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Benign paroxysmal positional vertigo (BPPV) Updated 2011 Apr 15 12:00:00 AM: particle repositioning maneuvers associated with
resolution of benign paroxysmal positional nystagmus (BPPN) in patients with BPPV (Phys Ther 2010 May) view update
vestibular rehabilitation may improve subjective dizziness in patients with unilateral peripheral vestibular dysfunction, but appears less effective than physical maneuvers (Cochrane Database Syst Rev 2011 Feb 16) view update
continued peer review
Related Summaries:
Dizziness - differential diagnosis
General Information (including ICD-9/-10 Codes)
Description:
disorder of inner ear manifested by repeated episodes of spinning sensation triggered by changes in head position (positional vertigo)(1)
Also called:
benign positional vertigo (BPV) positional vertigo of Barany
ICD-9 codes:
386.1 other and unspecified peripheral vertigo o 386.10 peripheral vertigo, unspecified
o 386.11 benign paroxysmal positional vertigo
o 386.19 other peripheral vertigo
386.2 vertigo of central origin
386.3 labyrinthitis
o 386.30 labyrinthitis, unspecified
o 386.31 serous labyrinthitis
o 386.32 circumscribed labyrinthitis
o 386.33 suppurative labyrinthitis
o 386.34 toxic labyrinthitis
o 386.35 viral labyrinthitis
CPT code 92599 canalith repositioning procedure
ICD-10 codes:
H81 disorders of vestibular function o H81.1 benign paroxysmal vertigo
o H81.3 other peripheral vertigo
o H81.8 other disorders of vestibular function
o H81.9 disorder of vestibular function, unspecified
H83.0 labyrinthitis
Definitions:
vertigo is illusion of movement of self or one's surroundings (for example, rotating, spinning, tilting, swaying)
Types:
posterior canal BPPV (85%-95% of cases)(1)
lateral (horizontal) canal BPPV(1)
anterior canal BPPV
Organs involved:
inner ear, usually ampulla of posterior semicircular canal
Who is most affected:
middle age to elderly, mean age 57 years benign paroxysmal vertigo in childhood usually begins before age 4 years, lasts 2-4 years
and resolves completely
o episodes of vertigo are brief (rarely more than a few minutes)
o creatine kinase-MB levels persistently increased in prospective study of 22 children with benign paroxysmal vertigo
o Reference - J Pediatr 2005 Apr;146(4):548 in Pediatric Notes 2005 Jun 16;29(24):93
Incidence/Prevalence:
most common cause of peripheral vertigo most common causes of vertigo in general practice are benign positional vertigo, acute
vestibular neuronitis, and Meniere's disease
o these 3 diagnoses accounted for 93% diagnoses among 70 patients with vertigo presenting to 13 general practitioners in prospective study
o Reference - Br J Gen Pract 2002 Nov;52(482):809, summary can be found in Am Fam Physician 2003 Feb 15;67(4):845
vestibular vertigo has 1.5% incidence, 5.2% 1-year prevalence and 7.8% lifetime prevalence
o based on random telephone screening of 4,869 persons in Germany followed by detailed neurotologic interviews of 1,003 persons
o vestibular vertigo defined as rotational vertigo, positional vertigo, or recurrent dizziness with nausea and oscillopsia or imbalance
o Reference - Neurology 2005 Sep 27;65(6):898
Causes and Risk Factors
Causes:
usually no precipitating factors may be due to
o head trauma
o viral illness
o vascular etiology (for example, labyrinthine artery vasospasm or embolic event)
o prolonged immobility of head
Pathogenesis:
normal functioning of inner ear sensory hair cells in inner ear structures detect fluid (endolymph) movements during
motion of head or body, leading to signals to brain for sensation of motion or position
o semicircular canals detect rotational acceleration
o utricle and saccule detect linear acceleration
theories of BPPV pathogenesis include cupulolithiasis and canalithiasis
o both theories include concept of solid matter (precipitate) within inner ear structure
as the head moves, the precipitate stimulates sensory hair cells and triggers sensation of motion
vertigo occurs because visual and somatosensory inputs do not match vestibular input
o cupulolithiasis
small crystal of calcium carbonate (otoconia, "grain of sand") from the utricle becomes lodged in ampulla (cupula) of posterior semicircular canal
may also occur in cases of posttraumatic vertigo
theoretically should respond to habituation therapy, for example, Cawthorne exercises
o canalithiasis
precipitation of solid matter or relocation of otoconia into semicircular canal distal to the ampulla
theoretically should respond to canalith repositioning (Epley maneuver)
o support for theory of debris floating in endolymph stimulating posterior semicircular canal found in study of "canal-clearing" treatment
study of 30 patients with BPPV symptoms for median 3 months
15 patients rotated backwards by 360 degrees over several minutes in flight simulator, 10 of 15 had complete cessation of symptoms
next 15 patients first underwent 360-degree forward rotation without benefit and then 360-degree backward rotation 1 week later, with 10 of 14 having cessation of symptoms
Reference - Neurology 1997 Sep;49(3):729 in J Watch 1997 Nov 1;17(21):170
Complications and Associated Conditions
Complications:
complications rare but might include o falls
o persistent vomiting could lead to dehydration or chloride-responsive metabolic alkalosis
Associated conditions:
additional otopathology and/or vestibulopathy identified in 31%-53% of BPPV patients(1)
osteopenia or osteoporosis may be associated with idiopathic benign positional vertigo
o based on case-control study
o 209 patients with idiopathic benign positional vertigo (BPV) and 202 controls had bone mineral densitometry
o increased risk for BPV was associated with osteopenia (adjusted odds ratio 2, 95% CI 1.2-3.4) and osteoporosis (adjusted odds ratio 3.1, 95% CI 1.4-7.7)
o Reference - Neurology 2009 Mar 24;72(12):1069
History
Chief concern (CC):
rotational or spinning sensation after changes in head position (relative to gravity)(1)
