Comparative Study of Clinical Features of Patients with Different Types of Benign Paroxysmal Positional Vertigo

Objectives: Even though BPPV is one of the most common causes of vertigo, it is often underdiagnosed and omitted in the diagnosis of patients reporting vertigo. The aim of the study was to establish a diagnostic pattern useful in patients admitted due to vertigo, based on the most common clinical characteristics of patients suffered from posterior canal BPPV (PC-BPPV), horizontal canal BPPV with geotropic (HCG-BPPV) and apogeotropic nystagmus (HCA-BPPV). Methods: The analysis covered the results obtained in 105 patients with a positive result of the Dix-Hallpike maneuver or the supine roll test. The patients were divided into 3 groups based on the BPPV type: gr.1:PC-BPPV (60%); gr.2: HCG-BPPV (27%); gr.3: HCA-BPPV (13%). Patients before the diagnostic maneuvers filled the questionnaire concerning their symptoms and previous diseases. Results: Almost all patients had vertigo during turning over in bed and the character of the symptoms was paroxysmal. The answers to questions about the type of head movement evoked vertigo and how long vertigo lasted were differentiating. The percentages of correct diagnosis speculated by the combined answers were 69.6% in PC-BPPV, 61.8% in HCG-BPPV, and 80% in HCA-BPPV. Conclusions: Basing on those observations there is presented the diagnostic schedule which could be useful in dizziness examination. The above results indicate that a properly collected interview with the patient allows for a high percentage of accurate diagnosis.

Treating benign paroxysmal positional vertigo in acute traumatic brain injury: a prospective, randomised clinical trial assessing safety, feasibility, and efficacy

Background

Benign paroxysmal positional vertigo (BPPV) affects approximately half of acute, moderate-severe traumatic brain injury (TBI) patients. To date, there have been no rigorous studies of BPPV assessment or treatment in this cohort. We aimed to determine the safety, practicability, and efficacy of therapist-led BPPV management in acute TBI and the feasibility of a larger effectiveness trial.

Methods

This was a multi-centre, three-arm, parallel-groups, randomised, feasibility trial. Recruitment was via convenience sampling. The main inclusion criteria were age over 18 years and a confirmed, non-penetrating, acute TBI. BPPV-positive patients were randomly allocated to one of three interventions (repositioning manoeuvres, Brandt-Daroff exercises or advice) using minimisation criteria. Outcome assessors were blinded to the intervention.

Results

Of 2014 patients screened for inclusion, 180 were assessed for BPPV. Of those assessed, 34% (62/180) had BPPV, and 58 patients received an intervention. Therapist-led interventions were delivered safely and accurately according to intervention monitoring criteria. Resolution of BPPV was observed in 35/58 (60%) patients. The resolution rate was highest following repositioning manoeuvres (78%), followed by the advice (53%) and Brandt-Daroff interventions (42%). 10 patients experienced recurrence. This was observed more frequently in those with skull fractures and bilateral or mixed BPPV.

Conclusions

Overall, the results provide strong evidence for the feasibility of a future trial. Therapist-led management of BPPV in acute TBI was safe and practicable. Repositioning manoeuvres seemingly yielded a superior treatment effect. However, given the high recurrence rate of post-traumatic BPPV, the optimal time to treat according to patients' specific recurrence risk requires further investigation.

Trial registration

ISRCTN91943864, https://doi.org/10.1186/ISRCTN91943864.

Clinical characteristics of benign paroxysmal positional vertigo after traumatic brain injury

INTRODUCTION

The aim of the present study was to evaluate the characteristics of brain injury and to assess the relationship between them and treatment outcomes in patients with traumatic benign paroxysmal positional vertigo (t-BPPV).

MATERIALS AND METHODS

Sixty-three consecutive patients who were diagnosed with BPPV within 2 weeks after head trauma were included.

RESULTS

Cerebral concussion, intracranial hemorrhages (ICH), skull fracture without ICH, and hemorrhagic contusion were observed in 68%, 24%, 5%, and 3% of t-BPPV patients, respectively. BPPV with single canal involvement was observed in 52 (83%) patients and that with multiple canal involvement was observed in 11 (17%) patients. The number of treatment sessions was not significantly different according to the cause of head trauma (p = 0.252), type of brain injury (p = 0.308) or location of head trauma (p = 0.287). The number of recurrences was not significantly different according to the cause of head trauma (p = 0.308), type of brain injury (p = 0.536) or location of head trauma (p = 0.138).

