What is the recommended management for a patient presenting with both herpes zoster (shingles) and benign paroxysmal positional vertigo (BPPV)?

Management of Concurrent BPPV and Herpes Zoster (Shingles)

Treat Both Conditions Simultaneously with Distinct Approaches

When a patient presents with both BPPV and herpes zoster, treat the BPPV immediately with canalith repositioning procedures (CRP) while managing the shingles with appropriate antiviral therapy—these conditions require parallel but separate treatment pathways. 1

BPPV Management Takes Priority for Vertigo Symptoms

Immediate Diagnostic Confirmation

• Perform the Dix-Hallpike maneuver to confirm posterior canal BPPV (85-95% of cases), looking for torsional upbeating nystagmus 1
• If negative, perform the supine roll test to assess for horizontal canal BPPV (10-15% of cases) 1

First-Line Treatment: Canalith Repositioning

• Execute the Epley maneuver immediately upon diagnosis without delay for medications or imaging 1
• Success rates reach 80% with just 1-3 treatments, and 90-98% with repeat maneuvers if needed 1
• The procedure involves: patient sitting upright with head turned 45° toward affected ear, rapidly laying back to supine head-hanging 20° position for 20-30 seconds, followed by sequential head and body turns 1

Critical Post-Treatment Instructions

• Patients can resume normal activities immediately—postprocedural restrictions provide no benefit and may cause unnecessary complications 1
• Reassess within 1 month to confirm symptom resolution 1

Understanding the Connection Between Shingles and BPPV

Secondary BPPV from Viral Vestibular Damage

• Herpes zoster oticus (Ramsay Hunt syndrome) is a recognized cause of secondary BPPV, accounting for approximately 20% of secondary BPPV cases alongside other unilateral vestibulopathies 2
• Secondary BPPV associated with viral vestibulopathy requires longer treatment duration (mean 5.07 days) compared to idiopathic BPPV (mean 2.28 days) 2
• The viral inflammation may damage the vestibular apparatus, causing otolith displacement that leads to BPPV 2

Expect More Challenging Treatment Course

• Secondary BPPV from viral causes may be more refractory to treatment, potentially requiring repeated repositioning maneuvers 2
• Monitor closely for canal conversion (occurs in 6-7% of cases), where debris moves from one canal to another during treatment 1

Medication Management: What NOT to Do

Avoid Vestibular Suppressants for BPPV

• Do NOT prescribe meclizine, antihistamines, or benzodiazepines as primary treatment for BPPV—there is no evidence these medications are effective as definitive treatment 1
• These medications cause significant adverse effects including drowsiness, cognitive deficits, and increased fall risk, especially problematic in elderly patients 1
• Vestibular suppressants interfere with central compensation mechanisms needed for recovery 3

Limited Role for Symptomatic Medications

• Consider vestibular suppressants ONLY for short-term management (3-5 days maximum) of severe nausea/vomiting in severely symptomatic patients 1, 3
• Prochlorperazine 5-10 mg may be used for severe nausea, maximum three doses per 24 hours 4
• Discontinue as soon as acute symptoms subside 3

Special Considerations for Concurrent Conditions

Assess Modifying Factors Before Treatment

• Question patients about impaired mobility, CNS disorders, lack of home support, and increased fall risk—these factors significantly modify management 5
• Elderly patients with BPPV have 12-fold increased fall risk, with studies showing 53% had fallen at least once in the past year 5
• Counsel patients and families regarding home safety assessment, activity restrictions, and need for supervision until BPPV resolves 5

Monitor for Atypical Features Suggesting Central Pathology

• If symptoms persist after 2-3 properly performed Epley maneuvers, reassess for: 1
  • Canal conversion or multiple canal involvement
  • Coexisting vestibular pathology
  • CNS disorders masquerading as BPPV
• Red flags requiring urgent evaluation include: downward-beating nystagmus, direction-changing nystagmus without head position change, spontaneous nystagmus, or accompanying neurological deficits 1

Treatment Algorithm for Persistent Symptoms

If BPPV Symptoms Continue After Initial Treatment

1. Repeat diagnostic testing (Dix-Hallpike or supine roll) to confirm persistent BPPV 1
2. Perform additional repositioning maneuvers—repeat CRP achieves 90-98% success rates 1
3. Check for canal conversion (6-7% incidence) requiring different maneuver 1
4. Evaluate for bilateral BPPV or multiple canal involvement 1
5. Consider vestibular rehabilitation therapy as adjunctive treatment, particularly for residual dizziness or postural instability 1

Vestibular Rehabilitation as Adjunct

• Offer VRT after successful CRP to reduce recurrence rates by approximately 50% 1
• VRT is particularly beneficial for patients with residual dizziness, postural instability, or heightened fall risk 1
• Do NOT use VRT as substitute for CRP—repositioning maneuvers remain first-line treatment 1

Common Pitfalls to Avoid

Don't Delay Definitive Treatment

• Avoid prescribing medications and scheduling follow-up without performing CRP—this leaves patients vulnerable to falls during the interval between diagnosis and treatment 5
• The time between initial diagnosis and definitive treatment represents a high-risk period for injury 5

Don't Assume Single Canal Involvement

• Secondary BPPV from viral causes may involve multiple canals or be bilateral, requiring comprehensive assessment 2
• Posterior canal remains most commonly involved, but horizontal canal involvement is more frequent in secondary BPPV than idiopathic cases 2

Don't Forget Recurrence Counseling

• BPPV has inherently high recurrence rates: 10-18% at 1 year, 30-50% at 5 years 1
• Educate patients about recognizing recurrent symptoms to allow earlier return for repeat CRP 5
• Each recurrence should be treated with repeat repositioning procedures, which maintain the same high success rates 1