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Philippine Society of Otolaryngology-Head and Neck Surgery,

Inc.-Task Force on Clinical Practice Guidelines


Unit 2512, 25th Floor Medical Plaza, Ortigas Condominium,
San Miguel Avenue, Ortigas Center, Pasig City
Tel # 633 8344 Fax # 633 2783
Website: http://www.psohns.org.ph
Email: pso_hns@yahoo.com

Officers and Board of Directors 2006

President Natividad A. Aguilar, M.D., MSClin. Epi


Vice President Charlotte M. Chiong, M.D.
Secretary Alexander C. Cabungcal, M.D.
Treasurer Antonio H. Chua, M.D.
Auditor William L. Lim, M.D.

Board of Trustees Eutrapio S. Guevara Jr., M.D.


Jacob S. Matubis, M.D.
Alfredo Q.Y. Pontejos Jr., M.D.
Gil M. Vicente, M.D.
Francisco A. Victoria, M.D.
Romeo L. Villarta Jr., M.D., MPH

Immediate Past President Felix P. Nolasco, M.D.

President, PBO-HNS Abelardo B. Perez, M.D., MBA

Adviser Cesar V. Villafuerte Jr., M.D., MHA

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

Consensus Report on Vertigo

Co-Chairs Ruzanne Magiba-Caro, M.D.


Charlotte M. Chiong, M.D.
Edilberto M. Jose, M.D.

CPG Working Group Abner L. Chan, M.D.


Teresa Luisa I. Gloria-Cruz, M.D.
Maria Rina T. Reyes-Quintos, M.D.
Nathaniel W. Yang, M.D.
Erasmo Gonzalo DV Llanes, M.D.
Christopher E. Calaquian, M.D.
Herbert Q. Gutierrez, M.D.
Desiree B. Vanguardia, M.D.
Florence Yul N. Saquian, M.D.

Panelists Marida Arend V. Arugay, M.D.


Raymond G. Belmonte, M.D.
Wilfredo E. Dela Cruz, M.D.
Bernardo D. Dimacali, M.D.
Howard M. Enriquez, M.D.
Ronald V. Javier, M.D.
Teodoro P. Llamanzares, M.D.
Norberto V. Martinez, M.D.
Abelardo B. Perez, M.D.
Edgardo C. Rodriguez, M.D.
Jose Antonio M. Santos, M.D.
Antonio G. Talapian, M.D.

Secretarial Staff Sharon T. Barraquiel


Melissa C. Baniqued

280
CPM 9 TH
EDITION Vertigo

The recommendations presented in this report are


intended as a guide for ENT practitioners in the diag-
nosis and management of peripheral vertigo in adults.
Under no circumstances should the recommendations
be regarded as absolute rules since differences in the
specific approach may exist in individual cases and/or
particular clinical settings. Above all, these recom-
mendations should supplement and not replace good
clinical judgment.

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.

Ruzanne Magiba-Caro, M.D.


Charlotte M. Chiong, M.D.
Edilberto M. Jose, M.D
281
Vertigo CPM 9TH EDITION

Algorithm for the Treatment of Meniere's Disease

Meniere's
Disease

2
3

Symptomatic Y Give Vestibular Sup-


treatment?  pressants

N
4

Institute
preventive
measures

5

TREATMENT OPTIONS: (Give for 2-3 months)


1. Betahistine dihydrochloride
2. Diuretics
3. Calcium antagonists
4. Lifestyle modifications (i.e. salt restriction)

6

Positive Y Discontinue
Response?  and observe

N
8

Refer

282
CPM 9 TH
EDITION Vertigo

Algorithm for the Treatment of Benign Paroxysmal


Positional Vertigo

BPPV

2  3

With spinal Y Vestibular


or orthopedic  Habituation
problems?