CONCLUSION

The present study demonstrated that there were no significant differences in treatment sessions until resolution and the mean number of recurrences according to the type of brain injury.

The Impact of the Angular Head Movement's Velocity during Diagnostic Maneuvers on Proper Benign Positional Paroxysmal Vertigo Diagnosis and Therapy

Based on the current state of the BPPV field, there are no guidelines that specify an angular head movement's velocity (AHMV) during diagnostic maneuvers of BPPV. The aim of this study was to evaluate the impact of AHMV during diagnostic maneuvers on proper BPPV diagnosis and therapy. The analysis covered the results obtained in 91 patients with a positive result of the Dix-Hallpike (D-H) maneuver or the roll test. The patients were divided into four groups based on values of AHMV (high 100-200°/s and low 40-70°/s) and the BPPV type (posterior: PC-BPPV or horizontal: HC-BPPV). The parameters of the obtained nystagmuses were analyzed and compared to AHMV. There was a significant negative correlation between AHMV and latency of nystagmus in all study groups. Furthermore, there was a significant positive correlation between AHMV and both maximum slow phase velocity and average frequency of nystagmus in the PC-BPPV groups, whereas it was not observed in the HC-BPPV patients. Complete relief of symptoms was reported after 2 weeks and was better in patients diagnosed with maneuvers performed with high AHMV. High AHMV during the D-H maneuver allows the nystagmus to be more visible, increasing the sensitivity of diagnostic tests and is crucial for a proper diagnosis and therapy.

Patterns of vestibular dysfunction in chronic traumatic brain injury

Background

Dizziness and imbalance are common following traumatic brain injury (TBI). While these symptoms are often attributed to vestibular dysfunction, the relative contribution of peripheral vs. central mechanisms is unclear. This study investigated the prevalence of semicircular canal and otolith abnormalities in a cohort of patients with chronic TBI and symptoms of dizziness or imbalance. The relationship between vestibular, oculomotor and posturography results was further explored.

Methods

Clinical records of patients attending the New Zealand Dizziness and Balance Centre from January 2015 to December 2019 were reviewed for consideration in the study. Inclusion required: an age of 18–80 years, a diagnosed TBI, and vestibular assessment using three-dimensional video head impulses (vHIT), cervical and ocular vestibular-evoked myogenic potentials (c and o VEMPs, respectively) and caloric testing. Severe TBI, pre-existing vestibular diagnoses, and incomplete test results were excluded. Rates of abnormalities were determined for each test and compared with results of oculomotor function testing and postural control, measured using the sensory organization test (SOT).

Results

Of 158 reviewed records, 99 patients aged 49 ± 15 years (59 female) fulfilled criteria for inclusion in the study. The median time between the head injury and the clinical assessment was 12 (IQR 6–21) months. Abnormalities involving one or more components of the vestibular labyrinth and/or nerve divisions were identified in 33 of 99 patients (33.3%). The horizontal semicircular canal was most frequently affected (18.2%), followed by the saccule (14.1%), utricle (8.1%), posterior (7.1%) and anterior (2.0%) semicircular canals. Vestibular test abnormalities were associated with skull-base fractures, superior canal dehiscence, and focal ear trauma. Oculomotor dysfunction and postural instability were recorded in 41.1 and 75.5% of patients, respectively. Postural instability correlated with abnormal oculomotor function (p = 0.008) but not peripheral vestibular hypofunction (p = 0.336).

Conclusions

Dizziness and/or imbalance in chronic TBI was associated with impaired postural stability for tasks requiring high levels of use of vestibular and visual input for balance. Vestibular hypofunction identified through vHIT, VEMP and caloric testing was recorded but was less common, except when the injury involved a fractured skull-base. There was no specific pattern of end-organ or nerve involvement which characterized this group of patients.

Early management for traumatic benign paroxysmal positional vertigo in traumatically injured patients

OBJECTIVES

The purpose of this study was to identify the clinical features of posttraumatic benign paroxysmal positional vertigo (t-BPPV) in traumatically injured patients, investigating the effectiveness of the early diagnosis and management including canalith repositioning procedures (CRPs).

