New Guidelines for Benign Paroxysmal Positional Vertigo

Jennifer Garcia

March 01, 2017

New recommendations provide guidance to healthcare providers to aid in diagnostic planning and increase implementation of therapeutic positioning maneuvers for patients with benign paroxysmal positional vertigo (BPPV).

The American Academy of Otolaryngology–Head and Neck Surgery Foundation present the recommendations online March 1 in Otolaryngology–Head and Neck Surgery.

The updated guidelines include an emphasis on patient education and shared decision making, expanded recommendations on radiographic and vestibular testing, and new recommendations on restrictions after canalith repositioning procedures.

The descriptor "benign" implies that the disorder is "not due to any serious central nervous system…disorder" and has "an overall favorable prognosis for recovery," the guideline authors, led by Neil Bhattacharyya, MD, from the Brigham and Women's Hospital, Boston, Massachusetts, write. "However, the clinical and quality-of-life impacts of undiagnosed and untreated BPPV may be far from 'benign,' as patients with BPPV are at increased risk for falls and impairment in the performance of daily activities," they explain.

The authors note that the goal of the new guidelines, on the basis of evidence from recent clinical trials and systematic reviews, is to optimize patient care by improving health-related quality-of-life measures, facilitating a more efficient return to daily activities and work and lessening the economic impact of undiagnosed or improperly treated BPPV.

A key change in the new guidelines is the inclusion of expanded action statement profiles. These are presented in an algorithm designed to help providers recognize improvement opportunities and clarify decision making when developing a diagnostic and therapeutic plan for their patient.

The updated guidelines also make a strong recommendation for the use of canalith repositioning procedures as an initial therapy for patients with BPPV that will immediately control symptoms and preclude the need for vestibular suppressant medications (eg, antihistamines and/or benzodiazepines).

Further, the guidelines recommend against routine application of postprocedural restrictions, which have been advocated in the past. The authors note that reducing these restrictions would result in a faster return to normal lifestyle, less interruption of sleep or work, reduced musculoskeletal discomfort, and reduced cost.

Finally, the new guidelines also list frequently asked questions meant to help educate patients about their diagnosis, symptoms, and treatment expectations. Patient education recommendations also include guidance for providers on talking with patients about their safety risks and the importance of follow-up care.

The authors acknowledge potential barriers to implementation of the guidelines in particular settings. For example, clinicians may be unfamiliar with how to perform certain diagnostic positional maneuvers or may be inclined to order advanced diagnostics because of the complexities involved in evaluating patients with vertigo. Dr Bhattacharyya and colleagues note, however, that "[c]linician and patient education regarding outcomes expectations and counseling on proper follow-up may offset these issues."

The authors have disclosed no relevant financial relationships.

Otolaryngol Head Neck Surg. Published online March 1, 2017.

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