often occurs when patient rolls over in bed or is tilting head(1)
may be sense of imbalance between discrete episodes(1)
History of present illness (HPI):
symptoms episodic, lasting < 1 minute(1)
symptoms recur with movement of head, often precipitated by recumbent head position either to left or right
tilting head may induce symptoms such as when(1)
o looking up in sky
o trying to reach top of shelf
o bending over to tie shoes
associated symptoms commonly include nausea and/or vomiting
Medication history:
ask about any new medications medications that can affect vestibular system include
o sedatives/tranquillizers
o anticonvulsants
o antidepressants
o antipsychotics
o antihistamines
Social history (SH):
ask about alcohol use (alcohol can affect vestibular system)
Review of systems (ROS):
last ocular exam new glasses, contacts or eyedrops
hearing
tinnitus
sinus problems
nasal allergies
weight loss or gain
gait ataxia
Physical
General physical:
blood pressure measurements in supine, seated and standing positions to rule out orthostatic hypotension
HEENT:
evaluate visual acuity, cataracts and extra-ocular motility nystagmus
o typical finding - rotatory nystagmus (torsional nystagmus)
o may also have nystagmus on lateral gaze
o nystagmus unidirectional
o if nystagmus is vertical or multidirectional, consider brainstem involvement (multiple sclerosis, tumor, stroke, alcohol or other sedative drugs, trauma)
o nystagmus can be assessed by observing limbus (border between iris and sclera)
Cardiac:
listen for murmurs, arrhythmias
Neuro:
attempt to reproduce symptoms with rotation, flexion, hyperextension of head; look for symptoms and nystagmus
BPPV not associated with central nervous system abnormalities (such as dysphagia, dysarthria, sensory deficits)
Dix-Hallpike maneuver for diagnosing posterior canal BPPV (1)
o Dix-Hallpike maneuver also called Nylen-Barany maneuver, Barany maneuver, Hallpike-Dix maneuver
o caution patient that positioning may elicit intense vertigo and nausea
o technique
begin with patient seated upright and examiner standing on patient's side
examiner rotates head 45 degrees towards first side to be tested
instruct patient to keep eyes open and while supporting head, quickly move patient to supine position so that the patient's head is extended past the examination table and is hanging about 20 degrees below horizontal plane with patient's chin slightly pointed upwards
examiner checks patient's eyes for nystagmus observing
latency period before onset
duration
direction
typically provokes vertigo and rotatory nystagmus when ear on affected side placed in downward position after 5-20 seconds (called latency and theorized to be the time to set otoliths in motion)
may cause increase in patient's subjective vertigo which usually resolves within < 20 seconds but can last up to 60 seconds from onset of nystagmus
after resolution of vertigo and nystagmus (if present), slowly return patient to upright position
nystagmus may recur in opposite direction
after patient asymptomatic, repeat process with other ear in dependent position
vertigo and nystagmus typically extinguish after repeated trials
o clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with nystagmus (typically torsional and also may have downward beating component) elicited by Dix-Hallpike maneuver (AAO Grade B)
o nystagmus findings may indicate which semicircular canal is involved
with posterior semicircular canal involvement (most common)
rotatory (torsional) and sometimes slight vertical (upbeating) nystagmus on Dix-Hallpike maneuver, downbeating nystagmus on return to sitting
rotatory nystagmus is clockwise if left ear involved and down; counterclockwise if right ear involved and down
with anterior semicircular canal involvement - rotatory and downbeating nystagmus on Dix-Hallpike maneuver, upbeating nystagmus on return to sitting
with horizontal semicircular canal involvement - horizontal nystagmus on Dix-Hallpike maneuver, horizontal (opposite direction) nystagmus on return to sitting
Reference - Arch Otolaryngol Head Neck Surg 1996 Mar;122(3):281
supine roll test (Pagnini-Clure maneuver) for diagnosis of lateral canal BPPV (1,2)
o should be performed on patients with history consistent with BPPV but with negative Dix-Hallpike maneuver
o clinicians should diagnose lateral canal BPPV when vertigo associated with nystagmus elicited by supine roll test (AAO Grade C)
o caution patient that positioning may elicit intense vertigo and nausea
o positioning procedure
patient supine with head in face-up neutral position
quickly rotate head to one side while examining for nystagmus
after resolution of vertigo and nystagmus (if present), slowly return head to neutral position
head is then quickly rotated 90 degrees to other side and again checked for nystagmus
o nystagmus may be very intense with horizontal component towards the ground
patient limitations for performing Dix-Hallpike or supine roll maneuvers include diagnoses of
o cervical stenosis
o severe kyphoscoliosis
o Down syndrome
o severe rheumatoid arthritis
o Paget disease
o ankylosing spondylitis
o spinal cord injury
o morbid obesity
o low back dysfunction
o limited range of motion of cervical spine
Diagnosis
Making the diagnosis:
American Academy of Otolaryngology-Head and Neck Surgery Foundation diagnostic criteria for posterior canal BPPV(1)
o history of repeated episodes of vertigo with changes in head position
o vertigo with nystagmus elicited by Dix-Hallpike maneuver
o latency period (typically 5-20 seconds) between completion of Dix-Hallpike test and onset of nystagmus and vertigo
o nystagmus and vertigo increase and then resolve ≤ 60 seconds from onset of nystagmus
Rule out:
neurologic disorders(1)
o vertebrobasilar insufficiency (may have isolated vertigo, but other brainstem signs and symptoms can be localizing)
o multiple sclerosis
o migraine-associated vertigo (episodic vestibular symptoms associated with migraine)
o intracranial tumors