PATIENTS AND METHODS

The subjects of the present study were 74 patients who were hospitalized in the Trauma Center, Ajou University Hospital. We investigated the relationship between injury mechanisms and t-BPPV. Patients with t-BPPV were categorized into mild (typical BPPV) and severe (bilateral, recurrent, or persistent) types.

RESULTS

Of the 74 patients, 41 were diagnosed with t-BPPV. Nineteen were mild and 22 were severe types. 'A fall' (36%) and 'pedestrian car accident' (32%) were common as the injury mechanisms provoking severe t-BPPV. In the severe t-BPPV group, they were hospitalized longer (as median value, 20 days in the severe group vs. 10 days in the mild group, P = 0.004), stayed longer in intensive care unit (3 days vs. 0 days, P = 0.016), and needed more days until the BPPV management (13.5 days vs. 6 days, P = 0.021). Major trauma (the Injury Severity Score >15) patients had a longer time to implementation of the first CRPs (10 days in major trauma and 3 days in minor trauma patients, P = 0.019).

CONCLUSIONS

Severity of trauma and longer duration of ICU treatment were factors delaying BPPV management. This delay could negatively affect the progress of t-BPPV. Diagnostic and therapeutic maneuvers including CRPs should be performed as early as possible, even in severely injured patients.

Self-Treatment of Posterior Canal Benign Paroxysmal Positional Vertigo: A Preliminary Study

Objectives: The purpose of this study is to investigate a modified Epley maneuver for self-treatment of posterior canal benign paroxysmal positional vertigo (PC-BPPV).

Methods: The study recruited 155 patients with PC-BPPV. All patients were randomized into the Epley maneuver group (n = 77) and modified Epley maneuver group (n = 78). We analyzed the resolution rate (1 day and 1 week), residual symptoms after the maneuver, and adverse effects.

Results: It was found that the modified Epley maneuver group had a higher resolution rate than that of the Epley maneuver group in the treatment of PC-BPPV after 1 day of the initial maneuver (p < 0.05). However, there was no difference in resolution rate between the Epley maneuver group and the modified Epley maneuver group in resolution rate after 1 week of the initial maneuver (p > 0.05). The modified Epley maneuver group had fewer residual symptoms than that of the Epley maneuver group 1 week after treatment of PC-BPPV (p < 0.05). Significant improvements were also observed in average DHI scores in patients who underwent the modified Epley maneuver compared to the Epley maneuver (p < 0.05). There was no significant difference in adverse effects between the two groups (p > 0.05).

Conclusions: The modified Epley maneuver has a satisfactory therapeutic efficacy with less residual symptoms and could be recommended as a self-treatment for patients with PC-BPPV.

Traumatic benign paroxysmal positional vertigo: personal experience and comparison with idiopathic BPPV

OBJECTIVE

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vestibular vertigo, with post-traumatic origin in about 15% of cases. Management and prognosis of traumatic BPPV (T-BPPV) are still debated, especially about recurrence. The aim was to compare T-BPPV to idiopathic (I-BPPV).

DESIGN AND STUDY SAMPLE

We analysed data about 795 BPPV patients: 716 idiopathic (90%) and 79 post-traumatic (10%), evaluating clinical history and bedside-examination, treating all patients with repositioning manoeuvres and reassessing them until the resolution of symptoms and nystagmus.

RESULTS

Persistence rate in T-BPPV and I-BPPV patients was significantly different (p = 0.0074, OR = 2.31), respectively 12.6% and 5%. Also the rate of bilateral disease (p = 0.0063, OR = 4.72) and multicanalar involvement (p = 0.0183; OR = 4.67) were significantly higher in T-BPPV patients . There were no significant differences in age and sex distribution, side and canal interested. In T-BPPV group, the resolution rate with one manoeuvre was lower than I-BPPV (p = 0.0132: OR: 0,56). Recurrence rate was 38% in the T-BPPV group and 30.6% in the I-BPPV group, without significant difference.

