Part 2  of the BPPV guidelines by the American Academy of Otolaryngology throw light on the medical therapy, assessment outcomes, evaluation of the therapeutic failure and patient education or counseling.

Part 1 of the BPPV guidelines by the American Academy of Otolaryngology dealt with diagnosis, differential diagnosis, repositioning procedures as the initial therapy.

 The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. 

Medical therapy

Unnecessary use of vestibular suppressive medications should be avoided, to safeguard the patients from potential adverse effects of the medications.

Avoiding these medications can improve the diagnostic sensitivity of tests such as Dix-Hallpike maneuvers. Patients who manifest severe symptoms of BPPV are exceptions.

Vestibular suppressants may have undesirable side-effects and may do more harm than good. The most common side-effects include drowsiness and cognitive deficits, making it difficult for the patients to drive or operate machinery. These medications may also increase the risk of falls, especially in elderly. Recent evidence indicates these medications to be associated with impaired gastrointestinal motility, urinary retention, vision, and dry mouth.

Evaluation of Treatment Outcomes

A) Assessment of the outcomes

The updated guidelines emphasize on reassessing the effectiveness of the therapy. The clinicians must reassess the patient within one month after the observation period or provision of treatment. This helps to determine if the persistent symptoms are resolved or if any further treatment is required.

Assessing the therapeutic outcomes helps in promoting effective prevention or treatment. This approach is beneficial in those patients who continue to have the same symptoms and will remain at risk of falls. Therefore, documenting the outcomes can be useful in elaborating the patient specific treatment needs.

As per the latest studies, CRP stands to be the most effective treatment strategy for BPPV and claims that (79.4% - 92. 7%) are treated with 1 or 2 CRPs. A repeat CPR would be needed in about 12.8% - 15.3% of the patients.

B) Evaluation of the therapeutic failure

The clinician should re-evaluate any imprecise diagnosis, patients with unresolved BPPV symptoms and the underlying comorbidities. This practice helps reduce the risk of secondary complications associated with underlying or unidentified condition. Evaluating the patients, who have failed to respond to the provided treatment, helps the clinicians understand different treatment algorithms specific to the patient.

Patient education or counseling

Patient education should be made an important part of BPPV care plan.

The discussion should focus on the factors that predispose to BPPV, its diagnosis, treatment methods, and the risk factors of recurrence. The patients should be made aware of the affect of BPPV on the quality of life, especially their safety, and their inability to carry out their family and work tasks. Awareness about recurrence may help in timely intervention. Most patients may want to choose medication therapy as an easy way to subside the BPPV symptoms, but they need to explained about the side effects of the medications that can be more harmful than the symptoms itself.