alexa Comments on an Update of Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo | Open Access Journals
ISSN: 2161-119X
Otolaryngology: Open Access
Like us on:
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

Comments on an Update of Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo

Xizheng Shan1, Amy Wang2 and Entong Wang1*

1Department of Otolaryngology-Head and Neck Surgery, General Hospital of Chinese People’s Armed Police Forces, Beijing, China

2Department of Geriatrics, Aintree University Hospital, Liverpool, UK

Corresponding Author:
Entong Wang, MD, PhD
Department of Otolaryngology-Head and Neck Surgery
General Hospital of Chinese People’s Armed Police Forces
Beijing 100039, China
Tel: 0086 10 88420757
E-mail: [email protected]

Received date: April 25, 2017; Accepted date: May 02, 2017; Published date: May 09, 2017

Citation: Shan X, Wang A, Wang E (2017) Comments on an Update of Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo. Otolaryngol (Sunnyvale) 7:305. doi:10.4172/2161-119X.1000305

Copyright: © 2017 Shan X, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distributionand reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Otolaryngology: Open Access

Abstract

The clinical practice guideline for benign paroxysmal positional vertigo (BPPV) is newly updated by the American Academy of Otolaryngology—Head and Neck Surgery Foundation. The guideline will guide clinicians to manage BPPV in their clinical practice. But some descriptions in the Statement 1a and Statement 1b of the guideline seem not quite clear or appropriate, which would make clinicians have some misunderstandings. Thus we present our opinions: 1) the Dix-Hallpike test should be repeated on the opposite side no matter the test on initial side is negative or positive due to possible presence of bilateral posterior canal BPPV; and 2) no matter the bilateral Dix- Hallpike tests are negative or positive, the supine roll test should be followed due to possible presence of multicanal BPPV variation with involvement of posterior and lateral canals.

Keywords

Benign paroxysmal positional vertigo; Posterior semicircular canal; Lateral semi-circular canal; Dix-Hallpike test; Supine roll test

Introduction

The American Academy of Otolaryngology—Head and Neck Surgery Foundation newly published an update of 2008 Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (BPPV) [1], which will guide clinicians to manage BPPV in their clinical practice. However we feel some descriptions in the Statement 1a and Statement 1b of the guideline are not quite clear or appropriate.

First, the guideline provided a strong recommendation: “Statement 1a. Diagnosis of posterior semicircular canal BPPV: Clinicians should 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 supine position with the head turned 45° to one side and neck extended 20° with the affected ear down. The maneuver should be repeated with the opposite ear down if the initial maneuver is negative.” Similar descriptions also occurred respectively in the Supporting Text section, Performing the Dix-Hallpike Diagnostic Maneuver section (and see Table 5 of the guideline [1]). According to the descriptions, clinicians would have such a misunderstanding that the Dix-Hallpike test should not be performed with the opposite side if the test on initial side is positive, although some additional descriptions were given in the Performing the Dix-Hallpike Diagnostic Maneuver section of the guideline: “The Dix-Hallpike maneuver may in certain circumstances be performed bilaterally to determine which ear is (or ears are) involved, particularly if the diagnosis is not clear with the first performance of the maneuver. In a small percentage of cases, the Dix-Hallpike maneuver may be bilaterally positive” [1].

As mentioned in the guideline, there are multicanal BPPV and bilateral multicanal BPPV, including bilateral posterior canal BPPV, although they are rare variations of BPPV [1]. An incidence of up to 10% of bilateral posterior canal BPPV among BPPV cases has been reported in several studies [2-8]. Thus if the Dix-Hallpike test should not be repeated with the opposite side when the test on initial side is positive, potential cases with bilateral posterior canal BPPV would not be diagnosed and treated appropriately. Therefore we think that the Dix-Hallpike test should be repeated with the opposite side no matter the test on initial side is negative or positive due to possible presence of bilateral posterior canal BPPV.

Second, a recommendation was made in the guideline: “Statement 1b. Diagnosis of lateral (horizontal) semicircular canal BPPV: If the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus, the clinician should perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV” [1]. Similar opinion was also reflected in one of the figure in the guideline [1]. But according to the description in text and the algorithm (of Figure 8 from [1]), clinicians would possibly understand that a supine roll test to examine lateral canal BPPV should not be performed if patient presents with a history compatible with BPPV and the Dix-Hallpike test is positive, namely on the test the patient exhibits upbeating-torsional nystagmus, a typical nystagmus for the diagnosis of posterior canal BPPV.

Lateral canal BPPV is also a common subtype of BPPV, accounting for 5% to 22% cases of BPPV [1], but its incidence may have been underestimated [9], since lateral canal BPPV may spontaneously recover more quickly than posterior canal BPPV [1,10]. Multicanal BPPV may also simultaneously involve in the posterior and lateral canals, either on the same side or on 2 sides, with a reported incidence of up to 13% among BPPV cases [4-8]. Thus if the supine roll test to evaluate lateral canal BPPV should not be performed since the patient presents with a history corresponding BPPV and shows a positive Dix- Hallpike test, potential cases with multicanal BPPV involving the posterior and lateral canals would not be diagnosed and treated appropriately. As mentioned in the Risk and Benefit Analysis section of Statement 1b in the guideline, “The benefit of performing the supine roll test is that it allows clinicians to confirm a diagnosis of lateral semicircular canal BPPV quickly and efficiently. It also allows clinicians to more accurately and comprehensively diagnose positional vertigo that is not due to the posterior canal, whereas without supine roll testing, patients with lateral semicircular canal BPPV might be diagnostically missed if only traditional Dix-Hallpike testing were done” [1]. Therefore we think that patient with a history corresponding BPPV should routinely undergo the supine roll test after receiving bilateral Dix-Hallpike tests, no matter the Dix-Hallpike tests are negative or positive, due to possible presence of multicanal BPPV subtype with simultaneous involvement of posterior and lateral canals.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Recommended Conferences

Article Usage

  • Total views: 140
  • [From(publication date):
    June-2017 - Jul 26, 2017]
  • Breakdown by view type
  • HTML page views : 107
  • PDF downloads :33
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

 
© 2008-2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version
adwords