What are the treatment options for vestibulitis?

Treatment Options for Vestibulitis

Canalith repositioning procedures (CRP) are the first-line treatment for benign paroxysmal positional vertigo (BPPV), which is the most common form of vestibulitis, with success rates of 90-98% when properly performed. 1, 2

Diagnosis and Initial Assessment

• Posterior canal BPPV: Diagnosed when vertigo with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver 1
• Lateral canal BPPV: Assessed using the supine roll test when Dix-Hallpike shows horizontal or no nystagmus 1
• Important: Clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo 1

Treatment Algorithm

First-Line Treatment: Canalith Repositioning Procedures

• For posterior canal BPPV: Epley or Semont maneuver 1, 2
• For lateral canal BPPV: Appropriate canal repositioning maneuvers 1
• No postprocedural restrictions needed after canalith repositioning 1

Second-Line Options

1. Vestibular rehabilitation: May be offered either self-administered or with a clinician 1, 2

   • Helps promote central compensation in vestibular disorders
   • Can be used as a complementary approach to CRP

2. Observation with follow-up: May be considered as initial management 1

   • BPPV may resolve spontaneously in some cases
   • Requires reassessment within 1 month to document resolution or persistence 1

Medications

• Vestibular suppressant medications should NOT be routinely used for BPPV treatment 1, 2
• Medications such as antihistamines (meclizine) and benzodiazepines:
  • Do not provide definitive treatment
  • Delay central compensation
  • May cause sedation and cognitive impairment
  • Should be limited only to short-term management of severe symptoms like nausea or vomiting 1, 2

Management of Treatment Failures

• Reassess within 1 month after initial treatment to confirm symptom resolution 1
• For persistent symptoms:
  1. Evaluate for unresolved BPPV
  2. Consider involvement of other semicircular canals
  3. Assess for underlying peripheral vestibular or central nervous system disorders 1

Special Considerations

• Assess for modifying factors that may affect management:

  • Impaired mobility or balance
  • Central nervous system disorders
  • Lack of home support
  • Increased fall risk 1

• Avoid unnecessary testing:

  • Do not obtain radiographic imaging if diagnostic criteria for BPPV are met 1
  • Do not order vestibular testing unless additional symptoms inconsistent with BPPV are present 1

Patient Education

• Educate patients about:
  • Safety concerns related to BPPV
  • Potential for disease recurrence (BPPV has a natural course of becoming less severe over time)
  • Importance of follow-up 1
  • Self-management techniques including physical counter-pressure maneuvers if applicable

Common Pitfalls to Avoid

• Overreliance on vestibular suppressant medications
• Inadequate follow-up after initial treatment
• Failure to identify specific causes of chronic dizziness
• Prolonged use of vestibular suppressants 2

By following this evidence-based approach to vestibulitis treatment, clinicians can effectively manage most cases of BPPV while minimizing unnecessary medication use and improving patient outcomes.