CONCLUSIONS

T-BPPV resulted different from I-BPPV in the resolution rate, bilateral or multiple canal involvement and persistence rate. T-BPPV and I-BPPV does not differ for recurrence rate, suggesting that, after resolution, the natural course of post-traumatic and idiopathic BPPV is similar.

Benign Paroxysmal Positional Vertigo After Pediatric Sports-Related Concussion

OBJECTIVE

Report the clinical findings and outcomes among pediatric patients diagnosed with benign paroxysmal positional vertigo (BPPV) after sports-related concussion (SRC).

DESIGN

Retrospective case series.

SETTING

Multidisciplinary pediatric concussion program.

PATIENTS

Patients younger than 19 years with a sport or recreation activity-related concussion referred for comprehensive vestibular physiotherapy assessment.

MAIN OUTCOME MEASURE

Symptom resolution after targeted particle repositioning (PR).

RESULTS

During the study period, 115 pediatric SRC patients underwent vestibular physiotherapy assessment including 12 (10.4%) who were diagnosed with BPPV. Unilateral posterior semicircular canal (SCC) BPPV was diagnosed in 8/12 (75%) patients, and unilateral anterior SCC BPPV diagnosed in 4/12 (25%) patients. Benign paroxysmal positional vertigo was successfully treated in all patients with a mean of 1.58 targeted PR maneuvers (range = 1-4).

CONCLUSIONS

Comprehensive management of pediatric SRC requires a multidisciplinary approach to address the heterogeneous pathophysiology of persistent postconcussion symptoms. Pediatric SRC patients with coexisting BPPV should be considered for targeted PR.

Review of the pathology underlying benign paroxysmal positional vertigo

The pathophysiological mechanism underlying benign paroxysmal positional vertigo (BPPV) is related to free-floating debris/otoliths in the semicircular canal (canalolithiasis) or debris/otoliths attached to the cupula (cupulolithiasis). These debris/otoliths are considered to originally accumulate after detachment from the neuroepithelium of the utricular macula secondary to a type of degeneration. An idiopathic form, which is assumed to occur spontaneously, is diagnosed when the causative pathology is obscure. However, an association between various other systemic or inner ear conditions and BPPV has been reported, indicating the existence of secondary BPPV. This study was performed to present the first review of the pathology underlying BPPV following a complete PubMed/Medline search. In total, 1932 articles published from 1975 to 2018 were reviewed. The articles were classified according to 17 potentially causative factors (aging; migraine; Meniere's disease; infection; trauma; idiopathic sudden sensorineural hearing loss; sleeping habits; osteoporosis and vitamin D insufficiency; hyperglycemia and diabetes mellitus; chronic head and neck pain; vestibule or semicircular canal pathology; pigmentation disorders; estrogen deficiency; neurological disorders; autoimmune, inflammatory, or rheumatologic disorders; familial or genetic predisposition; and allergy). A discussion of the underlying cause of BPPV for each factor is presented.

Simultaneous Presentation of Benign Paroxysmal Positional Vertigo and Meniere's Disease - Case Report

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is one of the most common clinical entities, which develops spontaneously in most of the cases, but it can be secondary as a result of different conditions such as head injuries, viral neurolabyrinthitis, Meniere's disease and vertebrobasilar ischemia. The aim of presenting this case is to point out to the need of taking a precise clinical history and performing Dix-Hallpike manoeuvre in all patients who complain about vertigo regardless of the previously diagnosed primary disease of the inner ear.

CASE PRESENTATION

A 63-year-old female patient presented with the classical triad of symptoms for Meniere's disease (fluctuating sensorineural hearing loss in the right ear, tinnitus and fullness in the same ear and rotary vertigo), two years later complained of brief episodes of vertigo linked to changes in head position relative to gravity. Dix-Hallpike manoeuvre showed a classical response in the head-hanging right position. Benign paroxysmal positional vertigo (BPPV) in the same ear was diagnosed in this patient. After treatment with Epley's canal repositioning manoeuvre for a few days, the symptoms of positional vertigo resolved.

CONCLUSION

The authors recommend complete audiological and otoneurological evaluation in all patients with vertigo for timely recognition/diagnosis of any inner ear associated pathology.