otologic disorders(1)
o Meniere's disease (often associated with protracted nausea and vomiting)
o vestibular neuronitis (gradual onset; can last days to weeks)
o labyrinthitis (gradual onset; can last days to weeks)
o superior canal dehiscence syndrome
o posttraumatic vertigo
other disorders(1)
o anxiety
o panic disorder
o cervical vertigo (degenerative cervical spine disease)
o postural hypotension
o side effects of medications including
carbamazepine
primidone
phenytoin
migrainous vertigo has been described (Neurology 2001 Feb 27;56(4):436)
see also Dizziness - differential diagnosis
Testing to consider:
Dix-Hallpike maneuver radiographic imaging and vestibular testing should not be ordered unless diagnosis
uncertain or other signs or symptoms unrelated to BPPV that would be indications for further testing (AAO Grade C)(1)
o imaging not clinically useful in routine diagnosis of BPPV
o if patient meets criteria for BPPV, vestibular function testing does not offer additional diagnostic benefit unless patient remains symptomatic after treatment
insufficient evidence to recommend audiometric testing (AAO Grade D)
Imaging studies:
imaging not clinically useful in routine diagnosis of BPPV(1)
American College of Radiology (ACR) Appropriateness Criteria for vertigo and hearing loss can be found at National Guideline Clearinghouse 2010 Aug 9:15749
Other diagnostic testing:
vestibular function testing o battery of tests that record nystagmus (electronystagmogram [ENG]) in response
to labyrinthine stimulation and/or voluntary eye movements including(1)
caloric stimulation helpful for unilateral vestibular hypofunctioning
rotational chair testing sensitive for quantifying magnitude of bilateral peripheral hypofunction
video-oculographic recordings of nystagmus may be helpful for posterior canal BPPV
o if patient meets criteria for BPPV, vestibular function testing does not offer additional diagnostic benefit(1)
o vestibular testing indicated(1)
if diagnosis of cause of vertigo or dizziness unclear
possibly when patient remains symptomatic after treatment for BPPV
o formal electronystagmography if nystagmus not apparent (American Academy of Neurology assessment of electronystagmography in Neurology 1996 Jun;46(6):1763)
insufficient evidence to recommend audiometric testing (AAO Grade D)(1)
o BPPV does not affect hearing and audiometric studies should be normal
o hearing loss and BPPV are both common conditions and may coexist in older patient population
o may be helpful in distinguishing other diseases that involve hearing (such as vestibular schwannoma [acoustic neuroma], Meniere's disease)
Prognosis
Prognosis:
usually abates spontaneously in weeks to months, but can last hours to years nystagmus in same direction during first and second position of Epley maneuver
predicts resolution of symptoms (level 1 [likely reliable] evidence)
o based on prospective cohort study
o 126 patients with posterior canal benign paroxysmal positional vertigo (BPPV) were treated with Epley maneuver (repeated after 1-3 days if persistent BPPV) and followed for 7 months
o nystagmus was evaluated after "first position" and "second position" of Epley maneuver
first position is patient supine with head extended off exam table and turned 45 degrees toward affected side (symptomatic ear), the same position as the end of the Hallpike maneuver
second position is after 90 degrees contralateral head turn and before turning trunk 90 degrees
orthotropic nystagmus defined as nystagmus in the same direction during both positions
reversed nystagmus defined as nystagmus in opposite directions in first and second position
o 99 patients had orthotropic nystagmus
94 (94.5%) had resolution of BPPV on first Epley maneuver
5 (5%) had resolution of BPPV after second Epley maneuver
no recurrences within 7 months
o 15 patients had reversed nystagmus
3 (20%) had resolution of BPPV on first Epley maneuver, no recurrences within 7 months
12 (80%) had persistent BPPV after 2 Epley maneuvers
o 12 patients had no nystagmus
4 (33%) had resolution of BPPV on first Epley maneuver, but 3 had recurrences 1-7 months later
8 (67%) had persistent BPPV after 2 Epley maneuvers
o Reference - Neurology 2007 Apr 10;68(15):1219
Treatment
Treatment overview:
patients with posterior canal BPPV should be treated with a particle repositioning maneuver (AAO Grade B, AAN Level A)
o canalith repositioning procedure (Epley maneuver)
Epley maneuver has short-term efficacy (level 1 [likely reliable] evidence) and may have long-term efficacy (level 2 [mid-level] evidence)
patients can treat themselves at home with modified Epley procedure (level 2 [mid-level] evidence)
addition of home use of Epley procedure may increase efficacy of in-office Epley procedure (level 2 [mid-level] evidence)
o Semont positioning maneuver may be simpler than Epley maneuver but less effective (level 2 [mid-level] evidence)
o postprocedure postural restrictions may not improve efficacy of Epley or Semont positioning maneuvers
other options for initial management of BPPV
o observation with follow-up may be initial management of BPPV (AAO Grade B)
o vestibular exercises
vestibular rehabilitation (either self-administered or with clinician) may be initial treatment of BPPV (AAO Grade C)
vestibular rehabilitation may improve subjective dizziness in patients with unilateral peripheral vestibular dysfunction, but appears less effective than physical maneuvers (level 2 [mid-level] evidence)
both canalith repositioning procedure and vestibular exercises may be taught to patient or patient may be referred to physical therapy
medications - vestibular suppressants
o BPPV should not be routinely treated with vestibular suppressant medications such as antihistamines or benzodiazepines (AAO Grade C)
o for acute vertigo in the emergency department , dimenhydrinate 50 mg IV may be more effective and more tolerable than lorazepam 2 mg IV (level 2 [mid-level] evidence)
