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Benign positional vertigo

Practical lowdown on...

It is usually possible to diagnose this condition from the history and by performing the Hallpike manoeuvre. Neurological referral is not necessary.

•Explain that the vertigo may last for a few weeks only or may continue with remissions and relapses for many years.

•Do not give labyrinthine sedatives.

•Teach the patient to minimise the vertigo by sitting up or lying down in stages.

•Ask the ENT department whether they

offer adaptive physiotherapy or Epley's manoeuvre. The latter involves repeated rapid positioning of the head, the theory being that this moves otoliths out of the labyrinth. Epley has shown that two sessions one week apart give relief in 97 per cent of patients1 with 70 per cent cured

after a single session2. If this technique is not offered locally, the patient can perform it at home (see box right). In a German trial, 90 per cent were symptom-free within a week3.

This is an extract from Practical General Practice 5e, ISBN 07506 8867X, Elsevier Ltd, April 2006, price £47.99. To order your copy please go to www.elsevierhealth.com or phone Elsevier customer services on 01865 474000.

Practical General Practice, fifth edition, is compiled by Alex Khot, a GP in East Sussex, and Andrew Polmear, a retired GP and former senior research fellow at the University of Sussex

1 The Hallpike

• Hold patient's head in both hands and turn it 45° towards the test

ear. Support the neck and, maintaining torsion along with fixed gaze, move head rapidly backwards to a head hanging position, 30-45° (optimally) below the horizontal as rapidly as possible

• Maintain the head hanging position for 30-60 seconds and observe

the patient's eyes. If nystagmus is present, note the latent period, magnitude and direction of rotation of the fast phase. Maintain that position for about one minute after onset to determine if nystagmus adapts, changes direction or alters

• Return the patient to the upright position while maintaining 45° neck rotation and observe for reversal of the nystagmus

• Wait until the patient is settled and then repeat on the same side to assess fatigability. Proceed to the opposite side if no nystagmus is

seen on the first side or when the patient has settled from the

first test

• Note that the nystagmus may only last a few seconds and will not

occur at all in some patients, in whom the diagnosis must be made

on the history alone. Note also that the patient will experience

vertigo at the same time as the nystagmus

2 modified Epley manoeuvre

These instructions are for a patient whose left ear is affected

1 Sit up on the bed with your head turned 45° to the left, having

placed a pillow on the bed so that it will be under your shoulders,

not your head, when you lie down

2 Lie back quickly, keeping your head turned as before. Wait 30 seconds

3 Turn your head to the other side. Wait 30 seconds

4 Roll onto your right side. Wait 30 seconds

5 Sit up without rolling over onto your back, ie still facing right

6 Repeat this three times a day until the symptoms have ceased

Guideline

Umapathy D. Benign paroxysmal positional vertigo (BPPV) diagnostic worksheet. British Association of Audiological Physicians. Online: www.baap.org.uk (choose 'guidelines')

References

1 Lempert T et al. Benign positional vertigo: recognition and treatment. BMJ 1995; 311: 489-91.

2 Ruckenstein MJ. Therapeutic efficacy of the Epley canalith repositioning maneuver. Laryngoscope 2001; 111: 940-5.

3 Radtke A et al. Self-treatment of benign paroxysmal positional vertigo. Neurology 2004; 63: 150-2.

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