The American Academy of Otolaryngology–Head and Neck Surgery Foundation has updated the clinical practice guideline for diagnosis and treatment of benign paroxysmal positional vertigo (BPPV).
Delays in the diagnosis and treatment of BPPV have cost and quality of life implications for both patients and their caregivers. “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,” said Neil Bhattacharyya, MD, chair of the guideline update group.
The AAO-HNS estimates that the cost to diagnose BPPV is approximately $2,000 and that more than 65% of individuals with the condition undergo potentially unnecessary diagnostic testing or therapeutic interventions.
The primary outcome considered in the updated guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of the condition, a more efficient return to regular activities and work for patients, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in disease recurrence, and a reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of the condition, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life in individuals with BPPV.
Key points from the updated guidelines include:
- 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.
- Lateral 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.
- 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 patients who have posterior canal BPPV with a canalith repositioning procedure.
- 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 of the initial period of observation or treatment to document resolution or persistence of symptoms.