Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)

Otolaryngology - Head and Neck Surgery - Tập 156 Số S3 - 2017
Neil Bhattacharyya1, Samuel P. Gubbels2, Seth Schwartz3, Jonathan A. Edlow4, Hussam K. El‐Kashlan5, Terry D. Fife6, Janene M. Holmberg7, Kathryn Mahoney8, Deena B. Hollingsworth9, Richard A. Roberts10, Michael D. Seidman11, Robert W. Steiner12, Betty S. Tsai13, Courtney C. J. Voelker14, Richard W. Waguespack15, Maureen D. Corrigan16
1Department of Otolaryngology Harvard Medical School Brigham and Women’s Hospital Boston Massachusetts USA
2Department of Otolaryngology, School of Medicine and Public Health, University of Colorado, Aurora, Colorado, USA
3Department of Otolaryngology, Virginia Mason Medical Center, Seattle, Washington, USA
4Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
5Department of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
6Barrow Neurological Institute and College of Medicine, University of Arizona, Phoenix, Arizona, USA
7Intermountain Hearing and Balance Center, Salt Lake City, Utah, USA
8Vestibular Disorders Association, Portland, Oregon, USA
9Ear, Nose & Throat Specialists of Northern Virginia, PC, Arlington, Virginia, USA
10Alabama Hearing and Balance Associates, Inc, Birmingham, Alabama, USA
11Department of Otolaryngology–Head and Neck Surgery College of Medicine University of Central Florida Orlando Florida USA
12Department of Health Management and Systems Science and Department of Family and Geriatric Medicine, School of Public Health and Information Science, University of Louisville, Louisville, Kentucky, USA
13Department of Otorhinolaryngology, Health Sciences Center, University of Oklahoma, Oklahoma City, Oklahoma, USA
14Department of Otolaryngology–Head and Neck Surgery Feinberg School of Medicine Northwestern University Chicago Illinois USA
15Department of Otolaryngology, University of Alabama at Birmingham, Birmingham, Alabama, USA
16American Academy of Otolaryngology–Head and Neck Surgery Foundation Alexandria Virginia USA

Tóm tắt

Objective

This update of a 2008 guideline from the American Academy of Otolaryngology—Head and Neck Surgery Foundation provides evidence‐based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV.

Purpose

The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health‐related quality of life of individuals afflicted with BPPV.

Action Statements

The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix‐Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix‐Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow‐up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow‐up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self‐administered or with a clinician, in the treatment of BPPV.

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