HNY Policy and Pathway Repository - York

Paroxysms of rotational vertigo lasting for seconds to minutes, often associated with change in position, without hearing loss or headache. Caused by otoliths in the vestibular apparatus.

Exclude Red Flag Symptoms

• Cerebellar signs should be excluded: Dysdiadochokinesis (DDK), Past-pointing, Limb/trunk/gait ataxia, dysarthria- refer Stroke pathway or Neurology as relevant.
• Syncope- not a feature of BPPV

• History: a good history of rotational vertigo on position change lasting for seconds to minutes.
• Examination: fatiguable nystagmus may be detected (to the affected side) routinely or upon Hallpike-Dix testing. View demonstration below:

• Treatment depends on severity:
• sometimes reassurance for mild cases suffices
• Cannolith repositioning: Epley’s Manoeuvre can be performed in surgery, but warn patient they may not be able to drive afterwards. View demonstration below:

• Brandt Daroff self-help exercises 
• Use of vestibular sedatives (e.g. prochlorperazine) should be reserved for severe cases and for short duration of use only e.g. 3-5 days, as delays recovery. NOT recommended by NICE CKS 2013 A US guideline on the management of BPPV found no evidence to suggest that symptomatic drugs are a substitute for repositioning manoeuvres. Those studies that showed improvement with medication were carried out over the same period that spontaneous resolution would be expected to occur [Bhattacharyya et al, 2008]. Expert opinion in a narrative review [Hain and Uddin, 2003] and the opinion of CKS expert reviewers was consistent with this, and suggests that most drugs are not effective in treating BPPV and may have adverse effects.
• Refractory Cases or if diagnostic uncertainty: refer to the Balance Clinic

 

Information to include in referral letter

• History: must include history of vertigo (seconds, hours, days), triggers, associated symptoms e.g. hearing loss, tinnitus, nausea and vomiting.
• Examination: Include auroscope findings postural BPs, neuro examination findings
• Treatment to date: Include details of impact of Epley’s Manoeuvre, Brandt Daroff exercises, any therapy trials.
• Past medical/ surgical history
• Drug History
• Smoking cessation

Patient information leaflets/ PDAs

Benign paroxysmal positional vertigo (patient.info)
 

References

• http://www.patient.co.uk/health/Benign-Paroxysmal-Positional-Vertigo.htm
• NICE CKS BPPV Sept 2013