Treatment and recurrence of traumatic versus idiopathic benign paroxysmal positional vertigo: a meta-analysis

Background: So far, there has been a controversy surrounding repositioning difficulty and recurrence rate between traumatic benign paroxysmal positional vertigo (t-BPPV) and idiopathic BPPV (i-BPPV). Objectives: This meta-analysis was aimed to explore whether or not the differences between t-BPPV and i-BPPV in the repositioning difficulty and recurrence rate existed. Material and methods: A literature search was performed in the databases including Pubmed, Embase, CENTRAL, which completed in 21 January 2019, with no restriction of publication language. Relative risk (RR) of number of repositioning maneuvers and the recurrence rate was calculated with its 95% confidence interval. Sensitive analysis was performed simultaneously. Results: Six retrospective cohort studies were included in our meta-analysis, including 865 t-BPPV patients and 3027 i-BPPV patients. All studies were high quality according to Newcastle-Ottawa Scale (NOS) assessment. Patients with t-BPPV required more repositioning maneuvers for resolution than those with i-BPPV (RR = 3.27, 95% CI = 1.88-5.69, p < .0001), and the recurrence rate of t-BPPV was higher than that of i-BPPV (RR = 2.91, 95% CI = 2.04-4.14, p < .00001). Conclusions and significance: Compared with i-BPPV, patients with t-BPPV require more repositioning maneuvers to resolve, and the recurrence of t-BPPV was more frequent.

Peripheral Vestibular Organ Degeneration After Temporal Bone Fracture: A Human Otopathology Study

OBJECTIVES/HYPOTHESIS

Vestibular symptoms are a common sequela of temporal bone fractures (TBFs). The mechanisms of injury to the peripheral vestibular system following TBF, however, are not well described. Herein, we aimed to investigate the histopathology of the peripheral vestibular system in patients who sustained TBFs.

STUDY DESIGN

Retrospective human specimen analysis.

METHODS

Specimens from the National Temporal Bone Pathology Registry with (cases) and without (controls) TBFs were evaluated. Specimens were analyzed by light microscopy for vestibular hair cell and/or dendritic degeneration, presence of endolymphatic hydrops, blockage of the endolymphatic duct, and number of Scarpa ganglion cells (ScGCs) in the superior and inferior vestibular nerves.

RESULTS

Seven temporal bones (TBs) from five individuals with TBFs, and seven TBs from six age-matched individuals without a history of head injury met inclusion and exclusion criteria. All fractures involved the otic capsule. Severe degeneration of the cristae was identified in the semicircular canals in all TBF cases. The utricular and saccular maculae showed mild to severe degeneration in the TBF cases. Vestibular hydrops (n = 2 TBs) and blockage of the endolymphatic duct (n = 3 TBs) were also present in the TBF cases. There was a decrease of 52.6% in the mean total ScGC count in the TBF cases (n = 3 TBs) compared to age-matched controls (n = 7 TBs, P = .015). There was a mean loss of 53% of the ScGCs in the superior vestibular nerve and a mean loss of 52.3% of the ScGCs in the inferior vestibular nerve compared to age-matched controls (P = .033 and P = .021, respectively).

CONCLUSIONS

In a cohort of patients with TBFs, there were distinct peripheral vestibular changes including reduction of ScGCs.

LEVEL OF EVIDENCE

NA Laryngoscope, 130:752-760, 2020.

A Physiological Approach to Assessment and Rehabilitation of Acute Concussion in Collegiate and Professional Athletes

Sport-related concussion is an important condition that can affect collegiate and professional athletes. Expert consensus guidelines currently suggest that all athletes who sustain acute concussion be managed with a conservative approach consisting of relative rest and gradual resumption of school and sport activities with active intervention reserved for those with persistent post-concussion symptoms lasting >10-14 days for adults. Unfortunately, these recommendations place little emphasis on the rapid physical deconditioning that occurs in athletes within days of exercise cessation or the pathophysiological processes responsible for acute concussion symptoms that can be successfully targeted by evidence-based rehabilitation strategies. Based on our evolving approach to patients with persistent post-concussion symptoms, we now present an updated physiological approach to the initial medical assessment, rehabilitation, and multi-disciplinary management of collegiate and professional athletes with acute concussion. Utilizing the results of a careful clinical history, comprehensive physical examination and graded aerobic exercise testing, we outline how team physicians, and athletic training staff can partner with multi-disciplinary experts in traumatic brain injury to develop individually tailored rehabilitation programs that target the main physiological causes of acute concussion symptoms (autonomic nervous system dysfunction/exercise intolerance, vestibulo-ocular dysfunction, and cervical spine dysfunction) while maintaining the athlete's physical fitness during the recovery period. Considerations for multi-disciplinary medical clearance of collegiate and professional athletes as well as the application of this approach to non-elite athletes are also discussed.

