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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