Outpatient Management of BPPV and Meniere's Disease
BPPV Management
First-Line Treatment: Canalith Repositioning Procedures
Clinicians should treat posterior canal BPPV (85-95% of cases) with the Epley maneuver as first-line therapy, which achieves 80% symptom resolution with 1-3 treatments and 90-98% success with repeat maneuvers if needed. 1, 2
Key treatment steps for posterior canal BPPV (Epley maneuver): 2
- Patient sits upright with head turned 45° toward affected ear
- Rapidly lay patient back to supine head-hanging 20° position for 20-30 seconds
- Turn head 90° to opposite side, hold 20-30 seconds
- Roll patient onto side with nose pointing down, hold 20-30 seconds
- Return to sitting position
Alternative for posterior canal: Semont (Liberatory) maneuver 1, 2
- Rapid lateral movements from side-lying to opposite side-lying
- 94.2% resolution at 6 months, though Epley shows superior 3-month outcomes 2
Treatment by Canal Type
For horizontal canal BPPV (10-15% of cases): 2, 3
- Geotropic variant: Barbecue Roll (Lempert) maneuver (50-100% success) or Gufoni maneuver (93% success) 2, 4
- Apogeotropic variant: Modified Gufoni maneuver (patient lies on affected side first) 2
The Gufoni maneuver is easier to perform than the Barbecue Roll because it only requires identifying the side of weaker nystagmus, not necessarily determining which side is involved. 4
Critical Post-Treatment Instructions
Do NOT recommend postprocedural restrictions (head elevation, sleep position restrictions, activity limitations) after canalith repositioning—these provide no benefit and may cause unnecessary complications. 1, 2
Patients can resume normal activities immediately after treatment. 2
Medication Management
Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment for BPPV—they have no evidence of effectiveness for treating the underlying condition and interfere with central compensation mechanisms. 2, 5
Limited exception: Short-term use (1-3 days maximum) may be considered only for severe autonomic symptoms (intractable nausea/vomiting) in severely symptomatic patients. 2
These medications cause significant adverse effects including drowsiness, cognitive deficits, and increased fall risk, especially in elderly patients. 2, 5
Self-Treatment Options
Self-administered Epley maneuver can be taught to motivated patients after at least one properly performed in-office treatment, with 64% improvement compared to only 23% with Brandt-Daroff exercises. 2, 5
Brandt-Daroff exercises are significantly less effective than repositioning maneuvers (24% vs 71-74% success at 1 week) but may be used for patients with physical limitations preventing repositioning procedures. 2
When to Reassess and Retreat
If symptoms persist after initial treatment: 2, 3
- Repeat Dix-Hallpike or supine roll test to confirm persistent BPPV
- Perform additional repositioning maneuvers (repeat CRPs achieve 90-98% success) 2
- Check for canal conversion (occurs in 6-7% of cases) 2, 3
- Evaluate for multiple canal involvement or bilateral BPPV
- Consider associated vestibular pathology (see below)
Reassess all patients within 1 month after initial treatment to confirm symptom resolution. 3, 5
Special Populations and Contraindications
Assess all patients for modifying factors before treatment: 1, 5
- Impaired mobility or balance
- CNS disorders
- Lack of home support
- Increased fall risk (elderly patients with BPPV have 9% prevalence in geriatric clinics, with three-quarters having fallen in previous 3 months) 2
Physical limitations requiring modified approach or specialized tables: 1, 2
- Cervical stenosis or severe radiculopathy
- Severe kyphoscoliosis or limited cervical range of motion
- Down syndrome
- Severe rheumatoid arthritis
- Paget's disease
- Ankylosing spondylitis
- Low back dysfunction or spinal cord injuries
- Morbid obesity
Vestibular Rehabilitation Therapy
VRT may be offered as adjunct therapy or for patients with contraindications to repositioning maneuvers, though it is initially less effective than CRPs for BPPV. 2, 3
Components include habituation exercises, gaze stabilization exercises, and Cawthorne-Cooksey exercises performed until symptoms fatigue. 3
When NOT to Order Testing
Do NOT obtain radiographic imaging in patients meeting diagnostic criteria for BPPV without additional signs/symptoms inconsistent with BPPV. 1
Do NOT order vestibular function testing in patients meeting diagnostic criteria for BPPV unless: 1
- Atypical nystagmus is present
- Additional vestibular pathology is suspected
- Failed or repeatedly failed response to CRP
- Frequent recurrences of BPPV (25-50% have associated vestibular pathology) 1
Meniere's Disease Management
Treatment Goals and Approach
Treatment goals for Meniere's disease focus on reducing severity and frequency of vertigo attacks, relieving associated symptoms (hearing loss, tinnitus, aural fullness), and improving quality of life. 3
Non-ablative procedures are preferred for patients with usable hearing, while ablative treatments may be considered for patients without useful hearing. 3
Important Association: BPPV + Meniere's Disease
Patients with both BPPV and Meniere's disease have significantly lower treatment success rates and higher recurrence rates compared to BPPV alone. 6, 7
Specific findings in this population: 6, 7
- Multiple semicircular canal involvement is more common
- Require repeated canalith repositioning procedures
- Highest recurrence rate occurs in multiple canal BPPV with Meniere's disease
- Only 37% report complete symptom resolution after CRP versus 86% in BPPV without associated vestibular pathology 1
When BPPV coexists with Meniere's disease, CRPs remain equally effective for resolving positional nystagmus, but complete symptom resolution is significantly less likely, requiring more aggressive follow-up and repeated treatments. 1, 6
Common Pitfalls to Avoid
- Relying on medications instead of repositioning procedures
- Imposing unnecessary postprocedural restrictions
- Failing to reassess after initial treatment
- Not checking for canal conversion when treatment fails
- Missing physical contraindications before attempting maneuvers
- Not moving patient quickly enough during maneuvers (reduces effectiveness) 2
- Expecting same success rates as isolated BPPV
- Not counseling patients about higher recurrence risk
- Failing to evaluate for multiple canal involvement