b)

The barbecue roll maneuver or Gufoni maneuver appear moderately effective for the geotropic form of lateral semicircular canal BPPV.

Moderate

Conditional Recommendation

RCT

Kim JS, Oh S-Y, Lee S-H, et al. Randomized clinical trial for

geotropic horizontal canal benign paroxysmal positional vertigo.

Neurology. 2012;79:700-707.

9.Post procedural restrictions

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.

High

Conditional Recommendation (against)

Diagnostic study with minor limitation

Well-designed RCT

Roberts RA, Gans RE, DeBoodt JL, et al. Treatment of benign

paroxysmal positional vertigo: necessity of postmaneuver

patient restrictions. J Am Acad Audiol. 2005;16:357-366.

Balikci HH, Ozbay I. Effects of postural restriction after modified

Epley maneuver on recurrence of benign paroxysmal positional

vertigo. Auris Nasus Larynx. 2014;41:428-431.

10.Number of CRP repetitions

1-2 sessions would resolve the condition in 87-100% of patients. A minority would require a 3ed trial. Otherwise persistent BPPV is suspected.

 Low

 Strong Recommendation

Observational study

Kentala E, Pyykkö I. Vertigo in patients with benign paroxysmal positional vertigo. Acta Otolaryngol Suppl. 2000;543:20-22.

11.If there is difficulty in performing successful maneuver

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.

  Low

 Strong Recommendation

Observational study

Kerber KA. Benign paroxysmal positional vertigo: opportunities

squandered. Ann N Y Acad Sci. 2015;1343:106-112.

12.Observation as initial therapy

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.

 Low

 Strong Recommendation

Observational study

Kerber KA. Benign paroxysmal positional vertigo: opportunities

squandered. Ann N Y Acad Sci. 2015;1343:106-112.

 Statement topic

 Egyptian Recommendation

 Evidence

Quality

 Strength of Recommendations

The statement is based up on:

13.Vestibular rehabilitation

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.

Moderate

Strong Recommendations

Systemic review

Hillier SL, Hollohan V. Vestibular rehabilitation for unilateral

peripheral vestibular dysfunction. Cochrane Database Syst

Rev. 2007;(4):CD005397.

14.Medical therapy

Clinicians should not treat BPPV with vestibular suppressant medications such as antihistamines and/ or benzodiazepines. Exceptions: Prior to CRP in patients with severe nausea and/or vomiting, or patients previously manifested severe nausea and/or vomiting during testing.

Moderate

Strong Recommendation (against)

Diagnostic study with minor limitation

Fujino A, Tokumasu K, Yosio S, et al. Vestibular training for

benign paroxysmal positional vertigo: its efficacy in comparison

with antivertigo drugs. Arch Otolaryngol Head Neck Surg.

1994;120:497-504.

14.Outcome

assessment

Clinicians should reassess patients within an initial period of observation following the canalith repositioning procedure ( 40 minutes up to one week) to document resolution, need for repetition of CRP session or persistence of symptoms.

Very low

Strong Recommendation

Observational study

Sekine K, Imai T, Sato G, et al. Natural history of benign paroxysmal

positional vertigo and efficacy of Epley and Lempert

maneuvers. Otolaryngol Head Neck Surg. 2006;135:529-533.

15.Evaluation of treatment failure

Clinicians should evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or or central nervous system disorders.

Low

Strong Recommendation

Observational study

Buttner U, Helmchen C, Brandt T. Diagnostic criteria for central

versus peripheral positioning nystagmus and vertigo: a

review. Acta Otolaryngol. 1999;119:1-5.

16.Patient Education

Clinicians should educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up.

Low

Strong Recommendation

Observational study

Brandt T, Dieterich M. Vestibular falls. J Vestib Res. 1993;3:3-14.