Vertigo: Diagnosis and Management
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Expires December 31, 2014
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Benign paroxysmal positional vertigo accounts for approximately 42% of cases of vertigo seen in primary care settings and is the single most common cause of vertigo in the United States. Our expert outlines an evidence-based approach to diagnosis, which results in an increase in desirable patient outcomes and a decrease in unnecessary tests and medications.
TREATMENT AND MANAGEMENT
Particle repositioning maneuvers are the recommended treatment for BPPV. These maneuvers have a success rate of greater than 90%5,6 and usually provide immediate resolution of symptoms.23 The canalith repositioning maneuver (CRP; also called the Epley maneuver) and the liberatory maneuver (LM; also called the Semont maneuver) are effective treatments for posterior canal BPPV (see “The Epley Maneuver”).4 The CRP can be performed immediately following positive results on the Dix-Hallpike test.
The CRP depends on gravity to treat BPPV.24 The otoconia settle in the lowest part of the semicircular canals as the patient is moved through a series of positions. The maneuver requires the patient to be rotated 180° (through four positions) beginning with the affected side and then to the uninvolved side before returning to a sitting position.24 Each position is maintained for at least 30 s. Once the otoconia migrate out of the affected semicircular canal and back into the vestibule, the particles should dissolve.
The LM begins with the patient in a seated position with the head turned away from the affected side (see Figure 2). The clinician quickly moves the patient into a side-lying position toward the affected side, with the head turned upward and supported there for approximately 30 s (Step 1).The clinician then quickly moves the patient through the initial seated position (without pausing) to the opposite side-lying position without changing the head position (Step 2). With the head now facing downward, the patient remains motionless for another 30 s before the clinician brings the patient upright to the original seated position. Although patients are sometimes advised to remain upright for 24 to 48 h following in-office treatment (which is not believed to cause harm), there is insufficient evidence to support this recommendation.4
For ongoing care, current clinical guidelines recommend that practitioners offer either vestibular rehabilitation (performed by a clinician or self-administered by the patient) or provide for watchful waiting and follow-up based on the natural course of spontaneous resolution of symptoms.4
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