What are alternative treatments for dizziness suspected to be related to vestibular disorders like Benign Paroxysmal Positional Vertigo (BPPV) in a patient who is not a good candidate for the Dix-Hallpike maneuver?

Alternative Treatment for Suspected BPPV When Dix-Hallpike Cannot Be Performed

If a patient cannot undergo the Dix-Hallpike maneuver but has symptoms consistent with BPPV, perform the supine roll test to assess for horizontal canal BPPV and treat accordingly with the appropriate repositioning maneuver, or offer vestibular rehabilitation therapy as an alternative treatment option. 1, 2

Diagnostic Alternatives

Supine Roll Test for Horizontal Canal BPPV

• The supine roll test is the recommended alternative diagnostic maneuver when the Dix-Hallpike cannot be performed, as it assesses for lateral (horizontal) semicircular canal BPPV, which accounts for 10-15% of BPPV cases. 1, 2
• This test involves the patient lying supine with the head turned rapidly 90° to each side, observing for horizontal nystagmus and vertigo. 1
• Horizontal canal BPPV may present with either geotropic (toward the ground) or apogeotropic (away from the ground) nystagmus patterns, which determine the specific treatment approach. 2

Treatment Options When Standard Positioning Maneuvers Are Not Feasible

Canalith Repositioning Procedures for Horizontal Canal BPPV

• For geotropic horizontal canal BPPV, use the Barbecue Roll (Lempert) Maneuver, which involves rolling the patient 360 degrees in sequential 90-degree steps, with success rates of 50-100%. 2
• The Gufoni Maneuver is an alternative for geotropic horizontal canal BPPV, with a 93% success rate, involving moving the patient from sitting to side-lying on the unaffected side for 30 seconds, then turning the head 45-60° toward the ground for 1-2 minutes. 2
• For apogeotropic horizontal canal BPPV, use the Modified Gufoni Maneuver, which involves lying on the affected side instead. 2

Vestibular Rehabilitation Therapy

• Vestibular rehabilitation may be offered as either initial therapy or as an adjunct to repositioning maneuvers for patients who cannot tolerate standard diagnostic or treatment maneuvers. 1, 2
• VRT includes habituation exercises, adaptation exercises for gaze stabilization, and compensation for vestibular deficits. 2
• Research demonstrates that vestibular rehabilitation reduces dizziness and improves balance in patients with chronic vestibular symptoms, unlike vestibular suppressant medications which only reduce dizziness without improving balance. 3

Self-Administered Treatment Options

• Self-administered canalith repositioning procedures can be taught to motivated patients and are significantly more effective (64% improvement) than Brandt-Daroff exercises (23% improvement). 2
• Brandt-Daroff exercises may be considered for patients with severe physical limitations (cervical stenosis, severe rheumatoid arthritis, cervical radiculopathies) who cannot perform standard repositioning maneuvers. 2
• These exercises involve moving quickly between sitting and side-lying positions with the head rotated 45° upward, performed three times daily. 2

What NOT to Do

Avoid Vestibular Suppressant Medications

• Do not routinely prescribe vestibular suppressant medications (antihistamines, benzodiazepines, meclizine) for BPPV treatment, as there is no evidence of effectiveness and they may interfere with central compensation mechanisms. 1, 2
• Despite FDA approval of meclizine for vertigo associated with vestibular system diseases 4, the American Academy of Otolaryngology-Head and Neck Surgery strongly recommends against their routine use in BPPV. 1, 2
• These medications cause significant adverse effects including drowsiness, cognitive deficits, increased fall risk (especially in elderly patients), and decreased diagnostic sensitivity. 2
• Vestibular suppressants may only be considered for short-term management of severe autonomic symptoms (nausea, vomiting) in severely symptomatic patients. 2

Avoid Unnecessary Testing

• Do not obtain radiographic imaging or vestibular testing in patients who meet clinical criteria for BPPV in the absence of additional signs or symptoms inconsistent with BPPV. 1

Assessment of Modifying Factors

Critical Safety Considerations

• Assess all patients for modifying factors before treatment, including impaired mobility or balance, CNS disorders, lack of home support, and increased fall risk. 1, 2
• Elderly patients are particularly at risk, with studies showing 9% of patients referred to geriatric clinics having undiagnosed BPPV, and three-quarters having fallen within the previous 3 months. 2
• Patients with cervical stenosis, severe rheumatoid arthritis, cervical radiculopathies, or spinal issues may not be candidates for standard repositioning maneuvers and require alternative approaches. 2

Follow-Up and Treatment Failure Management

Reassessment Protocol

• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms. 1, 2
• If symptoms persist, repeat diagnostic testing to confirm persistent BPPV, check for canal conversion (occurs in 6-7% of cases), evaluate for multiple canal involvement, and rule out coexisting vestibular conditions or CNS disorders. 2, 5
• Repeat repositioning maneuvers can achieve success rates of 90-98% for persistent BPPV. 2

Common Pitfalls to Avoid

• Do not assume treatment failure means the diagnosis is wrong—multiple canal involvement, bilateral BPPV, or canal conversion may require additional treatments. 2, 5
• Do not rely solely on the presence of nystagmus during treatment as a marker of success—research shows that vertigo and nystagmus throughout the Epley maneuver is not indicative of treatment success. 5
• Be vigilant for post-treatment otolithic crisis (down-beating nystagmus and vertigo), which occurs in 19% of patients after the first or second consecutive Epley maneuver and increases fall risk. 5
• Do not fail to consider horizontal canal BPPV when the Dix-Hallpike cannot be performed or is negative—this variant requires different diagnostic and treatment approaches. 1, 2