Current Therapies in Patients With Posterior Semicircular Canal BPPV, a Systematic Review and Network Meta-analysis

This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").

Section: "Isolated" Dizzinessmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

Edlow,

Carpenter,

Akhter

et al. 2023

“…Treatment of BPPV with Epley in older adults, the most likely population to have the disease and be negatively affected by the sensation of imbalance, decreases their risk of subsequent falls by more than half 71 . In fact, earlier treatment (within 24 h of symptom onset) cuts the recurrence rate in half 72 and increases the likelihood of resolution 73 . For all these reasons, prompt treatment in the ED is important.…”

Section: Discussionmentioning

confidence: 99%

“…71 In fact, earlier treatment (within 24 h of symptom onset) cuts the recurrence rate in half 72 and increases the likelihood of resolution. 73 For all these reasons, prompt treatment in the ED is important.…”

Section: Discussionmentioning

confidence: 99%

Epley maneuver for benign paroxysmal positional vertigo: Evidence synthesis for guidelines for reasonable and appropriate care in the emergency department

Khoujah

Naples

Silva

et al. 2023

Background: Canalith repositioning maneuvers (such as the Epley maneuver) are recommended by specialty guidelines for management of benign paroxysmal positional vertigo (BPPV) yet are frequently underutilized in the emergency department (ED). Methods:We conducted a systematic review (SR) of SRs to summarize the evidence of Epley maneuver for the treatment of posterior canal (pc) BPPV in any setting. We included SRs of randomized controlled trials (RCTs) that compared Epley to control in adult patients with pc-BPPV. Titles, abstracts, and full texts were screened in duplicate. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) assessment was used to rate certainty of evidence. Odds ratios (ORs) and 95% confidence intervals (CIs) are reported. Meta-analysis of individual studies was conducted with random and fixed effects.Results: From 2228 titles, seven SRs were selected for quality assessment. One review was of higher methodological quality, included only RCTs, and was the most current and comprehensive. Five of the 11 RCTs of the review, including 312 patients with pc-BPPV diagnosed by Dix-Hallpike, were relevant to our question. Meta-analysis of four RCTs (251 patients) showed the use of Epley (compared to control) was associated with higher complete resolution of vertigo at 1 week (OR 7.19, 95% CI 1.52-33.98, moderate certainty). Meta-analysis of three RCTs (195 patients) showed the use of Epley was associated with higher conversion to negative Dix-Hallpike at 1 week (OR 6.67, 95% CI 1.52-33.98, moderate certainty). The number-needed-to-treat was three. Meta-analysis of the outcomes at 1 month, and when observational studies were included, showed similar results. No serious adverse effects were reported. Conclusions: Symptoms of pc-BPPV improve with the Epley maneuver. Emergency clinicians should become familiar with performing the Epley for BPPV. Further studies on ED implementation and clinician education of Epley are needed.

“…Treatment for BPPV with canalith repositioning maneuvers (CRM; e.g., Epley maneuver) is extremely effective in treating the condition. 5,6 The American Academy of Otolaryngology (AAO) and the American Academy of Neurology recommend treatment of BPPV with a CRM and the former specifically recommends against the use of vestibular suppressant medications. 7,8 The clinical practice guideline by the AAO made their recommendation against the use of vestibular suppressants in BPPV based on Grade C observational studies and a preponderance of benefit over harm.…”

Section: Introductionmentioning

confidence: 99%

Vestibular suppressants for benign paroxysmal positional vertigo: A systematic review and meta‐analysis of randomized controlled trials

Sharif

Khoujah

Greer

et al. 2022

Background: Benign paroxysmal positional vertigo (BPPV) is a common cause of acute dizziness. Medication use for its treatment remains common despite guideline recommendations against their use. Objectives:The objective was to evaluate the efficacy and safety of vestibular suppressants in patients with BPPV compared to placebo, no treatment, or canalith repositioning maneuvers (CRMs). Methods: We searched MEDLINE, Cochrane, EMBASE, and ClinicalTrials.gov from inception until March 25, 2022. for randomized controlled trials (RCTs) comparing antihistamines, phenothiazines, anticholinergics, and/or benzodiazepines to placebo, no treatment, or a CRM.Results: Five RCTs, enrolling 296 patients, were included in the quantitative analysis.We found that vestibular suppressants may have no effect on symptom resolution at the point of longest follow-up (14-31 days in four studies) when evaluated as a continuous outcome (standardized mean difference -0.03 points, 95% confidence interval [CI] −0.53 to 0.47). Conversely, CRMs may improve symptom resolution at the point of longest follow-up as a dichotomous outcome when compared to vestibular suppressants (relative risk [RR] 0.63, 95% CI 0.52 to 0.78). Vestibular suppressants had an uncertain effect on symptom resolution within 24 h (mean difference [MD] 5 points, 95% CI −16.92 to 26.94), repeat emergency department (ED)/clinic visits (RR 0.37, 95% CI 0.12 to 1.15), patient satisfaction (MD 0 points, 95% CI −1.02 to 1.02), and quality of life (MD −1.2 points, 95% CI −2.96 to 0.56). Vestibular suppressants had an uncertain effect on adverse events. Conclusions:In patients with BPPV, vestibular suppressants may have no effect on symptom resolution at the point of longest follow-up; however, there is evidence toward the superiority of CRM over these medications. Vestibular suppressants have an uncertain effect on symptom resolution within 24 h, repeat ED/clinic visits, patient satisfaction, quality of life, and adverse events. These data suggest that a CRM, and not vestibular suppressants, should be the primary treatment for BPPV.