4

Do Epley's or
Semont's maneuver
(Weekly intervals,
maximum of 4
maneuvers per side)

5

Positive Y End of treat-


Response?  ment and
follow-up

7

Refer

283
Vertigo CPM 9TH EDITION

Algorithm for the Treatment of Vestibular Neuronitis/Viral


Labyrinthitis

Vestibular
Neuronitis/Viral
Labyrinthitis

2 3

Give Vestibular Sup- Steroids


+/-

pressants
Antiviral Agent

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

Clinical Practice Guidelines for Peripheral Vertigo in


Scope of the Practice Guideline were 528 new consults for dizziness and vertigo (preva-
lence of 2.5%). In the Department of Neuro­sciences, out
This clinical practice guideline is for use by general of 4547 patients, there were 42 consults for vertigo and
otorhinolaryngologists and resident trainees in dizziness (18 new, 24 referrals) in 2001, and 39 (7 new,
otorhinolaryngology. It covers the diagnosis and 32 referrals) in 2002. In the outpatient department of
management of peripheral vertigo in adults (19 years the University of Sto. Tomas Hospital, there were 688
old and above) in an ambulatory care setting. patient visits for dizziness from 1999-2002.

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

STatements of evidence Grades of recommendations


Ia Obtained from meta-analysis of randomized con-
trolled trials Requires at least one randomized controlled
A trial as part of a body of literature of overall good
Ib Obtained from at least one randomized controlled quality and consistency addressing the specific
trial recommendation

IIa Obtained from at least one well-designed controlled


study without randomization Requires the availability of well conducted
B clinical trials but no randomized clinical trials on
IIb Obtained from at least one other type of well-de- the topic of recommendation
signed quasi-experimental study

III Obtained from well-designed non-experimental


descriptive studies, such as comparative studies,
correlation studies and case studies
C Requires evidence obtained from expert commit­tee
IV Obtained from expert committee reports or opinions reports or opinions and/or clinical expe­­riences of
and/or clinical experience of respected authorities respected authorities. Indicates an ab­sence of di-
rectly applicable clinical studies of good quality

285
Vertigo CPM 9TH EDITION

RECOMMENDATIONS ON THE DIAGNOSIS least, observation for spontaneous nystag­mus


OF VERTIGO should be included and the Dix-Hallpike
maneuver should be performed)
1. A carefully obtained medical history is the most 3.4 neurological testing (with emphasis on the
important part in the evaluation of a patient with cranial nerves and vestibulospinal tests e.g.
vertigo. The history alone may be very suggest­ Romberg's test.)
ive of a diagnosis. It guides the examination and
work-up. Grade C Recommendation

Grade C Recommendation The Romberg's test detects impaired pro­prio­ception


by demonstrating loss of postural control in dark-
The history should include the following: ness. It is present when a patient is able to stand
1.1 chief complaint with feet together and eyes open, but sways or falls
1.2 history of the present illness (recent history with eyes closed. The anatomic basis of the sign
of viral infections, colds, co-morbid symp­ as an indication of proprioceptive sensory deficits
toms) solidified, so that patients with cerebellar, vestibu-
1.3 past medical history (previous head trauma, lar, pyramidal, and muscle diseases were generally
medications, medical and surgical illness- excluded by a positive Romberg's sign.
es)
1.4 pertinent family, personal and social his- 4. Pure tone audiometry and speech testing must
tory be performed.
1.5 brief review of systems
Grade C Recommendation
To guide the examination and work-up, it is pro-
posed that a simple dizziness questionnaire vali- Conventional pure tone and speech audiometry re-
dated in the local dialect should be filled up by the mains to be the most useful and cost effective screen­
patient. Based on the prospective blinded study by ing tool in defining patients who should undergo
Kentala, questionnaire can correctly classify 60% further testing with an auditory brainstem response
of patients with otogenic causes of vertigo. testing and/or an imaging study. The PTA-ST helps
identify the population of patients with vertigo who
2. The chief complaint of vertigo should be evalu- are at risk of having an acoustic neuroma.
ated and described thoroughly.
The panel is cognizant of the fact that speech testing
Grade C Recommendation may be difficult in some situations e.g. language
barriers, and in these cases a pure tone audiometry
The vertigo episode must be described as to the may suffice.
following:
2.1 what the patient actually felt in his own 5. Abnormal PTA-ST results that would warrant
words further diagnostic testing (e.g. ABR or MRI) are
2.2 mode of onset the following:
2.3 frequency, severity, intensity and duration
of individual and succeeding episodes (di-
a) more than 15 dB difference in 2 kHz alone or
minishing or increasing) and in compa­rison
in the threshold average (1,2,4, & 8 kHz),
with the initial episode
b) more than or equal to 15% SDS difference.
2.4 triggering and alleviating factors
2.5 associated auditory symptoms (hearing loss,
Grade B Recommendation
tinnitus or ear fullness)
2.6 effects of medication
Allowing for inter-test variability that can range
from 5 to 10 dB, the consensus panel decided on
3. The physical examination should include the
the >15dB difference as a prudent threshold.
following:

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

Common Causes of Vertigo


Disease Entities History Physical Examination Diagnostics
Benign • Sudden attacks of vertigo • (+)Dix-Hallpike with the following • PTA-ST: normal
Paroxysmal • Precipitated by certain characteristics (preferably done • Calorics: normal
Positional head positions without fixation)
Vertigo (BPPV) • Short attacks of vertigo • latency (10-15 s)
(sec-min) • geotropic
• brief (~30s)
• symptomatic
• fatigable
• reverses on sitting position
Meniere's • Characteristic Triad • May be normal • PTA-ST: low frequency sensori-
Disease • Hearing loss neural hearing loss
• Tinnitus The average of hearing thresh-
• Recurrent, spontaneous, olds at 0.25, 0.5 and 1.0 kHz is
episodic vertigo (~30 min- 15dB or more higher than the
287
Vertigo CPM 9TH EDITION

to less than 24 hours) average of 1, 2 and 3 kHz;


In unilateral cases, the average
of threshold values at 0.5, 1, 2,
and 3 kHz is 20 dB or poorer in
the ear in question than on the
opposite side;
In bilateral cases, the average of
threshold values at 0.5, 1, 2,
and 3 kHz is greater than 25 dB
in the studied ear;
• High SISI score
• No tone decay
Vestibular • May have non-specific • (+) spontaneous nystagmus to • PTA-ST: normal
Neuronitis/ viral illness prior to the contralateral ear • Calorics: reduced or absent
Viral onset of vertigo caloric response in one ear
Labyrinthitis • Sudden onset of severe
vertigo with unsteadiness,
nausea or vomiting
• Persistent vertigo
(days-weeks)
• (-) auditory deficits
• (-) other neurologic
symptoms
Acoustic • Non-specific • May have cranial nerve deficits • PTA-ST:
Neuroma • Patient may complain more (e.g. CN V - ↓corneal reflex) • > 15dB difference in 2 kHz
of unsteadiness rather than alone or in the threshold
vertigo average of 1, 2, 4 & 8 kHz
• May have unilateral tinni- • 15% SDS difference
tus or hearing loss • ABR
• AbN interaural wave V latency
difference > 0.2 ms
• Prolonged wave V latency
• Absence of later waves (III,IV,
V)
• MRI w/gadolinium
• (+) intracanalicular mass
Cervicogenic • One of these symptoms • On PE, one of these symptoms • PTA-ST: mostly normal
Vertigo appear when head/neck maybe elicited on cervical ROMs: • Calorics: mostly normal
positions assumes a certain • Headache • Neck AP-L: may show cervical
position/change of position: • Vertigo spondylosis or degenerative
• Headache • Syncope changes
• Vertigo • Tinnitus
• Syncope • Loss of hearing
• Tinnitus • Nausea & vomiting
• Loss of hearing • Visual symptoms e.g. flashing
• Nausea & vomiting lights
• Visual symptoms e.g. • Supraclavicular bruit
flashing lights

of acoustic neuroma, a neurotologic consult is Grade B Recommendation


recommended
Intramuscular Droperidol or Dimenhydrinate are both
Grade C recommendation. effective in reducing the acute symptoms of peripheral
vertigo.