insufficient evidence to recommend or refute surgical treatments for BPPV (AAN Level U)
reassess patients within 1 month after initial period of observation or treatment to confirm symptom resolution (AAO Grade C)
Activity:
Observation:
observation with follow-up may be initial management of BPPV (AAO Grade B)(1)
o benign illness which is usually self-limited
o if patients being observed without any other intervention, need to counsel patients to avoid activities that may be associated with injury (such as falling from ladder, turning head while driving)
Vestibular exercises:
vestibular rehabilitation (either self-administered or with clinician) may be initial treatment of BPPV (AAO Grade C)(1)
o vestibular exercises also called
vestibular rehabilitation
vestibular therapy
Brandt-Daroff exercises
Cawthorne-Cooksey exercises
o form of physical therapy promoting habituation, adaptation or compensation for deficits from balance disorders
specific approaches to vestibular exercises include
o simple instructions can be to hold symptom-inducing position for 10 seconds 5 times/day
o Brandt-Daroff exercises
patients instructed to sit on bed, drop trunk and head to affected side until head on bed with head angled upwards, return to sitting, drop to opposite side, maintain each position for 30 seconds, repeat 5 times 3 times daily
self-administered Brandt-Daroff exercises or habituation exercises are less effective than canal repositioning exercises for treatment of posterior canal BPPV(AAN Level C)(2)
picture of Brandt-Daroff exercises can be found at dizziness-and-balance.com
o Cawthorne-Cooksey exercises
consist of eye and head movements while supine and sitting, frequent changes in position with eyes open or closed while standing and walking
exercises to be done for 15 minutes twice daily, increasing to 30 minutes
eye exercises
look up, then down; first slowly then quickly; 20 times
look from one side to the other; first slowly then quickly; 20 times
focus on finger at arm's length, moving finger one foot closer and back again; 20 times
head exercises
bend head forward then backward with eyes open; first slowly then quickly; 20 times
turn head from side to side; first slowly then quickly; 20 times
as dizziness decreases, perform theses exercises with eyes closed
sitting
shrug shoulders 20 times
turn shoulders from side to side 20 times
bend forward and pick up objects from ground and sit up 20 times
standing
change from sitting to standing and back to sitting, 20 times with eyes open, repeat with eyes closed
throw small rubber ball from hand to hand above eye level 10 times
throw ball from hand to hand under one knee
moving about
walk across room with eyes open, then closed; 10 times
walk up and down slope with eyes open, then closed; 10 times
walk up and down steps with eyes open, then closed; 10 times
any game involving stooping or turning
vestibular rehabilitation may improve dizziness in patients with unilateral peripheral vestibular dysfunction, but appears less effective than physical maneuvers (level 2 [mid-level] evidence)
o based on Cochrane review limited by clinical heterogeneity
o systematic review of 27 randomized trials evaluating vestibular rehabilitation for symptomatic unilateral peripheral vestibular dysfunction in 1,668 community-dwelling adults
o vestibular rehabilitation was compared to sham intervention (control), medical interventions or other forms of vestibular rehabilitation
o comparing vestibular rehabilitation to control (placebo, sham, usual care or no intervention)
methods of vestibular rehabilitation varied across trials so unclear if meta-analysis is appropriate despite lack of statistical heterogeneity
vestibular rehabilitation associated with subjective improvement in subjective dizziness in analysis of 4 trials with 565 patients
odds ratio 2.67 (95% CI 1.85-3.86)
NNT 4-8 assuming 26% improvement in controls
o movement-based vestibular rehabilitation less effective than physical maneuvers for benign paroxysmal positional vertigo (BPPV) for short-term cure rate (62% vs. 93%, p = 0.004) in 1 trial with 71 patients
o no adverse effects reported
o Reference - Cochrane Database Syst Rev 2011 Feb 16;(2):CD005397 EBSCO host Full Text
addition of vestibular stimulation exercises reported to improve balance ability and functional gain performance in patients having canalith repositioning maneuver (level 3 [lacking direct] evidence)
o based on randomized trial without clinical outcomes
o 26 patients with benign positional vertigo involving posterior semicircular canal randomized to canalith repositioning maneuver plus vestibular exercise training 3-4 times weekly for 4 weeks vs. canalith repositioning maneuver alone
o patients having combined vestibular exercise and canalith repositioning maneuver reported to have significant improvement in measures of gait performance and balance stability
o Reference - Clin Rehabil 2008 Apr;22(4):338
vestibular rehabilitation may improve symptoms and function in patients with chronic unilateral vestibular dysfunction (level 2 [mid-level] evidence)
o based on small randomized trial without attention control
o 42 patients with chronic vestibular dysfunction were randomized to vestibular rehabilitation group for 4 weeks vs. no treatment
o vestibular rehabilitation associated with significant improvements at 4 weeks in (p < 0.05 for all comparisons to control group)
symptom scores
dizziness-related disability scores
balance scores
postural stability scores
o Reference - Arch Phys Med Rehabil 2009 Aug;90(8):1325
Medications:
BPPV should not be routinely treated with vestibular suppressant medications such as antihistamines or benzodiazepines (AAO Grade C)(1)
o potential side effects including drowsiness, cognitive side effects, and restrictions operating machinery (including driving)
o may also interfere with central nervous system compensation for vestibular injury
no evidence to support recommendation of any medication in the routine treatment of BPPV (AAN Level U)(2)
