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Chapter Presidents
Northern Luzon Louie V. Medenilla, M.D.
Southern-Luzon Pio R. Pajarillo, M.D.
Bicol Diosdado C. Uy, M.D., MClinAud.
Central Eastern Visayas Eduardo R. Arcenas, M.D.
Western Visayas Teodoro L. Jardeleza, M.D.
Southeast Mindanao Jose Antonio M. Santos, M.D.
Northwest Mindanao Jesus M. Jardin, M.D.
Vertigo CPM 9TH EDITION
280
CPM 9 TH
EDITION Vertigo
Introduction
The Task Force on Clinical Practice Guidelines-Vertigo of the Philippine Society of Otolaryngology-Head &
Neck Surgery, Inc. met on November 7, 2003 at Makati, Metro Manila to come up with practical guidelines
and algorithms for the diagnosis and treatment of peripheral vertigo in adults. Participants included general
otolaryngologists, otologists and neurotologists from the different accredited ENT training institutions and
provincial ENT practitioners.
The recommendations in this report are based on a review of the available literature and clinical expertise
of the participants.
This report will need to be reviewed, modified and updated periodically according to the availability of new
knowledge.
Meniere's
Disease
2
3
N
4
Institute
preventive
measures
5
6
Positive Y Discontinue
Response? and observe
N
8
Refer
282
CPM 9 TH
EDITION Vertigo
BPPV
2 3
4
Do Epley's or
Semont's maneuver
(Weekly intervals,
maximum of 4
maneuvers per side)
5
7
Refer
283
Vertigo CPM 9TH EDITION
Vestibular
Neuronitis/Viral
Labyrinthitis
2 3
4
5
Positive Y Vestibular
Response? Rehabilitation
N
6 7
8
Refer Positive Y
Response? Continue
N
9
Refer
284
CPM 9 TH
EDITION Vertigo
Literature Search
Objectives
The National Library of Medicine's PubMed database
The objectives of the guideline are (1) to assist general was searched for literature using the keyword vertigo.
ENT practitioners to determine true peripheral vertigo The search was limited to articles involving humans and
in adults; (2) to evaluate current diagnostic techniques; those published in English in the last fifteen years, WHO
and (3) to describe treatment options. reports, and the PGH 2002 Annual Report. This search
yielded 2375 articles, and the titles and contents of
which were carefully screened for possible relevance to
Definition the guideline. One hundred ninety three (193) abstracts
were chosen and results were further assessed for rel-
Vertigo is defined as an illusion of movement of self evance. Full text articles were obtained when possible.
or of the environment. Peripheral vertigo is defined as The chosen articles were divided as follows:
vertigo arising from disorders of the 8th cranial nerve
and inner ear. Randomized Controlled Trials 11
Non-Randomized Controlled Study 5
Prevalence Case Series 3
Descriptive Study 3
According to the United States National Institutes of Review of Literature 1
Health (NIH) national report, 40% of all Americans seek Committee Report 1
consult for dizziness at one point in time. However, the
real prevalence of vertigo is yet undetermined. All literature were classified according to levels of
evidence and grades of recommendations based on
At the Philippine General Hospital Department of guidelines from the US Agency for Health Care Policy
Otorhinolaryngology, there were 103 cases of vertigo and Research and were set out as follows:
out of 3056 new patients seen in 2002. The Department
of Family Medicine, on the other hand, reported that out
of 20,902 new patient consults from 1999-2002, there
285
Vertigo CPM 9TH EDITION
3.1 vital signs - blood pressure (lying, sitting In a study by Mangham et.al, it was observed that
and standing position to rule out orthostatic the most effective threshold difference, (in terms of
hypotension), heart rate, respiratory rate cost-effectiveness and in reducing the false nega-
3.2 ORL examination (otoscopy, fistula test and tives and positives), that can be used for referring
tuning fork tests) patients for ABR testing is 5 to 20 dB. In the same
3.3 evaluation of the vestibular system (at the study, the authors recommended that a more than
286
CPM 9 TH
EDITION Vertigo
20 dB difference warranted further evaluation with ear.
magnetic resonance imaging.
Grade B Recommendation
5.1 For PTA-ST results that are highly suggestive
of an acoustic neuroma, the clinician may Kanzaki et al compared various ABR parameters
opt to have an immediate imaging study. in 2 groups of patients, those with acoustic
However, if the clinical findings and PTA- neuromas, and those without acoustic neuromas
ST result remain equivocal, an ABR may be but with sensorineural hearing loss. The value
requested. of each parameter was adjusted so that the false
positive rate would be less than 20%, whereas
Grade C Recommendation. the false negative rate would be less than 10%.
