Benign Paroxysmal Positional Vertigo: Current Status of Medical Management

Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder and can be simply and reliably diagnosed by positioning tests.1 The evolution of highly effective therapeutic positioning maneuvers has made BPPV the most successfully treatable cause of vertigo. After a single maneuver with either Epley's2 and Semont et al's3 maneuver, complete recovery is achieved in 50% to 80% of patients.3-5 We wanted to know whether this progress in the diagnosis and treatment of BPPV has been established in medical practice. Patients with BPPV of the posterior canal were evaluated retrospectively with regard to the past medical history and disease-related diagnostic and therapeutic procedures. Forty-two patients with BPPV of the posterior semicircular canal were recruited from a specialized dizziness clinic and an additional 29 patients were recruited from a neurologic practice. Diagnosis was confirmed in all 71 cases by observation of typical positional nystagmus1 and successful treatment by positioning maneuvers. Data were collected by means of a questionnaire. The mean age of the patients was 60.5 years (range, 32 to 89 years). Half of the group (51%) presented with recurrent BPPV. The mean duration of the disease was 3.2 years with an average of 2.4 episodes typically lasting several weeks to months. Fifty-five percent of patients felt severely disabled by BPPV, and 25% were temporarily unfit for work. Three different medical specialties were consulted on average, most often internal/general medicine (86%), otolar-yngology (72%), and neurology (51%). Eight percent of the patients had hospital admission for BPPV. Cerebral imaging (42%), caloric testing (46%), audiometry (49%), and carotid Doppler ultrasonography (34%) were performed more often than diagnostic positioning (28%). Only 31% of the consulted neurologists, 16% of otolaryngologists, and 2% of specialists for internal medicine and general practitioners performed positioning tests. Thirty percent of patients did not receive a diagnosis. BPPV was suspected in 45% of patients. Most patients received noneffective therapy such as antivertiginous medication (39%), physical therapy (14%), chiropractic treatment (13%), betahistine (10%), acupuncture (7%), or no therapy (39%). Brandt-Daroff exercises were recommended to 15% of patients, and only 4% were treated with a specific therapeutic positioning maneuver. Our study provides insights into the medical care of patients with BPPV in Germany. The most striking result is the lack of competence of the specialists for otolaryngology and neurology with regard to the diagnosis and treatment of BPPV. The disease is probably not as benign as the name suggests. Instead, our results show that BPPV is a long-lasting and frequently recurring disorder that leads to significant morbidity and medical costs when treated incorrectly. In a North American study, the costs of BPPV were calculated at more than $2000 per individual; most of these expenses were for useless diagnostic measures and ineffective therapy.6 The psychosocial impact of the disease has been explored in a study that found high scores for depression and loneliness in patients with BPPV.7 Therefore it appears not to be appropriate to await spontaneous remission, which may take months to occur. Instead, every physician treating patients with vertigo should be familiar with the therapeutic maneuvers introduced by Epley2 and Semont et al,3 which are easy to perform and usually lead to immediate cessation of positional vertigo.