benzodiazepines not shown to be beneficial (level 2 [mid-level] evidence)
o based on small randomized trial
o 25 patients with BPPV randomized to diazepam 5 mg vs. lorazepam 1 mg vs. placebo orally 3 times daily for 4 weeks
o no significant differences in nystagmus or dizziness
o Reference - J Otolaryngol 198 Dec;9(6):472 in J Fam Pract 2003 Dec;52(12):971 EBSCO host Full Text
vestibular suppressants may include
o meclizine (Bonine, Antivert) 12.5-50 mg orally every 6-8 hours
o scopolamine orally or via transdermal patch
o phenothiazines
o benzodiazepines
for acute vertigo in the emergency department, dimenhydrinate 50 mg IV may be more effective and more tolerable than lorazepam 2 mg IV (level 2 [mid-level] evidence)
o based on randomized trial with baseline differences
o 74 patients with acute vertigo presenting to emergency department were randomized to dimenhydrinate 50 mg IV vs. lorazepam 2 mg IV
o cause of vertigo was not reported
o vertigo rated on 10-point scale, reduction in vertigo at 2 hours was 2.8 with dimenhydrinate vs. 2.3 with lorazepam
o no difference in nausea
o more drowsiness with lorazepam
o lorazepam patients were sicker at baseline
o Reference - Ann Emerg Med 2000 Oct;36(4):310 in J Watch 2000 Dec 1;20(23):184
Surgery:
insufficient evidence to recommend or refute as treatments for BPPV either (AAN Level U)(2)
o posterior semicircular canal obliteration or selective vestibular nerve section
o singular neuroectomy (sectioning of singular nerve which innervates posterior semicircular canal)
Other management:
recommendations for particle repositioning maneuver for posterior canal BPPVo patients should be treated with a particle repositioning maneuver (AAO Grade B)
(1)
o canalith repositioning procedure is safe and effective therapy that should be offered to patients of all ages with posterior semicircular canal BPPV (AAN Level A)(2)
o maneuvers include
Epley maneuver (canalith repositioning procedure)
Semont maneuver (liberatory maneuver)
particle repositioning maneuvers associated with resolution of benign paroxysmal positional nystagmus (BPPN) in patients with BPPV (level 3 [lacking direct] evidence)
o based on systematic review without clinical outcomes
o systematic review of 10 randomized or quasi-randomized trials evaluating particle repositioning maneuvers in patients with posterior canal BPPV
o patients were assessed with Dix-Hallpike test ≥ 24 hours after treatment
o canalith repositioning procedure associated with greater likelihood of BPPN resolution compared to sham in 2 randomized trials, similar results obtained in 2 quasi-randomized trials
o liberatory maneuver associated with greater likelihood of BPPN resolution compared to no treatment in 2 quasi-randomized trials
o no significant difference in treatment success rates between canalith repositioning procedure and liberatory maneuver in 2 quasi-randomized trials
o Reference - Phys Ther 2010 May;90(5):663 EBSCO host Full Text
canalith repositioning procedure (Epley maneuver)
o moves sludge from posterior semicircular canal to utricle giving relief to most patients
o technique for Epley maneuver
inform patient that any of nausea, vomiting, or sense of falling may occur during positioning(1)
from seated position, have patient turn head 45 degrees to side of BPPV (toward head-down position which elicits vertigo)
quickly move patient into Hallpike-Dix position (fully extended and lying down) and hold for 3 minutes
rotate head through extension until opposite ear is downward, turn body on unaffected side with head still turned 45 degrees and hold for 3 minutes
slowly sit patient up
chin tucked down at 20 degrees has been recommended to help drop canalith into utricle
Reference - Epley in Otolaryngol Head Neck Surg 1992 Sep;107(3):399 for original description
picture of Epley maneuver can be found at dizziness-and-balance.com
o Epley maneuver improves symptoms in short-term (level 1 [likely reliable] evidence)
based on Cochrane review
systematic review identified 22 randomized trials of Epley maneuver for posterior canal BPPV (including positive Dix-Hallpike test)
17 trials were excluded due to high-risk of bias (primarily inadequate randomization sequence generation and poor allocation concealment)
5 included trials compared Epley maneuver to sham maneuver or control group in 273 adults (follow-up 24 hours to 4 weeks)
Epley maneuver associated with
complete symptom resolution (odds ratio [OR] 4.42, 95% CI 2.62-7.44, NNT 3-5 assuming symptom resolution in 21% of controls)
conversion from positive to negative Dix-Hallpike test (OR 6.4, 95% CI 3.63-11.28)
no serious adverse effects reported
no trials compared Epley maneuver to other treatments or assessed long-term outcomes
Reference - Cochrane Database Syst Rev 2010 Sep 8;(9):CD003162 EBSCO host Full Text
o Epley maneuver has short-term efficacy (level 1 [likely reliable] evidence)
based on randomized trial
67 patients with acute unilateral benign paroxysmal positional vertigo of posterior canal (brief vertigo and nystagmus) were randomized to Epley maneuver vs. sham procedure (Epley maneuver for opposite side)
Epley maneuver group had procedure repeated (up to 3 maneuvers) until vertigo and nystagmus no longer elicited, mean 1.8 maneuvers
sham group had number of maneuvers equal to previous Epley maneuver patient
outcome assessed at 24 hours by blinded investigator using Dix-Hallpike maneuver
1 patient did not show up for follow-up, 66 patients analyzed
comparing Epley vs. sham group
80% vs. 10% no longer had positional nystagmus (p < 0.001, NNT 2)
80% vs. 13% no longer had positional vertigo (p < 0.001, NNT 2)
23% vs. 3% had transient nausea (NNH 5)
11% vs. 0 had vomiting (NNH 9)
sham patients were treated with Epley maneuver at 24 hours, so no longer-term outcomes are reliable
Reference - J Neurol Neurosurg Psychiatry 2006 Aug;77(8):980 , full-text
o Epley maneuver appears effective within 1 week (level 2 [mid-level] evidence)