They found out that a prolonged interaural
Abnormal PTA-ST results that are highly sug- wave V latency difference is the most useful
gestive of acoustic neuroma include (1) more parameter. This was also validated by a separate
than 20 dB difference in 2 kHz alone or in the study by Selters et. al.
threshold average (1, 2, 4, 8 kHz) and (2) more
than 15% SDS difference. Signs and symptoms 5.3 Abnormal pure tone audiometry result sug-
that may point to an acoustic schwannoma gestive of Meniere's disease is a low frequency
are (1) unsteadiness more than vertigo; (2) sensorineural hearing loss.
unilateral tinnitus or progressive hearing loss;
(3) associated cranial nerve abnormalities Grade B Recommendation
- trigeminal nerve abnormality (specifically
decreased corneal reflex) and facial nerve pal- In Stage I of Meniere's disease, when the first
sies. vertiginous episodes occur, it is the presence of
a low-tone hearing loss that indicates the onset
Overall sensitivity of ABRs in diagnosing of the disease and the beginning of the disabling
acoustic neuromas is 90%. However, only 58% state.
of tumors 1 cm or smaller in greatest diameter
were detected by ABR. Thus, the clinician In a prospective cohort study by Mateijsen et.
should be aware of the ABR's limitation in al, they found out that affected ears significantly
diagnosing smaller tumors. show low frequency hearing losses. The hear-
ing loss, however, does not correlate with the
To this date, magnetic resonance imaging with duration of the disease.
gadolinium remains to be the gold standard in
diagnosing acoustic neuroma. 6. The history, physical examination and diagnostic
tests should be correlated to arrive at a logical
5.2 Auditory brainstem response findings that diagnosis.
are suggestive of acoustic neuroma include
at least one or more of the following: Grade C recommendation
5.2.1 abnormal interaural wave V latency
difference >0.2 ms The table below provides a simple tabulation of the
5.2.2 abnormally prolonged wave V history, PE and diagnostic tests results of the most
5.2.3 I-V interpeak interval interaural dif- common peripheral causes of vertigo that can help
ference > 0.2 ms the clinician have a quick working impression.
5.2.4 presence of wave I and absence of later
waves (III, IV, V)
7. In case of doubtful diagnosis or high suspicion
5.2.5 absent wave response in the involved
months of treatment, better results were obtained with Treatment Recommendations on Vestibular Neuro-
the Epley maneuver than with the Semont maneuver. nitis or Viral Labyrinthitis
In another randomized controlled trial by Cohen et al., 1. In the acute attack of vertigo associated with
87 subjects diagnosed with posterior canal BPPV were vestibular neuronitis or viral labyrinthitis,
randomly assigned to three treatment groups: modified vestibular suppressants may be given. However,
Epley maneuver, modified Epley maneuver with aug- prolonged administration of vestibular suppres
mented head rotations, and modified Semont maneuver. sants may delay central compensation.
Their data suggested that augmented head rotations are
unnecessary and that the modified Epley and modified Grade C Recommendation
Semont maneuvers are equally effective.
In a case series involving 23 subjects with vestibular
Grade B Recommendation neuritis, oral flunarizine at 5 mg tablet daily in a single
dose was taken together with physical exercises. Flu-
In the retrospective chart review by Haynes et al, 127 narizine appears to be useful in the treatment of vertigo
cases of objective BPPV and 35 cases of subjective caused by vestibular neuritis. However, it could not
BPPV underwent the Semont liberatory maneuver and be determined whether the portion of the change was
was assessed after 3 weeks for complete, partial, and obtained by flunarizine and exercises and what was due
failure of resolution. There was 90% improvement after to spontaneous evolution.
an average of 1.5 maneuvers, 91% with objective BPPV
after 1.6 maneuvers and 86% of subjective BPPV after 2. Vestibular rehabilitation initiated as early as
1.13 maneuvers had improvements. 29% recurrence possible to improve balance function is recom
after first maneuver, where 96% of the remaining re- mended.
sponded to the succeeding maneuvers.
Grade B Recommendation
Prospective cohort study of 86 patients with BPPV who
was treated with the Epley maneuver and evaluated In the randomized controlled trial by Strupp et al,
within the 2 weeks following treatment. Seventy per thirty-nine patients (20 in the control group, 19 in the
cent (70%) had complete resolution within 2 days after physiotherapy group) diagnosed with vestibular neu-
first maneuver. Additional 9% had complete resolution ronitis were analyzed. Vestibular exercises were found
within 2 days after first maneuver. Additional 9% had to improve vestibulo-spinal compensation in these
complete resolution after 1 week after first maneuver. patients, thereby improving balance function. It seems
best to start as early as possible with the exercises after
More than 90% of patients were cured after a maximum symptom onset.
of 4 Semont's maneuvers, and 83.5% were cured after
2 maneuvers. The efficacy decreased each time it was 3. Steroids, plus an antiviral agent, may be useful
repeated. for improving peripheral vestibular function in
vestibular neuritis.
