Guidelines Summary

In 2017, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF)released an update to a 2008 guideline regarding benign paroxysmal positional vertigo (BPPV). The update included recommendations that clinicians do as follows^{[15, 16, 17]}:

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 a supine position with the head turned 45° to one side, the neck extended 20°, and the affected ear aimed downward
Treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure
Not impose postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV
Perform, or refer the patient 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 results in horizontal or no nystagmus
Differentiate, or refer the patient to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo
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
Reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms
Evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or CNS disorders
Educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up
Not perform radiographic imaging in a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging
Not perform vestibular testing in a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing
Not routinely treat BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines

Medication

Palmeri R, Kumar A. Benign Paroxysmal Positional Vertigo. StatPearls. 2022 Jan. [QxMD MEDLINE Link]. [Full Text].
Anagnostou E, Kouzi I, Spengos K. Diagnosis and Treatment of Anterior-Canal Benign Paroxysmal Positional Vertigo: A Systematic Review. J Clin Neurol. 2015 May 28. [QxMD MEDLINE Link].
Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1980 Sep-Oct. 88(5):599-605. [QxMD MEDLINE Link].
Yetiser S, Ince D. Diagnostic Role of Head-Bending and Lying-Down Tests in Lateral Canal Benign Paroxysmal Positional Vertigo. Otol Neurotol. 2015 May 1. [QxMD MEDLINE Link].
Chang TP, Lin YW, Sung PY, Chuang HY, Chung HY, Liao WL. Benign Paroxysmal Positional Vertigo after Dental Procedures: A Population-Based Case-Control Study. PLoS One. 2016. 11 (4):e0153092. [QxMD MEDLINE Link]. [Full Text].
Faralli M, Cipriani L, Del Zompo MR, et al. Benign paroxysmal positional vertigo and migraine: analysis of 186 cases. B-ENT. 2014. 10(2):133-9. [QxMD MEDLINE Link].
Picciotti PM, Di Cesare T, Tricarico L, De Corso E, Galli J, Paludetti G. Is drug consumption correlated with benign paroxysmal positional vertigo (BPPV) recurrence?. Eur Arch Otorhinolaryngol. 2020 Feb 20. [QxMD MEDLINE Link].
Messina A, Casani AP, Manfrin M, Guidetti G. Italian survey on benign paroxysmal positional vertigo. Acta Otorhinolaryngol Ital. 2017 Aug. 37 (4):328-35. [QxMD MEDLINE Link].
Teggi R, Guidetti R, Gatti O, Guidetti G. Recurrence of benign paroxysmal positional vertigo: experience in 3042 patients. Acta Otorhinolaryngol Ital. 2021 Oct. 41 (5):461-6. [QxMD MEDLINE Link]. [Full Text].
Tirelli G, Nicastro L, Gatto A, Tofanelli M. Repeated canalith repositioning procedure in BPPV: Effects on recurrence and dizziness prevention. Am J Otolaryngol. 2017 Jan - Feb. 38 (1):38-43. [QxMD MEDLINE Link].
Yoon J, Lee JB, Lee HY, Lee BD, Lee CK, Choi SJ. Potential Risk Factors Affecting Repeated Canalith Repositioning Procedures in Benign Paroxysmal Positional Vertigo. Otol Neurotol. 2018 Feb. 39 (2):206-11. [QxMD MEDLINE Link].
Power L, Murray K, Szmulewicz DJ. Characteristics of assessment and treatment in Benign Paroxysmal Positional Vertigo (BPPV). J Vestib Res. 2019 Dec 13. [QxMD MEDLINE Link].
Laurent G, Vereeck L, Verbecque E, Herssens N, Casters L, Spildooren J. Effect of age on treatment outcomes in benign paroxysmal positional vertigo: A systematic review. J Am Geriatr Soc. 2022 Jan. 70 (1):281-93. [QxMD MEDLINE Link]. [Full Text].
Shim DB, Kim JH, Park KC, Song MH, Park HJ. Correlation between the head-lying side during sleep and the affected side by benign paroxysmal positional vertigo involving the posterior or horizontal semicircular canal. Laryngoscope. 2012 Feb 16. [QxMD MEDLINE Link].
[Guideline] Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017 Mar. 156 (3_suppl):S1-S47. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Garcia J. New guidelines for benign paroxysmal positional vertigo. Medscape Medical News. 2017 Mar 1. [Full Text].
[Guideline] Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov. 139(5 Suppl 4):S47-81. [QxMD MEDLINE Link].
Picciotti PM, Lucidi D, De Corso E, Meucci D, Sergi B, Paludetti G. Comorbidities and recurrence of benign paroxysmal positional vertigo: personal experience. Int J Audiol. 2016 May. 55 (5):279-84. [QxMD MEDLINE Link].
Tan J, Deng Y, Zhang T, Wang M. Clinical characteristics and treatment outcomes for benign paroxysmal positional vertigo comorbid with hypertension. Acta Otolaryngol. 2016 Nov 14. 1-3. [QxMD MEDLINE Link].
[Guideline] Fife TD, Iverson DJ, Lempert T, et al. 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. [QxMD MEDLINE Link]. [Full Text].
Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992 Sep. 107(3):399-404. [QxMD MEDLINE Link].
Fung K, Hall SF. Particle repositioning maneuver: effective treatment for benign paroxysmal positional vertigo. J Otolaryngol. 1996 Aug. 25(4):243-8. [QxMD MEDLINE Link].
Herdman SJ, Tusa RJ, Zee DS, et al. Single treatment approaches to benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg. 1993 Apr. 119(4):450-4. [QxMD MEDLINE Link].
Li JC. Mastoid oscillation: a critical factor for success in canalith repositioning procedure. Otolaryngol Head Neck Surg. 1995 Jun. 112(6):670-5. [QxMD MEDLINE Link].
Li JC, Epley J. The 360-degree maneuver for treatment of benign positional vertigo. Otol Neurotol. 2006 Jan. 27(1):71-7. [QxMD MEDLINE Link]. [Full Text].
Massoud EA, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol. 1996 Apr. 25(2):121-5. [QxMD MEDLINE Link].
Roberts RA, Gans RE, Montaudo RL. Efficacy of a new treatment maneuver for posterior canal benign paroxysmal positional vertigo. J Am Acad Audiol. 2006 Sep. 17 (8):598-604. [QxMD MEDLINE Link].
Smouha EE, Roussos C. Atypical forms of paroxysmal positional nystagmus. Ear Nose Throat J. 1995 Sep. 74(9):649-56. [QxMD MEDLINE Link].
Weider DJ, Ryder CJ, Stram JR. Benign paroxysmal positional vertigo: analysis of 44 cases treated by the canalith repositioning procedure of Epley. Am J Otol. 1994 May. 15(3):321-6. [QxMD MEDLINE Link].

