Benign Paroxysmal Positional Vertigo: Experts Update Best Practices for Diagnosis and Treatment

Delays in the diagnosis and treatment of BPPV have both cost and quality-of-life implications for both patients and their caregivers. “The significant incidence of BPPV, its impact on the daily lives of patients, and the wide diversity of diagnostic and therapeutic interventions for BPPV drove the need for an up-to-date practice guideline,” said Neil Bhattacharyya, MD, chair of the guideline update group. “In updating the guideline, it was our goal to do so utilizing a focused and transparent process, reconsidering more current evidence while ultimately factoring in BPPV treatments that result in improved quality-of-life for the patient.”

BPPV is the most common inner ear problem and cause of vertigo (vertigo is false sense of spinning). It is defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Given the prevalence of BPPV, its health-care and societal impacts are tremendous. A primary complaint of dizziness accounts for an estimated 5.6 million clinic visits in the United States per year and between 17 and 42 percent of patients with vertigo ultimately receive a diagnosis of BPPV. Almost 86 percent of patients with BPPV will suffer some interruption to their daily activities and lost days at work due to BPPV; 68 percent of patients with BPPV will reduce their workload while four percent will change their jobs and six percent will quit their jobs because of the condition.

BPPV is more common in older individuals with a correspondingly more pronounced health and quality-of-life impact. Older patients with BPPV experience a greater incidence of falls, depression, and impairments of their daily activities. With the increasing age of the U.S. population, the incidence and prevalence of BPPV may correspondingly increase over the next 20 years. It is estimated that it costs approximately $2,000 to diagnose BPPV and that greater than 65 percent with this condition will undergo potentially unnecessary diagnostic testing or therapeutic interventions. Healthcare costs associated with the diagnosis of BPPV alone approach $2 billion per year.

The primary outcome considered in this updated 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. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality- of-life of individuals afflicted with BPPV.

Differences between the 2008 guideline and the 2017 update include:• a consumer advocate added to the development group; • new evidence from two clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; • emphasis on patient education and shared decision-making;• expanded action statement profiles to explicitly state quality improvement opportunities, confidence in the evidence, intentional vagueness, and differences of opinion;• enhanced external review process to include public comment and journal peer review;• a new algorithm to clarify decision-making and action statement relationships; and• new and expanded recommendations for the diagnosis and management of BPPV.

The update is endorsed by American Academy of Audiology (AAA), American Neurotology Society (ANS), American Otological Society (AOS), Society of Otorhinolaryngology Head-Neck Nurses (SOHN), American Academy of Emergency Medicine (AAEM), Vestibular Disorders Association (VEDA), American Physical Therapy Association (APTA), and The Triological Society. Additionally, the American Academy of Family Physicians (AAFP) and American Academy of Neurology (AAN) gave an Affirmation of Value.

The guideline authors are: Neil Bhattacharyya, MD; Samuel P. Gubbels, MD; Seth R. Schwartz, MD, MPH; Jonathan A. Edlow, MD; Hussam El-Kashlan, MD; Terry Fife, MD; Janene M. Holmberg, PT, DPT, NCS; Kathryn Mahoney; Deena B. Hollingsworth, MSN, FNP-BC, CORLN; Richard Roberts, PhD; Michael D. Seidman, MD; Robert Wm. Prasaad Steiner, MD, PhD; Betty Tsai Do, MD; Courtney C. J. Voelker, MD, PhD; Richard W. Waguespack, MD; Maureen D. Corrigan.

Members of the media who wish to obtain a copy of the guideline or request an interview should contact: Tina Maggio at 703-535-3762, or [email protected]. Upon release, the guideline can be found at www.entnet.org.

------FACT SHEET-------------------

Why is the BPPV guideline update important?The significant incidence of BPPV, its functional impact, and the wide diversities of diagnostic and therapeutic interventions for BPPV make this an important condition for an up-to-date evidence-based practice guideline.

Delays in the diagnosis and treatment of BPPV have both cost and quality-of-life implications for both patients and their caregivers. Significant improvements in the diagnosis and treatment of patients with BPPV may lead to significant healthcare quality improvements as well as medical and societal cost savings. Such improvements may be achievable with the composition and implementation of a well-constructed clinical practice guideline for BPPV.