based on systematic review with limited evidence
systematic review of 5 randomized trials of Epley maneuver in adults with BPPV confirmed by Dix-Hallpike test
review limited to trials scoring at least 3 points on 5-point Jadad quality scale
all trials had small samples sizes and follow-up generally limited to 1 month
comparing Epley maneuver vs. control
25% vs. 61% had symptoms at 1 week (p < 0.00001, NNT 3) in analysis of 4 trials with 179 patients
analysis limited by heterogeneity (p = 0.03) with 1 trial with large effect size contributing 43% of the weighted data
results without this trial would be 31% vs. 54% symptoms at 1 week (NNT 5)
34% vs. 77% had positive Dix-Hallpike test at 1 week (p < 0.0001, NNT 3) in meta-analysis of 3 trials with 146 patients, limited by heterogeneity (p = 0.05)
23% vs. 71% had positive Dix-Hallpike test at 1 month (p < 0.0001, NNT 2) in meta-analysis of 4 trials with 178 patients, limited by heterogeneity (p = 0.03)
additional interventions that have no evidence of effect
mastoid vibration
subtle changes in maneuver movements
neck collar to restrict neck movements
movement limitation recommendations
avoiding lying down on affected side after maneuver
no trials found for Semont maneuver
Reference - Braz J Otorhinolaryngol 2006 Jan-Feb;72(1):130
o Epley maneuver may improve vertigo severity within 30 minutes (level 2 [mid-level] evidence)
based on small randomized trial with early termination
22 patients presenting to emergency department with BPPV randomized to Epley maneuver vs. placebo maneuver
trial stopped early after planned interim analysis
severity of vertigo rated before and 15-30 minutes after Epley maneuver on 1-10 scale
median decrease in severity was 6 with Epley maneuver vs. 1 with placebo (p = 0.001)
Reference - Acad Emerg Med 2004 Sep;11(9):918
o modified Epley maneuver may be effective in elderly patients (level 2 [mid-level] evidence)
based on randomized trial without blinding
47 patients > 70 years old with unilateral posterior canal BPPV randomized to canalith repositioning maneuver (modified Epley maneuver) vs. avoidance (no treatment)
at 1 month, 64% treatment group vs. 5% control group had improvement of provoked vertigo and nystagmus on Dix-Hallpike testing (NNT 2)
Reference - Otolaryngol Head Neck Surg 2003 May;128(5):719
o Epley maneuver may have long-term efficacy (level 2 [mid-level] evidence)
based on small randomized trial
40 patients with BPPV randomized to particle repositioning maneuver vs. placebo and followed for 1 year
placebo maneuver was having patient seated and tilted laterally to horizontal precipitating position, maintained for 2 minutes after nystagmus subsided, then returned to sitting position; repeated by patient every 3 hours while awake
comparing maneuver vs. placebo
95% vs. 15% had complete resolution of symptoms without recurrence at 1 week (NNT 2)
95% vs. 15% had no vertigo symptoms at 6 months (NNT 2)
90% vs. 15% had no symptoms at 1 year (NNT 2)
Reference - Am J Otolaryngol 2003 Nov-Dec;24(6):355
o self-treatment with Epley maneuver
patients can treat themselves at home with modified Epley procedure (level 2 [mid-level] evidence)
based on non-randomized trial
modified Epley procedure as used in this trial
patients instructed to start by sitting on bed with head turned 45 degrees to side of BPPV
pillow placed on bed to be under shoulders
lie back quickly with neck extended and resting on bed still turned 45 degrees, wait 30 seconds
turn head 90 degrees to face other direction and wait 30 seconds
turn body and head another 30 degrees and wait 30 seconds, then sit up
perform maneuver three times daily
repeat daily until symptom-free for 24 hours
study methods
included were patients with acute untreated unilateral BPPV of posterior semicircular canal at dizziness clinic who had
short-lasting positional vertigo
transient torsional nystagmus lasting < 1 minute and beating toward inferior ear in lateral head-hanging position
nystagmus in reversed direction after sitting up
fatigability after repeated positioning
44 such patients were non-randomly assigned to Brandt-Daroff exercise vs. modified Epley procedure
10 patients who had previously failed to respond to Brandt-Daroff exercise were also assigned to modified Epley group
no blinding
Brandt-Daroff exercise patients instructed to sit on bed, drop trunk and head to affected side until head on bed, return to sitting, drop to opposite side, maintain each position for 30 seconds, repeat 8 times
comparing Brandt-Daroff exercise vs. modified Epley procedure
23% vs. 64% were asymptomatic after 1 week of performing maneuvers at home (p < 0.01, NNT 3)
all 10 nonresponders in modified Epley group reported by authors to have stopped prematurely or performed incorrectly
11 vs. 6 patients had side effects related to self-treatment
self-treatment with modified Epley technique can be done easily at home, illustrated patient instructions can be found at Neurologische Klinik (available in English, Spanish, French and German)
Reference - Neurology 1999 Oct 12;53(6):1358
addition of home use of Epley procedure may increase efficacy of in-office Epley procedure (level 2 [mid-level] evidence)
based on randomized trial without blinding
80 patients aged 24-85 years with BPPV randomized to Epley procedure in doctor's office followed by Epley procedure 3 times daily at home for 1 week vs. Epley procedure in office only
outcomes with supplemental treatment vs. control at 1 week
88% vs. 69% had better results based on symptoms and nystagmus (p = 0.048, NNT 6)
7.5% vs. 2.6% experienced complications (not statistically significant)
Reference - Neurology 2005 Oct 25;65(8):1299, commentary can be found in Evidence-Based Medicine 2006 May-Jun;11(3):78
insufficient evidence to recommend or refute self-treatment of canal repositioning maneuvers for BPPV (AAN Level U)(2)
Semont positioning maneuver may be simpler than Epley maneuver but less effective (level 2 [mid-level] evidence)
