The American Academy of Otolaryngology has updated the clinical practice guidelines for BPPV to have all the treating physicians on the same page.

 

 

 

 

BPPV symptoms hugely impact  the patients’ day-to-day life. 

According to a study conducted on the economic burden of BPPV, out of 4,105 patients with BPPV, only half were employed. Among those, 69.8% had reported having a reduction in their work efficiency, 63.3% had compromised on their working hours, 4.6% had looked for other means of employment, and the rest 5.7% of the people had to leave their jobs. 

 

The lifetime prevalence of BPPV is 2.4 percent.  Despite being a highly prevalent condition, it is under-reported; although it has a considerable impact on the work efficiency and the use of healthcare resource.Patients with BPPV are usually referred to either a specialty doctor who is well-trained in treating vestibular disorders, a rehabilitation therapist, or an ENT specialist. Unfortunately, many physicians are unaware of the effective treatment modalities to help patients overcome disturbing symptoms of BPPV.

The American Academy of Otolaryngology updated clinical practice guidelines for BPPV have all the treating physicians on the same page.The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The updated guidelines include evidence from two clinical practice guidelines,20 systematic reviews, and 27 randomized controlled trials and make several strong recommendations.

The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV.

The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV.

Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV

Improving the quality of care, Obtaining better treatment outcomes, Promoting appropriate use of vestibular suppressants, Reducing the use of ancillary tests, Promoting effective use of different maneuvers in treatment

1. Diagnosis of BPPV

A) Diagnosis of posterior semicircular canal in BPPV

The clinicians should use Dix-Hallpike maneuver to help diagnose posterior semicircular canal BPPV when vertigo is associated with torsional, up-beating nystagmus. The Dix-Hallpike maneuver is the gold-standard test for diagnosing BPPV. It is performed by making the patient lie supine, with the head placed at 45ᵒ and the neck extended to 20 ᵒ, ensuring that the affected ear is placed downwards. If the initial maneuver tends to be negative, the maneuver must be repeated by placing the opposite ear downwards. This method improves the accuracy of diagnosing BPPV. However, patients with certain physical limitations such as cervical stenosis, Down’s syndrome, ankylosing spondylitis, spinal cord injuries, and severe rheumatoid arthritis are exceptions to it.

B) Diagnosis of lateral semicircular canal BPPV

When a patient has a history suggestive of BPPV and if the Dix-Hallpike reveals horizontal or no nystagmus, then the doctor must perform a supine roll test to detect lateral semicircular canal BPPV. This test helps to avoid the missed diagnosis of lateral semicircular canal BPPV, and safeguard from imprecise diagnosis and treatments.

Patients with cervical stenosis, cervical radiculopathies, Paget’s disease, spinal cord injuries, severe rheumatoid arthritis and who are morbidly obese are considered exceptions for undergoing the supine roll test.

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2. Differential Diagnosis and Modifying Factors

A) Differential diagnosis

The clinicians must rule out other causes of imbalance, vertigo, and dizziness, before confirming the diagnosis of BPPV.

This approach is valuable in avoiding a false-positive diagnosis of BPPV, when the patient may have some other condition that mimics BPPV.

B) Modifying factors

The updated guidelines focus on identifying and decreasing the risks that may cause complications. The modifying factors may include impaired balance, central nervous system disorders, and risk of falls. The goal of the diagnostic approach is to manage the patients with BPPV by providing an appropriately structured comprehensive treatment strategy. This strategy includes identifying patients’ risk for falls and preventing the fall-related injuries.

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3. Diagnostic Testing

A) Radiographic testing

The radiographic tests must be reserved for the patients who do not fit the diagnostic criteria for BPPV and in whom the additional signs and symptoms are atypical.

The updates guidelines aim to reduce unnecessary testing and avoid radiation exposure and adverse reactions associated with the radiographic test.

B) Vestibular testing

The vestibular testing must be performed only when the clinical presentation is atypical, or if Dix-Hallpike testing indicates any unusual nystagmus findings.

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4. Non-interventional Therapies for BPPV

A) Repositioning procedures as the initial therapy

Canalith repositioning procedure (CPR) should be the initial therapy for posterior canal BPPV as it helps in successful resolution of symptoms.

B) Postprocedural restrictions

After the CRP for posterior canal BPPV, posture changes should not be restricted. This approach helps the patient to resume the daily activities faster and reduces the musculoskeletal discomfort.

C) Observation as initial therapy

Watchful waiting or observation, rather than specific therapeutic interventions, should be the initial therapy, anticipating that the symptoms can be self-limiting.

It is beneficial, especially when the treatments are contraindicated or if there is any history of adverse reactions.

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5. Non-interventional Therapy for Non-Respondents to CRP

Vestibular rehabilitation

Vestibular rehabilitation (VR), a group of therapies/exercise to help treat dizziness and balance disorders, should be the choice of treatment, if the patient has failed to show any progress with CRP or if the patient is not the right candidate for CRP.

VR  group of therapies/exercise  

CRP, Habituation exercises, exercises for gaze stabilization, balance retraining and facilitation of sensory and motor integration, gait retraining, fall prevention, relaxation training, conditioning exercises, functional and occupational skills retraining, patient and family education