Grade C Recommendation
Grade C Recommendation
Current therapy of BPPV organized around reposi
tioning maneuvers that use gravity to move canalith A preliminary interim analysis on the data of 51 pa-
debris out of the affected semicircular canal and into tients shows that the recovery rate was 31% in the
the vestibule. placebo group, 46% in the valacyclovir group, 61% in
the methylprednisolone group, and 67% in the methyl
When these patients were managed with customized prednisolone plus valacyclovir group. However, this
vestibular rehabilitation therapy, 100% had complete has to be further evaluated in an ongoing randomized,
resolution of their symptoms. prospective study with a larger group of patients.
2. Repeated repositioning maneuvers may be at- Figure 3. Semont's Maneuver
tempted on recurrent attacks of BPPV. However,
recurrent attacks may warrant further investiga- "The patient is laid on the ipsilateral side to the sick
tion. ear with his head slightly declined. The nystagmus can
appear in this condition one must wait until it stops. If
Grade C Recommendation nothing happens the head is turned 45 degrees facing
up in order to have the cupula in a perpendicular plane
to gravity. In this position, after a variable latency,
290
CPM 9 TH
EDITION Vertigo
Appendix
Lifted from “Emergency Medicine at NCEMI: Emergency Medicine and Primary Care Resources”.
291
Vertigo CPM 9TH EDITION
Fig. 1. Positions for CRP, targeting left PSC. Dark figure, side view, boxes, operato's exposed
view of left labyrinth, showing gravitating canaliths. Semicircular canals are labeled. S (Start),
Patient is seated, operator behind, oscillator applied. 1. Head is placed over the end of the table,
45 degrees to the left (canaliths gravitate to center of PSC). 2. While head is kept tilted downward,
it is rotated to 45 degrees right (canaliths reach common crus). 3. Head and body are rotated until
facing downward 135 degrees from supine position (canaliths traverse common crus). 4. While
head is kept turned right, patient is brought to sitting position (canaliths enter utricle). 5. Head is
turned forward, chin down 20 degrees. General: Pause at each position until induced nystagmus
approaches termination, or T sec (latency + duration) if no nystagmus. Keep repeating entire series
(1 through 5) until no nystagmus any position.
Exerpted from the article “The canalith repositioning procedure: For treatment of benign paroxysmal positional vertigo.”
by JM Epley, Otolaryngol Head Neck Surg 1992; 107: 399-404.
292
CPM 9 TH
EDITION Vertigo
the paroxysmal rotatory nystagmus rolling toward Suppl 526:10-13.
the examination table appears. One wait until it has 17. Mateijsen, DJ, et. al. Pure tone and speech audiometry in
patients with Meniere's Disease. Clin Otolaryngol 2001
completely stopped and then the patient is left in this Oct;26(5):379-87.
position for 2 or 3 minutes." 18. Committee on Hearing and Equilibrium guidelines for the
diagnosis and evaluation of therapy in Meniere's disease.
Otolaryngology-Head and Neck Surgery 1995; 113(3): 181-
"Then, holding patient's head and neck with two hands, 5.
he is swung quickly to the opposite side. The speed of the 19. Irving, Carol, et al. June 2002. Intramuscular Droperidol versus
head must be zero moment the head touches the exami- Intramuscular Dimenhydrinate for the Treatment of Acute Pe-
ripheral Vertigo in the Emergency Department: A Randomized
nation table. Then a rotatory nystagmus appears still Clinical Trial. Acad Emerg Med, Vol. 9, No. 6, pp 650-653.
rolling toward the sick ear, which is now the higher one. 20. Claes, J and Van De Heyning, PH. Medical Treatment of
It must not be an inverted nystagmus. The nystagmus is Meniere's Disease: A Review of Literature. 1997. Acta
slightly different: wide amplitude, slower frequency, not Otolaryngol (Stockh) Suppl 526:37-42.
21. Mira, Eugenio, et al. September 2002. Betahistine dihydrochlo-
so paroxysmal as the original one." ride in the treatment of peripheral vestibular vertigo. Eur Arch
Otorhinolaryngol 260: 73-77.
