A critical appraisal of clinical practice guidelines for the diagnosis and management of benign paroxysmal positional vertigo

Introduction

Benign paroxysmal positional vertigo (BPPV) is the most common inner-ear pathology and type of vertigo seen in emergency departments, out-patient neurology and otolaryngology clinics today.^1,2 It is characterised by brief sensations of dizziness and nystagmus induced by changes in head position with respect to gravity, with associated nausea and vomiting. Patients with BPPV are at an increased risk of depression, anxiety, falls and significant impairment of daily activities, with some studies suggesting an increased risk of osteoporosis.^3–8 This disease most often occurs in middle-aged patients, with a peak onset between 50 and 60 years of age and an increased incidence among women.⁹ For older adult patients aged over 60 years, BPPV has been shown to increase the risk of neurodegenerative dementia.¹⁰ The seriousness of the long-term implications of BPPV for quality of life and associated health conditions highlights the need for efficient diagnosis and management.

The basic pathophysiology of BPPV is well elucidated in the literature. Calcium carbonate particles in the utricular otolith membrane of the elliptical capsule are dislodged and enter the semicircular canals.¹¹ When there is a change in position with respect to gravity, these particles are moved to different positions in the semicircular canals, leading to the sensation of motion and dizziness. Management for BPPV can vary depending on the suspected location of origin. The posterior semicircular canal is the most common origin site of BPPV (60–90 per cent of cases), as it is the most gravity-dependent canal.¹² The horizontal semicircular canal can also be involved, but this site is more likely to resolve spontaneously. Rarely, particles can gather in the anterior semicircular canal, the most anatomically superior site.

Although BPPV is a common disease with a good prognosis, evidence-based diagnosis and treatment are essential to effectively manage this condition. Studies show that the cost to ultimately diagnose BPPV is on average greater than $2000 per patient, with a majority of patients receiving unnecessary diagnostic testing, including imaging such as magnetic resonance imaging and echocardiography, inappropriate medications, physical therapy and numerous office visits.^13,14 The burden of vertigo has been shown to greatly affect the working population, with 63.3 per cent of afflicted patients losing workdays, 4.6 per cent changing their jobs and 5.7...