The panel, however, is cognizant that Droperidol is not


recommendations on the treatment
available locally.
of specific causes of vertigo
Diazepam is widely used as a vestibular suppressant
Treatment Recommendations for Meniere's Dis-
ease because of its additional tranquilizing effect.
Dimenhydrinate, meclizine and diphenhydramine
1. For acute attacks of vertigo associated with
have been studied in double - blind trials in humans
Meniere's disease, vestibular suppressants may
and have been found to be more effective compared
be given.
with placebo.
288
CPM 9 TH
EDITION Vertigo
Anti-vertiginous medications, anti-emetics, sedatives, tinnitus.
antidepressants, and psychiatric management have
been reported to be beneficial in reducing the severity The panel, however, is aware that the above drug
of vertigo and vegetative symptoms and in improving preparation is not available locally.
tolerance of Meniere's symptoms.
2.3 Calcium antagonists, e.g. nimodipine and
2. Because of the episodic nature of Meniere's dis- cinnarizine, may also be helpful.
ease, a trial of treatment to prevent the attacks
should be instituted for 2-3 months. Grade B Recommendation

2.1 Betahistine dihydrochloride, at 16 mg tablet In a comparative double blind study involving
BID for 2-3 months, is recommended. 181 subjects, two calcium antagonists, namely
nimodipine and cinnarizine, were found to be
Grade A Recommendation equally effective in the symptomatic treatment
of vestibular vertigo. The dosages were at 30
Betahistine dihydrochloride significantly mg nimodipine tablet taken TID and 150 mg
reduced the number of vertigo attacks, their cinnarizine tablet taken OD for 12 weeks. Both
intensity score and duration both in Meniere's had similar safety profiles.
and PPV. Dosage was at 16 mg twice per day
for 3 months. 2.4 Non-pharmacologic treatment options in-
clude lifestyle modifications, i.e. salt restric-
In a double-blind crossover study in 88 patients, tion.
both betahistine and cinnarizine were shown to
Grade C Recommendation
be equally effective in reducing the duration and

severity of symptoms of peripheral vertigo of
Salt restriction and diuresis are believed by
unknown origin. Significantly fewer attacks of
many to be the best medical therapy for those
vertigo, however, occurred during betahistine
with Meniere's disease. The goal is to reduce
therapy. Side effects (e.g. drow­si­ness or leth-
endolymph volume by fluid removal or reduced
argy) were most common in cinnarizine.
production.
In a double-blind, randomized, multicenter
2.5 The panel is cognizant of other treatments
study comparing betahistine dihydrochloride
reported for Meniere's disease, including
(16 mg tab TID) and flunarizine (10 mg tab OD) hyperbaric oxygen therapy, pressure therapy
on patients with recurrent vestibular vertigo, (Meniett device). It is recommen­ded that
betahistine was found to be signi­ficantly more these be considered only within the limits of
effective than flunarizine. Meniere's disease a well-controlled clinical trial.
was diagnosed in 38/69 cases (55%). Both
treatments were administered for 8 weeks. Grade C Recommendation

