EXECUTIVE SUMMARY

Updated guidelines on the diagnosis and treatment of benign paroxysmal positional vertigo (BPPV) suggest a series of in-office maneuvers, rather than expensive imaging tests or medications, offer a faster route to diagnosis and cure.

  • Typically, patients with BPPV present with symptoms of intense dizziness that may be accompanied by nausea, vomiting, or an intense feeling of disorientation or instability.
  • A very specific diagnostic step called the Dix-Hallpike maneuver can enable physicians to quickly spot the signs of BPPV.
  • When the diagnosis is positive for BPPV, canalith repositioning maneuvers typically can resolve the symptoms.
  • When BPPV is suspected, guideline authors urged providers to stay away from vestibular suppressive medications, which produce a host of side effects and can contribute to a delay in diagnosis.

Every year, vague symptoms of intense dizziness drive millions of Americans to EDs and other frontline providers, and a large percentage of these cases (17-42%) are the result of benign paroxysmal positional vertigo (BPPV). Although the inner-ear problem itself is not generally serious, delays in diagnosis can affect quality of life negatively and lead to the loss of work, falls, and even depression in some patients. Since BPPV becomes more prevalent as people age, the effect on seniors is more pronounced.

However, updated guidelines from the American Academy of Otolaryngology – Head and Neck Surgery highlight advances in the diagnosis and treatment of BPPV that can help providers quickly arrive at a correct diagnosis and immediately apply treatment, generally leading to a quick resolution of symptoms without resorting to expensive imaging studies or potentially harmful medications.1

Although the dizziness associated with BPPV is episodic, it can be very intense and it is quite daunting, notes Neil Bhattacharyya, MD, FACS, chair of the guideline update group and associate chief of the division of otolaryngology at Brigham and Women’s Hospital in Boston. “A lot of patients will think they are having a stroke, or that something much more serious is going on,” he says. “It can be paralyzing because if you don’t know what is causing the dizziness, you don’t want to move around. You just kind of sit there in bed, hoping it is going to go away.”

Sometimes, physicians will adopt a wait-and-see approach toward complaints of dizziness; meanwhile, the intense spinning sensation that goes along with BPPV may keep patients from driving or going to work. The dizziness may be accompanied by nausea, vomiting, or an intense feeling of disorientation or instability. “Many physicians will prescribe medications such as Valium or other agents to try to suppress the dizziness, but that is not the best treatment for BPPV,” Bhattacharyya stresses.

However, the new guidelines make clear that opting for expensive imaging studies generally is unnecessary and ill-advised as well. “We were able to strengthen some of the statements about the diagnosis of BPPV, bringing it to the forefront so that it is more at the top of the tongue for a differential diagnosis of dizziness for patients and for physicians, Bhattacharyya says. “We also strengthened the treatment recommendations so that if the provider is aware of the diagnosis, it can become a relatively straightforward treatment, skipping all the bells and whistles of MRIs and hearing tests and things like that, and going right to the treatment, all in that one visit.”

Further, the evidence-based guidelines are an attempt to address the fact that providers use a wide variety of diagnostic and therapeutic interventions for BPPV, some of which are ineffective, expensive, and needlessly time-consuming. However, Bhattacharyya acknowledges that getting to the root cause of dizziness can be especially challenging for providers.

“It is one of those symptoms where the patient will come in and complain that they are dizzy, but when you look at them, they are walking normally and talking normally, and they are obviously not having a stroke,” he says. “They may say that they felt dizzy last night or yesterday or a few days ago, but they are not dizzy now.”

However, if the cause of the dizziness is BPPV, there is now strong evidence that physicians can make the diagnosis in the ED or in an office setting with a five- to 10-minute history and physical exam, using a very specific diagnostic step called the Dix-Hallpike maneuver, Bhattacharyya explains.

The maneuver involves moving the patient from an upright to a supine position, with the head turned 45 degrees to one side and the neck extended roughly 20 degrees with one ear facing down. The procedure can be repeated with the opposite ear facing down.

“If you do this maneuver, you can elicit the same dizziness symptomatology and make the diagnosis,” Bhattacharyya says. In particular, in cases of BPPV, the clinician will observe rapid eye movements or nystagmus. “Once you make the diagnosis [of BPPV], there is very compelling evidence that you can do a particle repositioning maneuver, and roughly 80% of the time, cure the patient in that same visit,” he says.

This second maneuver involves a series of head movements that are designed to move the small crystals of calcium carbonate or canaliths that have collected in the ear canal, which essentially cause the dizziness.

The updated guidelines stress the importance of completing these maneuvers when BPPV is suspected. “That is one of the very key points here rather than just saying, ‘well, I guess the patient was dizzy three days ago; we ought to rule out the bad stuff. Let’s get an MRI and follow up with neurology in a month,’” Bhattacharyya notes. “By then, you have missed the boat.” While the maneuvers used to diagnose and treat BPPV are not new, the evidence behind them is much stronger than it was seven years ago when the last guidelines were published. “Almost all of the multidisciplinary panel members were familiar with the maneuvers, but they weren’t quite as familiar with how effective they are because there is relatively new data in the literature,” Bhattacharyya explains. “We would like to see 100% penetration of these diagnostic and therapeutic maneuvers, particularly when patients come in with a vague complaint of dizziness.”

As a result of the new evidence, the guidelines stress two very strong negative recommendations or things the expert panel advises providers not to do. “You don’t have to get an MRI or a CT scan, which saves the patient anxiety, saves the system money, and saves you time,” Bhattacharyya notes. “Also, we really want to steer clinicians away from vestibular suppressive medications, which have a host of side effects and contribute to both a delay in diagnosis and time out of work because the patient generally can’t drive or go to work on Valium or other similar medications.”

The guideline authors suggested there is ample room for improvement in the way BPPV is addressed. They estimated that it costs about $2,000 to diagnose BPPV, and that more than 65% of patients with BPPV will undergo potentially unnecessary diagnostic testing and interventions. In fact, the authors noted that healthcare costs associated with the diagnosis of BPPV top $2 billion per year.

To partially address these cost implications, a consumer advocate was added to the guideline development group for this most recent update. Bhattacharyya explains that this step was taken because of the growth of shared cost models in medicine. “A lot of patients have insurance plans where they have a high deductible, or they have a 20% copay ... so, increasingly, we are seeing patients who are not only concerned about their body, but their pocketbook as well,” he says.

For example, if a patient is going to undergo an MRI, he wants to know if that is cost-effective because it may not be a covered service under his health plan, Bhattacharyya observes. “We felt it was important to include the consumer side of the equation, because patient-centered decision-making is so important,” he says.

REFERENCE

  1. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: Benign paroxysmal positional vertigo (update) executive summary. Otolaryngol Head Neck Surg 2017;156:403-416.

SOURCE

  • Neil Bhattacharyya, MD, FACS, Associate Chief, Division of Otolaryngology, Brigham and Women’s Hospital, Boston. Phone: (617) 525-6540.