The Audiology Department offers management for BPPV when symptoms have persisted for at least 6 weeks, despite first line approaches in General Practice. The ENT department runs balance clinics for more complex disorders.
BPPV
This short-lived (paroxysmal) sensation of movement (vertigo) is often related to changes in head position, usually lasting less than 30 seconds, but may feel longer to the patient. It can follow minor head injury but is often spontaneous, prevalence increasing with age. It is most commonly caused by otolithic crystals becoming dislodged and moving around the posterior semi-circular canal of the labyrinth. BPPV is frequently found alongside other causes of balance disturbance and is often overlooked.
It can settle without treatment but responds readily to particle repositioning manoeuvres (Epley manoeuvre). Please see Primary Care Management for further detail. Avoidance of significant Vitamin D deficiency may have a role in helping prevent episodes (NHS Lothian policy is not to test for this indication: information on Vitamin D for patients is available Vitamin D and you.pdf).
Most BPPV will settle spontaneously – around 70% over three months – but during that time symptoms can be intrusive and incapacitating. Primary Care management should therefore be optimised to help rapid resolution, and patients can be referred after 6 weeks if symptoms persist.
Where primary care treatment has been unsuccessful, patients can be referred directly to Audiology when balance issues are thought to be purely due to BPPV. The diagnosis should ideally be confirmed by a Hallpike test, which helps ensure patients are being appropriately referred to a non-medical specialty. Patients with additional symptoms (e.g. pain, alteration in hearing with vertigo, discharge) should be referred to ENT where they will be triaged into Otology or Balance clinics as appropriate.
Who to refer:
GPs and AHPs can refer patients with BPPV who have failed to respond to initial Primary Care Management. Ideally this should include a trial of Hallpike testing and Epley manoeuvre, the only options for rapid symptom resolution with lengthening Audiology waiting times. Many with mild symptoms will respond to reassurance, medication and Brandt-Daroff exercises. Brandt-Daroff exercises are not suitable for those with severe symptoms.
Who not to refer:
- Patients with the following red flags should be referred directly to ENT:
- Recurrent infections
- Active perforations/mastoid cavities/discharge/abnormal appearance of ear drum
- Polyps, possible foreign bodies
- Persistent ear pain
- Pulsatile tinnitus
- Sudden hearing loss or sudden deterioration
- Abnormal auditory perceptions (dysacuses)
- Vertigo/unsteadiness not consistent with BPPV
- Conductive hearing loss
- Patients where Primary Care Management has not been optimised.
- Symptom onset of <6 weeks
How to refer:
SCI Gateway to Audiology at Lauriston or St Johns (but NOT East Lothian Community Hospital)
For patients with complicating factors (see above) – please refer to ENT.
History:
BPPV history is classically short-lived vertigo (<1 minute), which can be severe, and is triggered by changing head position. Classic examples include turning over in bed, lying down / sitting up, looking up or bending down. After an acute episode, patients can feel disorientated for a period of time, describing balance disturbance of longer duration, but the actual vertigo is short lived. Some patients will also describe days of vertigo but closer questioning reveals multiple short-lived episodes of vertigo, with a general feeling of balance disturbance between times.
Testing and management:
For recent onset BPPV, the diagnosis may be clear from the history, particularly once other ENT and neurological complications are excluded.
The ideal is to undertake a Hallpike test looking for torsional nystagmus (the eyeball twisting). Where seen, this confirms objective nystagmus as opposed to patients reporting symptoms of vertigo (not lightheadedness) who are described as having subjective nystagmus. In more frail patients, or if both sides of the examination couch are not accessible, the Sidelying test is an alternative.
In the event of a positive Hallpike or Sidelying test an Epley manoeuvre should ideally be performed, and this readily follows on from the Hallpike, which positions the patient appropriately.
Please see the patient information leaflet on BPPV.
If any training is required beyond the instructional videos, please contact the Audiology department who are happy to arrange this (groups or individuals).