Peripheral Vestibular System Histopathologic Changes following Head Injury without Temporal Bone Fracture

Objective

Vestibular symptoms such as dizziness and vertigo are common after head injury and may be due to trauma to the peripheral vestibular system. The pathophysiology of peripheral vestibular symptoms following head injury without temporal bone (TB) fracture, however, is not well understood. Herein, we investigate the histopathology of the peripheral vestibular system of patients who sustained head injury without a TB fracture.

Study Design

Otopathology study.

Setting

Otopathology laboratory.

Subjects and Methods

TB of subjects with a history of head injury without TB fractures were included and evaluated by light microscopy. Specimens were assessed for qualitative and quantitative characteristics, such as number of Scarpa’s ganglion cells in the superior and inferior vestibular nerves, vestibular hair cell and/or dendrite degeneration in vestibular end organs, presence of vestibular hydrops, and obstruction of the endolymphatic duct.

Results

Five cases (n = 5 TBs) had evidence of vestibular pathology. There was a decrease of 48.6% (range, 40%-59%) in the mean count of Scarpa’s ganglion cells as compared with that of normative historical age-matched controls. Moderate to severe degeneration of the vestibular membranous labyrinth was identified in the posterior, superior, and lateral canals in several cases (50%, n = 4 TBs). The maculae utriculi and sacculi showed mild to severe degeneration in 2 cases. Additional findings include vestibular hydrops (25%, n = 2 TBs) and blockage of the endolymphatic duct (n = 1 TB).

Conclusions

Otopathologic analysis of patients with a history of head injury without TB fracture demonstrated peripheral vestibular otopathology. Future studies are necessary to determine if otopathology findings are directly attributable to head injury.

Practice Guidelines for the Diagnosis and Management of Benign Paroxysmal Positional Vertigo Otoneurology Committee of Spanish Otorhinolaryngology and Head and Neck Surgery Consensus Document

Benign Paroxysmal Positional Vertigo is the most frequent episodic vestibular disorder. The purpose of this guide, requested by the committee on otoneurology of the Spanish Society of Otolaryngology and Head and Neck Surgery, is to supply a consensus document providing practical guidance for the management of BPPV. It is based on the Barany Society criteria for the diagnosis of BPPV. This guideline provides recommendations on each variant of BPPV, with a description of the different diagnostic tests and the therapeutic manoeuvres. For this purpose, we have selected the tests and manoeuvres supported by evidence-based studies or extensive series. Finally, we have also included a chapter on differential diagnosis and a section relating to general aspects in the management of BPPV.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)

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.

Benign Paroxysmal Positional Vertigo Secondary to Mild Head Trauma

Objectives:

We studied the clinical characteristics, nystagmographic findings, and treatment outcome of a group of patients with benign paroxysmal positional vertigo (BPPV) secondary to mild head trauma and compared them with a group of patients with idiopathic BPPV.

Methods:

The medical records of 33 patients with BPPV associated with mild head trauma were reviewed. Data of a complete otolaryngological, audiological, neurotologic, and imaging evaluation were available for all patients. Three hundred and twenty patients with idiopathic BPPV were used as a control group.

Results:

The patients with BPPV secondary to mild head trauma presented the following features, in which they differed from the patients with idiopathic BPPV: (1) lower mean age, with more intense symptoms; (2) increased rate of horizontal and anterior semicircular canal involvement and frequent multiple canal and bilateral involvement; (3) greater incidence of canal paresis and presence of spontaneous nystagmus; (4) poorer treatment results, attributed mainly to coexisting canal paresis in many patients, and higher rate of recurrence.

Conclusions:

Benign paroxysmal positional vertigo associated with mild head trauma differs from idiopathic BPPV in terms of several epidemiological and clinical features; it responds less effectively to treatment and is prone to recurrence.