Treatment of Post-Traumatic BPPV with Subgaleal Hematoma
Perform the canalith repositioning procedure (Epley maneuver) immediately upon diagnosis without obtaining imaging or prescribing medications, as the normal CT scan has already ruled out serious intracranial pathology and anticoagulation is not a contraindication to repositioning maneuvers. 1, 2, 3
Immediate Management Algorithm
Step 1: Confirm BPPV Diagnosis
- Perform the Dix-Hallpike maneuver to identify posterior canal BPPV (85-95% of cases), looking for torsional upbeating nystagmus 2, 3
- If Dix-Hallpike is negative but BPPV suspected, perform the supine roll test for horizontal canal BPPV (10-15% of cases) 2, 3
- The normal CT scan already excludes serious CNS pathology, so no additional imaging is needed 1
Step 2: Perform Appropriate Repositioning Maneuver
For posterior canal BPPV: Execute the Epley maneuver immediately with 80% success rate after 1-3 treatments 2, 4, 3
- Position patient upright with head turned 45° toward affected ear
- Rapidly lay back to supine head-hanging 20° position for 20-30 seconds
- Turn head 90° toward unaffected side
- Roll patient onto side while maintaining head position
- Return to upright position 2
For horizontal canal BPPV: Use Barbecue Roll maneuver (50-100% success) or Gufoni maneuver (93% success) 2, 3
Step 3: Post-Treatment Instructions
- Allow immediate return to normal activities - postprocedural restrictions provide no benefit and may cause complications 1, 2, 4, 3
- Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as they have no evidence of effectiveness for BPPV and increase fall risk, particularly dangerous given the patient's anticoagulation 1, 2, 4, 3
Critical Considerations for Post-Traumatic BPPV
Expect More Challenging Course
Post-traumatic BPPV differs significantly from idiopathic BPPV:
- Requires repeated CRP in up to 67% of cases versus 14% in non-traumatic forms 1
- Higher recurrence rate of 55% versus typical rates 5
- More likely to be bilateral (25% of cases) 5
- May require 13.5 days median time to first treatment in severe trauma versus 6 days in mild trauma 6
Anticoagulation is NOT a Contraindication
- The normal CT scan excludes active intracranial bleeding 1, 7
- The subgaleal hematoma is extracranial and does not contraindicate repositioning maneuvers 1
- Anticoagulation does not prevent safe performance of CRP 1, 2
When to Reassess
Reassess within 1 month if symptoms persist 1, 2, 3:
- Repeat diagnostic testing to confirm persistent BPPV
- Perform additional repositioning maneuvers (90-98% success with repeat treatments) 2, 4, 3
- Evaluate for canal conversion (occurs in 6-7% of cases) 2
- Consider bilateral or multiple canal involvement 1, 5
- Rule out coexisting vestibular dysfunction if symptoms occur with general head movements 2
Fall Risk Assessment and Safety Counseling
Address fall risk immediately as BPPV increases fall risk 12-fold, particularly critical given anticoagulation status 2, 3:
- Assess for impaired mobility or balance 1, 2, 3
- Evaluate home support and need for supervision 1
- Counsel regarding home safety modifications 1
- Consider vestibular rehabilitation therapy as adjunctive treatment to reduce recurrence by 50% 2, 3
Common Pitfalls to Avoid
- Do NOT delay treatment waiting for symptoms to resolve spontaneously - early CRP is safe and effective even in trauma patients 8, 6
- Do NOT order additional imaging when diagnostic criteria are met and CT is normal 1, 4
- Do NOT prescribe vestibular suppressants as primary treatment - they cause drowsiness, cognitive deficits, and increase fall risk without treating the underlying condition 1, 2, 4
- Do NOT impose postprocedural restrictions - patients can resume normal activities immediately 1, 2, 4, 3
- Do NOT miss the diagnosis by attributing all symptoms to concussion - post-traumatic BPPV is frequently underdiagnosed 8, 5