o also called Semont maneuver, liberatory maneuver, Semont liberatory maneuver
o technique
patient seated in middle of exam table with head rotated 45 degrees away from affected side
while maintaining this head position throughout maneuver, patient rapidly moved to side-lying position onto affected side for 5 minutes, then moved en bloc to opposite side-lying position for 5 minutes
then slowly return patient to sitting position
patients were discharged with instructions to sleep upright and avoid head movements, looking up or down and bending for 24 hours
o Semont maneuver possibly effective for BPPV (AAN Level C)
o insufficient evidence to compare effectiveness of Semont maneuver vs. canalith repositioning procedure (AAN Level U)
o self-treatment with modified Epley maneuver appears more effective than self-treatment with modified Semont maneuver (level 2 [mid-level] evidence)
based on randomized trial
70 patients with unilateral posterior canal BPPV randomized to instruction in modified Epley maneuver vs. modified Semont maneuver three times daily until no vertigo for 24 hours
9 patients (11%) not analyzed due to loss to follow-up (7) or did not complete the exercise (2)
vertigo and nystagmus abolished after 1 week in 95% Epley group vs. 58% Semont group (p < 0.001, NNT 3)
Reference - Neurology 2004 Jul 13;63(1):150 full-text
o higher response rates reported in 2 uncontrolled retrospective studies (level 3 [lacking direct] evidence)
based on retrospective study of 278 patients with unilateral BPPV of posterior semicircular canal treated exclusively with Semont maneuver performed weekly for up to 4 maneuvers
90.3% cure rate after maximum of 4 maneuvers
83.5% cured after 2 maneuvers
efficacy decreased with repeated maneuvers, from 62.6% for first maneuver to 18.2% for fourth maneuver
Reference - Arch Otolaryngol Head Neck Surg 2003 Jun;129(6):629
in retrospective study of Semont maneuver in 162 patients with BPPV
90% had significant improvement with mean 1.49 maneuvers
29% recurrence rate (96% recurrences responded to further maneuvers)
Reference - Laryngoscope 2002 May;112(5):796
post-procedure postural restrictions may not improve efficacy of Epley or Semont positioning maneuvers (level 2 [mid-level] evidence)
o based on pooled analysis of individual patient data from observational studies
o data from 523 patients (6 studies) comparing postural restrictions vs. no restrictions after Epley or Semont positioning maneuvers for benign paroxysmal positional vertigo were analyzed
o no significant differences in clinical outcomes
o Reference - Otolaryngol Head Neck Surg 2010 Feb;142(2):155
mastoid vibration probably of no added benefit to patients treated with canal repositioning for posterior canal BPPV (AAN Level C)(2)
Lempert roll maneuver for horizontal canal BPPV(2)
o patient is taken through a series of step-wise 90 degree turns away from the affected side
o hold each position for 10-30 seconds
o patient then positions themselves to lying on back in preparation for rapid simultaneous movement from supine face up to sitting
o discussion of Lempert roll maneuver can be found in Laryngoscope 1996 Apr;106(4):476
Consultation and referral:
both canalith repositioning procedure and vestibular exercises may be taught to patient or patient may be referred to physical therapy
Follow-up:
reassess patients within 1 month after initial period of observation or treatment to confirm symptom resolution (AAO Grade C)
o lack of response to therapy may indicate incorrect diagnosis
o patients may not respond to initial treatment with vestibular rehabilitation due to poor compliance
o treatment failure with Dix-Hallpike maneuver may respond to repeat treatment
patient may respond to different maneuver, such as Semont maneuver
patient may have lateral canal BPPV or horizontal canal BPPV rather than posterior canal BPPV
persistent vertigo following repositioning maneuvers may suggest alternative diagnosis
o canalith repositioning maneuver may cause conversion of posterior canal involvement to anterior or horizontal canals
based on case series
85 consecutive patients treated with canalith repositioning maneuver
19 remained symptomatic after treatment
based on changes in symptoms and nystagmus testing, 5 patients had repositioning of canalith from posterior semicircular canal to
anterior canal in 2 patients
horizontal canal in 3 patients
Reference - Arch Otolaryngol Head Neck Surg 1996 Mar;122(3):281
o 7 of 90 patients with BPPV of posterior semicircular canal had persistent vertigo after at least 3 sessions of modified Epley maneuvers over 2 weeks
final diagnoses included
coincident horizontal canal positional vertigo (2 patients)
Meniere's disease (2 patients)
persistent posterior canal BPPV associated with cervical spondylosis (2 patients)
posterior fossa meningioma (1 patient)
Reference - Arch Otolaryngol Head Neck Surg 2004 Apr;130(4):436
after successful treatment with canalith repositioning procedure, prophylactic Brandt-Daroff exercises do not appear to reduce recurrence risk (level 2 [mid-level] evidence)
o based on retrospective study
o 116 patients with posterior canal semicircular canal BPPV were successfully treated with canalith repositioning procedure and followed up to 2 years
o 50 (43%) had recurrent symptoms
o no significant difference in recurrence rates or time to recurrence comparing 73 patients who did not perform exercises (47% recurrence rate) and 43 patients who performed daily Brandt-Daroff exercises (37% recurrence rate)
o Reference - Arch Otolaryngol Head Neck Surg 2005 Apr;131(4):344
Prevention and Screening not applicable
References including Reviews and Guidelines
General references used:
1. Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, Chalian AA, Desmond AL, Earll JM, Fife TD, Fuller DC, Judge JO, Mann NR, Rosenfeld RM, Schuring LT, Steiner RW, Whitney SL, Haidari J, American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov;139(5 Suppl 4):S47-81.
2. Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, Hain TC, Herdman S, Morrow MJ, Gronseth GS, Quality Standards Subcommittee, American Academy of Neurology. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008 May 27;70(22):2067-74. full-text or at National Guideline Clearinghouse 2009 Jan 5:12940
MEDLINE search:
to search MEDLINE for (Benign paroxysmal positional vertigo) with targeted search (Clinical Queries), click therapy, diagnosis or prognosis
Reviews:
comprehensive summary with references and pictures can be found at dizziness-and-balance.com
review can be found in CMAJ 2003 Sep 30;169(7):681 EBSCO host Full Text full-text
editorial review can be found in BMJ 2003 Mar 29;326(7391):673 EBSCO host Full Text full-text
review can be found in N Engl J Med 1999 Nov 18;341(21):1590 EBSCO host Full Text
reviews of vertigo
o review of diagnosis of vertigo (including video clips) can be found in BMJ 2009 Sep 22;339:b3493
o review of vertigo (assessment in general practice) can be found in Aust Fam Physician 2008 May;37(5):341
o review of vertigo (management in general practice) can be found in Aust Fam Physician 2008 Jun;37(6):409
o review of peripheral vertigo in general practice can be found in New Zealand Fam Physician 2006 Aug;33(4):267 PDF
o review of initial evaluation of vertigo can be found in Am Fam Physician 2006 Jan 15;73(2):244, correction can be found in Am Fam Physician 2006 May 15;73(10):1704
o brief "What you should do" review of vertigo can be found in BMJ 2005 Mar 5;330(7490):523 full-text
o review of vertigo can be found in Am Fam Physician 2005 Mar 15;71(6):1115
o review of vertigo can be found in Lancet 1998 Dec 5;352(9143):1841 EBSCO host Full Text (summary can be found in Am Fam Physician 1999 Apr 15;59(8):2318), commentary can be found in Lancet 1999 Feb 13;353(9152):591
o review of vertigo can be found in Aust Fam Physician 1999 Sep;28(9):883 (Am Fam Physician 2000 Mar 1;61(5):1518)
review of evaluation and treatment of BPPV can be found in Annals of Long-Term Care 2007 Jun;15(6):33
review of dizziness can be found in Aust Prescr 2005 Aug;28(4):94
review of acute vestibular syndrome can be found in N Engl J Med 1998 Sep 3;339(10):680 EBSCO host Full Text , commentary can be found in N Engl J Med 1999 Jan 14;340(2):151 EBSCO host Full Text
Guidelines:
American Academy of Otolaryngology-Head and Neck Surgery Foundation clinical practice guideline can be found in Otolaryngol Head Neck Surg 2008 Nov;139(5 Suppl 4):S47 or at National Guideline Clearinghouse 2009 Apr 20:13403
American Academy of Neurology (AAN) evidence-based practice parameter on therapies for benign paroxysmal positional vertigo Neurology 2008 May 27;70(22):2067 full-text or at National Guideline Clearinghouse 2009 Jan 5:12940
American College of Radiology (ACR) Appropriateness Criteria for vertigo and hearing loss can be found at National Guideline Clearinghouse 2006 Sep 4:9602
Guideline grading systems used:
American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO) grades of evidence
o Grade A - well-designed randomized trials or diagnostic studies performed on representative population
o Grade B - randomized controlled trials or diagnostic studies with minor limitations; observational studies with overwhelmingly consistent evidence
o Grade C - case control or cohort studies
o Grade D - expert opinion, case reports
o Grade X - validating studies cannot be performed and clear preponderance of benefit over harm
o Reference - American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO) clinical practice guideline on benign paroxysmal positional vertigo (Otolaryngol Head Neck Surg 2008 Nov;139(5 Suppl 4):S47)
American Academy of Neurology (AAN) grading system
o Classification of recommendations
Level A - effective, ineffective, or harmful for given condition in the specified population; requires at least two consistent Class I studies
Level B - probably effective, ineffective, or harmful for given condition in specified population; rating requires at least one Class I study or at least two consistent Class II studies
Level C - possibly effective, ineffective, or harmful for given condition in specified population; rating requires at least one Class II study or at least two consistent Class III studies
Level U - data inadequate or conflicting; given current knowledge, treatment is unproven
o Classification of evidence
Class I - prospective, randomized, controlled clinical trial with masked outcome assessment in representative population requiring:
a. primary outcome(s) clearly defined
b. exclusion/inclusion criteria clearly defined
c. adequate accounting for dropouts and crossovers with numbers sufficiently low to have minimal potential for bias
d. relevant baseline characteristics are presented and substantially equivalent among treatment groups or there is appropriate statistical adjustment for differences
Class II - prospective matched group cohort study in representative population with masked outcome assessment that meets a-d above or randomized controlled trial in population that lacks one criteria a-d
Class III - all other controlled trials (including well-defined natural history controls or patients serving as own controls) in representative population, where outcome is independently assessed, or independently derived by objective outcome measurement
Class IV - uncontrolled studies, case series, case reports, or expert opinion
o Reference - American Academy of Neurology practice parameter on therapies for benign paroxysmal positional vertigo (Neurology 2008 May 27;70(22):2067 full-text or at National Guideline Clearinghouse 2009 Jan 5:12940)
Patient Information
Patient information:
handout from American Academy of Family Physicians comprehensive summary with references and pictures can be found at dizziness-and-
balance.com
handout on vertigo can be found in Am Fam Physician 2006 Jan 15;73(2):254
handout on vertigo can be found in Am Fam Physician 2005 Mar 15;71(6):1129
information on vestibular rehabilitation therapy from Chicago Dizziness and Hearing
Acknowledgements
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