What is benign paroxysmal positional vertigo (BPPV)?BPPV is the most common inner ear problem and cause of vertigo (vertigo is false sense of spinning). It is defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo.

What causes BPPV?BPPV is caused when otoconia, tiny rocklike crystals of calcium carbonate that are located in the inner ear, become dislodged and get stuck on sensors in the wrong part or wrong canal of the inner ear. The intensity of BPPV symptoms relate to how long it takes the crystals to settle down after the head or position is moved/changed. As the crystals move and settle in the inner ear, the brain gets powerful, false messages that the individual is violently spinning. BPPV can sometimes be associated with trauma, migraine, other inner ear problems, diabetes, osteoporosis, and lying in bed for long periods of time.

What are the common symptoms of BPPV?• Distinct triggered spells of vertigo or spinning sensations• Nausea (sometimes vomiting)• Severe feeling of disorientation in space, or instability

What is the prevalence of BPPV?• BPPV is very common and most cases of BPPV happen for no reason. • A primary complaint of dizziness accounts for 5.6 million clinic visits in the United States per year and between 17 and 42 percent of patients with vertigo ultimately receive a diagnosis of BPPV. • Almost 86 percent of patients with BPPV will suffer some interruption to their daily activities and lost days at work due to BPPV: o 68 percent of patients with BPPV will reduce their workload o 4 percent will change their jobs and o 6 percent will quit their jobs because of the condition• BPPV is more common in older individuals with a correspondingly more pronounced health and quality-of-life impact.o Older patients with BPPV experience a greater incidence of falls, depression, and impairments of their daily activities. • It is estimated that it costs approximately $2,000 to arrive at the diagnosis of BPPV and that greater than 65 percent with this condition will undergo potentially unnecessary diagnostic testing or therapeutic interventions. • Healthcare costs associated with the diagnosis of BPPV alone approach $2 billion per year.

Where can I get more information?Healthcare providers should discuss all treatment options and find the best approach for the patient. There are printable patient handouts of frequently asked questions and other resources that further explain BPPV and can help with decisions about care options. For more information BPPV, go to http://www.entnet.org/BPPVCPG.

SIGNIFICANT POINTS MADE IN THE GUIDELINE:

DIAGNOSIS OF POSTERIOR SEMICIRCULAR CANAL BPPV: Clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with torsional, up-beating nystagmus is provoked by the Dix Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45 degrees to one side and neck extended 20 degrees with the affected ear down. The maneuver should be repeated with the opposite ear down if the initial maneuver is negative.

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.

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

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

RADIOGRAPHIC TESTING: Clinicians should not obtain radiographic imaging in a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging.

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.

REPOSITIONING PROCEDURES AS INITIAL THERAPY: Clinicians should treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure.

POSTPROCEDURAL RESTRICTIONS: Clinicians should not recommend postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV.

OBSERVATION AS INITIAL THERAPY: Clinicians may offer observation with follow-up as initial management for patients with BPPV.

VESTIBULAR REHABILITATION: The clinician may offer vestibular rehabilitation in the treatment of BPPV.

MEDICAL THERAPY: Clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines.

OUTCOME ASSESSMENT: Clinicians should reassess patients within one month after an initial period of observation or treatment to document resolution or persistence of symptoms

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 central nervous system disorders.

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

About the AAO-HNS/F The American Academy of Otolaryngology—Head and Neck Surgery (www.entnet.org), one of the oldest medical associations in the nation, represents about 12,000 physicians and allied health professionals who specialize in the diagnosis and treatment of disorders of the ears, nose, throat, and related structures of the head and neck. The Academy serves its members by facilitating the advancement of the science and art of medicine related to otolaryngology and by representing the specialty in governmental and socioeconomic issues. The AAO-HNS Foundation works to advance the art, science, and ethical practice of otolaryngology-head and neck surgery through education, research, and lifelong learning. The organization's vision: "Empowering otolaryngologist-head and neck surgeons to deliver the best patient care."