Media Gallery

The patient is placed in a sitting position with the head turned 45° towards the affected side and then reclined past the supine position.
The patient is then brought back up to the sitting position.
Next, the patient is rolled 180° from the affected side to the opposite side. Note that the position of the head is 45° toward the affected side before the roll. The head winds up facing down, 180° away from the starting position.

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Author

John C Li, MD Private Practice in Otology and Neurotology; Medical Director, Balance Center

John C Li, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Tinnitus Association, Florida Medical Association, North American Skull Base Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Peter S Roland, MD Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director, Clinical Center for Auditory, Vestibular, and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Chief of Pediatric Otology, Children’s Medical Center of Dallas; President of Medical Staff, Parkland Memorial Hospital; Adjunct Professor of Communicative Disorders, School of Behavioral and Brain Sciences, Chief of Medical Service, Callier Center for Communicative Disorders, University of Texas School of Human Development

Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Neurotology Society, American Otological Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, The Triological Society

Disclosure: Received honoraria from Alcon Labs for consulting; Received honoraria from Advanced Bionics for board membership; Received honoraria from Cochlear Corp for board membership; Received travel grants from Med El Corp for consulting.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan; Ryte; Neosoma; MI10<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10.

Additional Contributors

Michael E Hoffer, MD Director, Spatial Orientation Center, Department of Otolaryngology, Naval Medical Center of San Diego

Michael E Hoffer, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Received royalty from American biloogical group for other.

Acknowledgements

John Epley, MD Director, Portland Otologic Clinic

John Epley, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Oregon Medical Association

Disclosure: Nothing to disclose.