What is the diagnosis and treatment of Benign Paroxysmal Positional Vertigo (BPPV) in ENT (Ear, Nose, and Throat) patients?

Diagnosis and Treatment of Benign Paroxysmal Positional Vertigo (BPPV)

BPPV should be diagnosed through specific bedside testing (Dix-Hallpike test for posterior canal BPPV and supine roll test for horizontal canal BPPV) and treated with canalith repositioning procedures, which have success rates of approximately 80% with just 1-3 treatments. 1, 2

Diagnosis

Posterior Canal BPPV (Most Common - 80-90% of cases)

• Diagnose posterior canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver 1
• Dix-Hallpike maneuver: Patient starts in seated position, head turned 45° to one side, then rapidly moved to supine position with head extended 20° off the examination table 1
• Positive test shows:
  • Latency period between position change and onset of vertigo/nystagmus 1
  • Brief rotatory vertigo (seconds to minutes) 1
  • Torsional, upbeating nystagmus 1
  • Test must be performed bilaterally to determine affected ear 1

Horizontal Canal BPPV (10-15% of cases)

• If posterior canal testing is negative but history suggests BPPV, perform the supine roll test 1
• Supine roll test: Patient lies supine with head in neutral position, then head is quickly rotated 90° to one side, then to the other 1
• Positive test shows horizontal nystagmus that changes direction with head position 1, 2

Diagnostic Pitfalls

• Normal imaging (MRI, CT) and laboratory testing cannot confirm BPPV 1
• Avoid Dix-Hallpike in patients with significant vascular disease, cervical stenosis, severe kyphoscoliosis, limited cervical range of motion, or other conditions limiting neck movement 1
• False negatives can occur; consider repeating the test at a separate visit if clinical suspicion is high 1, 3

Treatment

Posterior Canal BPPV

• First-line treatment: Canalith Repositioning Procedure (Epley maneuver) 1, 2
  • Success rate: 80% with 1-3 treatments 1, 2
  • Patients treated with CRP have 6.5 times greater chance of symptom improvement compared to controls 2
• Alternative: Semont (Liberatory) maneuver 2, 4
  • 71% symptom resolution at 1 week 2

Horizontal Canal BPPV

• First-line treatment: Barbecue Roll Maneuver (Lempert maneuver) 2, 5
  • Involves rolling the patient 360 degrees in sequential steps 2
  • Success rate of about 70% after a few maneuvers 5
• Alternative: Gufoni maneuver for geotropic variant and Modified Gufoni for apogeotropic variant 2

Self-Treatment Options

• Self-administered CRP can be taught to motivated patients 1, 2
• Self-administered CRP is more effective (64% improvement) than self-treatment with Brandt-Daroff exercises (23% improvement) 2

Post-Treatment Considerations

• Do NOT recommend postprocedural postural restrictions after canalith repositioning procedure 1, 2
• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms 1
• Patients may experience mild residual symptoms for a few days to weeks after successful treatment 1, 2
• For treatment failures, evaluate for:
  • Persistent BPPV that may respond to additional repositioning maneuvers 2
  • Involvement of other semicircular canals 2
  • Underlying peripheral vestibular or central nervous system disorders 1

Medication Use

• Do NOT routinely treat BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines 1, 2
• Vestibular suppressant medications can cause:
  • Drowsiness and cognitive deficits 2
  • Increased risk of falls, especially in elderly patients 1, 2
  • Interference with central compensation 2
• Limited role: Consider only for short-term management of severe autonomic symptoms (nausea, vomiting) 2

Special Considerations

• Assess patients for modifying factors:
  • Impaired mobility or balance 1
  • Central nervous system disorders 1
  • Lack of home support 1
  • Increased risk for falling 1, 2
• Post-traumatic BPPV may be more refractory and/or bilateral, requiring specialized treatment 1
• Elderly patients are at higher risk for falls with BPPV 1, 2
• Canal conversion (changing from one type of BPPV to another) can occur in about 6-7% of cases during treatment 2, 6

When to Refer to a Specialist

• Patients with severe disabling symptoms 1, 2
• History of falls or fear of falling, especially in seniors 1
• Difficulty moving due to joint stiffness or weakness 1
• Treatment failures after repeated repositioning maneuvers 1, 2
• Suspected horizontal or anterior canal BPPV (rare variants) 5
• Presence of additional symptoms inconsistent with BPPV 1