"If nothing happens, the head is slowly turned nearly 90 22. Deering, RB et al. A double -blind crossover study comparing
betahistine dihydrochloride and cinnarizine in the treatment
degrees facing up and then quickly turned to 45 degrees of recurrent vertigo in patients in general practice. 1986, June
facing down. Then the nystagmus occurs. The patient 11. Curr. Med. Res. Opin. 10: 209-14.
must stay in this last position for at least 5 minutes and 23. Albera, Roberto, et al. December 2002. Double -blind, Rand-
omized, Multicenter Study Comparing the Effect of Betahistine
is brought back to orthostatism very, very slowly." dihydrochloride and Flunarizine on the The Dizziness Handi-
cap Inventory Scores in Patients with Recurrent Vestibular
"The patient is then asked to keep his head absolutely Vertigo. Acta Otolaryngol 2003; 00:1-6.
vertical in space during at least 48 hours day and night. 24. Colletti, V. Medical Treatment in Meniere's Disease: Avoid-
ing Vestibular Neurectomy and Facilitating Postoperative
He is asked to avoid fast head movements upward or Compensation. Acta Otolaryngol 2000; Suppl 544:27-33.
downward and not to sleep on the vertigo-generating 25. Van Deelen, GW and Huizing, EH. Use of Diuretic (Dyazide)
side for a week. If the maneuver is not successful, it is in the Treatment of Meniere's Disease. A Double Blind Cross-
over Placebo-controlled Study. ORL J Otorhinolaryngol Relat
performed again a week later." Spec. 1986 48(5): 287-92.
26. Pianese, CP, et al. New Approaches to the Management of
Excerpted from the article “Curing the BPPV with a Liberatory Maneu- Peripheral Vertigo: Efficacy and Safety of Two Calcium An-
ver” by A. Semont et al, Adv Oto-Rhino-Laryngl, Vol 42:290-293. tagonists in a 12-week, Multinational, Double-Blind Study.
Otology and Neurotology, Vol 23, No 3, 2002: 357-363.
27. Soto, et al. Benign Paroxysmal vertigo: a comparative pro-
References: spective study of the efficacy of Brandt and Daroff exercises,
1. Otolaryngology, Head and Neck Surgery, 3rd edition, volume Semont and Epley maneuvers. Rev Laryngol Otol Rhinol 2001;
4, 1998, edited by Cummings et al., p. 2681 and p. 2748 122,3:179-183.
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for peripheral system Disorders. Otolaryngol Clin of North 30. Ruckenstein, M. Therapeutic efficacy of the Epley canalith
America 2000, 33:563-577. repositioning maneuver. Laryngoscope 2001 111:940-945.
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293
Vertigo CPM 9TH EDITION
Recommended Therapeutics
(Drugs Mentioned in the Treatment Guideline)
The following index lists therapeutic classifications as recommended by the treatment guideline. For the prescriber's
reference, available drugs are listed under each therapeutic class.
Nifestad
Adrenocorticosteroid hormones Anti-viral Normadil
Methylprednisolone Valacyclovir Nimodipine
Adrena Valtrex Nimotop
Depo-medrol Verapamil
Medrol Calcium antagonists Isoptin/Isoptin SR
Solu-medrol Amlodipine Tarka
Envacar Verelan
Norvasc
Anti-emetic/Anti-vertigo Barnidipine
Betahistine Hypoca Hypnotics/Sedatives
Diazepam
Merislon Benidipine
Valium
Serc Coniel
Cinnarizine Diltiazem
Drugmaker's Biotech Cordazem
Cinnarizine Dilatam
Stugeron/Stugeron forte Diltac
Difenidol Diltelan
Cephadol Dilzem/Dilzem SA/Dilzem SR
Dimenhydrinate Drugmaker's Biotech Diltiazem
Drugmaker's Biotech RiteMED Diltiazem
Dimenhydrinate Tildiem
Meclizine Zandil
Bonamine Felodipine
Postadoxine Dilahex
Metoclopramide Felim
Biclomet Felop ER Tab
Clovomet Logimax
Plasil Plendil ER
Versant XR
Lacidipine
Antihistamines Lacipil
Diphenhydramine Lercanidipine
Allerin AH Zanidip
Allerin reformulated Manidipine
Am-Europharma Caldine
Diphenhydramine HCl Minadil
Benadryl Nicardipine
Dramelin Cardepine
Drugmaker's Biotech Nifedipine
Diphenhydramine Adalat
Hizon Diphenhydramine Calcheck
Injection Calcibloc
Nebrecon Calcibloc OD
Calcigard-5
Denkified
Anti-migraine Drugmaker's Biotech Nifedipine
Flunarizine Heblopin
Sibelium Nelapine
294