In a randomized controlled trial comparing Treatment Recommendations for Benign Paroxys­mal


betahistine dihydrochloride (16 mg tablet TID) Positional Vertigo
and acetazolamide (125 mg tablet OD) on 95
patients with Meniere's disease, betahistine was 1. Epley's or Semont's maneuver done at weekly
significantly more effective than acetazolamide intervals, maximum of 4 maneuvers per side, is
in reducing the severity and frequency of vertigo recommended.
spells. Treatment duration was 6 months.
Grade A Recommendation
2.2 The use of diuretics (with potassium monito­
ring) in Meniere's disease is likewise recom­ In the randomized controlled trial by Soto et al., a total
mended. of 106 BPPV patients were randomly assigned to three
Grade A Recommendation treatment groups: Brandt and Daroff habituation exer-
cises, Semont maneuver, and Epley maneuver. Their
In a cross-over placebo - controlled study of 33 results indicate that: 1) the Epley and Semont maneuver
patients with Meniere's disease, dyazide (50 mg are more effective than Brandt and Daroff habituation
triamterene and 25 mg hydrochloro­thiazide) was exercises, 2) the initial response to the Epley maneuver
found to decrease significantly the vestibular was similar to the Semont maneuver, and 3) after 3
complaints, but had no effect on hearing and
289
Vertigo CPM 9TH EDITION

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

Figure 1. Dix-Hallpike Maneuver

Lifted from “Emergency Medicine at NCEMI: Emergency Medicine and Primary Care Resources”.

291
Vertigo CPM 9TH EDITION

Figure 2. Epley’s Maneuver

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.
2. Department of Otorhinolaryngology OPD-PGH Census 2002 28. Cohen, HS et al. Efficacy of treatments for posterior canal
3. Department of Family Medicine OPD-PGH Census 2002 benign paroxysmal positional vertigo. The Laryngoscope 109:
4. Department of Neurosciences OPD-PGH Census 2002 April 1999: 584-590.
5. Outpatient Department Census Santo Tomas University Hos- 29. Resser, Haynes D., et al. The treatment of benign positional
pital 2002 vertigo using the Semont maneuver: Efficacy in patients pre-
6. El-Kashlan & Telian, S. Diagnosis and initiating treatment senting without nystagmus. Laryngoscope 2002 112:796-801
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.
7. Davidson, TM. Ambulatory healthcare pathways for ear, nose, 31. Levrat, E., et al. June 2003. Efficacy of the Sermont Maneuver
and throat disorders. in Benign Paroxysmal Positional Vertigo. Arch Otolaryngol
8. Kentala, E & Rauch, S. A practical assessment algorithm for Head Neck Surg, vol 129, pp. 629-633.
diagnosis of dizziness. Otolaryngol Head Neck Surg 2003, 32. Corvera, et al. Objective Evaluation of the Effect of Flunarizine
128:54-59. on Vestibular Neuritis. Otology & Neurotology 2002, 23:933-
9. Lanska, DJ and Goetz, CG. Romberg's sign: Development, 937.
adoption and adaptation in the 19th century. Neurology 2000; 33. Strupp, et al. 1998. Vestibular exercises improve central vesti-
55:1201-1206. bulospinal compensation after vestibular neuritis. Neurology
10. Jackler, R. K. and Brackmann, DE. Neurotology. Mosby Year 51:838-844.
Books Publisher, 1994. 34. Strupp, et al. Exercise and Drug Therapy Alter Recovery from
11. Mangham, C. Hearing threshold differences between ears and Labyrinth Lesion in Humans. Annals New York Academy of
risk of acoustic neuroma. Otolaryngol Head Neck Surg 1991, Sciences .
105:814.
12. Lee, KJ. Essential Otolaryngology. Appleton and Lange,
1999.
13. Schmidt, R., et al. The sensitivity of ABR testing for the diag-
nosis of acoustic neuromas. Arch Otolaryngol Head Neck Surg
2001, 127: 19-22.
14. Kanzaki J., et al. Audiological findings in acoustic neuroma.
Acta Otolaryngol Suppl 1991, 487:125-132.
15. Selters, WA & Brackmann, DE. Acoustic tumor detection with
brainstem electric response audiometry. Arch Otolaryngol
1977, 103:181-87.
16. Filipino R., Barbara M. Natural History of Meniere's Disease:
Staging the patients or their symptoms? Acta Otolaryngol 1997;
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

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