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

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

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