A new comprehensive clinical guideline for benign paroxysmal positional vertigo
Nov 1, 2008 - 3:51:45 AM
Head and Neck Surgery Foundation (AAO-HNSF) will issue a comprehensive clinical guideline to help healthcare practitioners identify and treat patients with benign paroxysmal positional vertigo (BPPV), one of the most common underlying conditions that cause dizziness. The guideline emphasizes evidence-based recommendations on managing BPPV, the most common vestibular (inner ear) disorder in adults.
BPPV is a disorder that causes feelings of vertigo, dizziness, and nausea. Episodes of BPPV can be brought on by abrupt changes in movement, like standing up or turning the head suddenly. The condition usually begins to affect people after the age of 50, but it can affect younger patients.
"Approximately 5.6 million medical appointments per year in the United States can be attributed to complaints of dizziness," said Neil Bhattacharyya, MD, chair of the multidisciplinary BPPV Guideline Panel. "We know now that anywhere from 17 to 42 percent of these patients will ultimately receive a diagnosis of BPPV. Unfortunately, proper diagnosis and treatment for those suffering is often delayed due to a lack of standardized diagnostic steps and relative unawareness of effective treatment options."
The primary purposes of the new AAO-HNSF guideline, for patients 18 years and older, are to improve quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of the condition, reducing the inappropriate use of suppressant medications, decreasing the inappropriate use of ancillary tests such as radiographic imaging and vestibular testing, and to promote the use of effective repositioning maneuvers for treatment.
Expenses relating to the diagnosis and treatment of BPPV cost the U.S. healthcare system approximately $2 billion per year. Additionally, 86 percent of patients suffer some interrupted daily activities and lost days at work because of BPPV.
Fortunately, BPPV can be readily diagnosed by clinicians in an outpatient setting most of the time without complicated testing. Once a proper diagnosis has been made, simple, effective treatment options are available to relieve symptoms quickly.
Some of the key recommendations of the guideline include:
A strong recommendation for clinicians to diagnose posterior semicircular canal BPPV with an office-based diagnostic test (the Dix-Hallpike maneuver, detailed within the guideline).
A recommendation for clinicians to also test patients for a second type of BPPV affecting the lateral semicircular canal when initial testing is not conclusive (using the supine roll test).
Clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo.
Clinicians should question patients with BPPV for factors that modify management including impaired mobility or balance, CNS disorders, a lack of home support, and increased risk for falling. These recommendations will help prevent some of the dangerous morbidities from BPPV.
Clinicians should not obtain radiographic imaging or vestibular testing in a patient diagnosed with BPPV, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to BPPV that warrant testing.
Clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines.
For patients who are initial treatment failures, clinicians should evaluate them for persistent BPPV or underlying peripheral vestibular or CNS disorders.
Clinicians should counsel patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up.
The guideline was created by a multidisciplinary panel of clinicians representing the fields of otolaryngology, audiology, emergency medicine, physical medicine and rehabilitation, geriatrics,physical therapy, family physicians, neurology, and chiropractics.
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