Clinical Practice Guidelines for

Peripheral Vertigo
in Adults
(2003)

Philippine Society of Otolaryngology

- Head and Neck Surgery, Inc.
 Vertigo
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 2008

President Gil M. Vicente, M.D.

Vice President Josefino G. Hernandez, M.D.
Secretary Teresa Paz G. Pascual, M.D.
Treasurer Antonio H. Chua, M.D.
Auditor William L. Lim, M.D.

Board of Trustees Alexander C. Cabungcal, M.D.

Benjamin S.A. Campomanes, Jr., M.D.
Charlotte M. Chiong, M.D.
Rodolfo B. Dela Cruz, M.D.
Jesus M. Jardin, M.D.
Jacob S. Matubis, M.D.

Immediate Past President Eutrapio S. Guevara, Jr., M.D.

President, PBO-HNS Remigio I. Jarin, M.D.

Chapter Presidents

Northern Luzon Mario Gerardo R. Tolentino, M.D.

Southern Tagalog Danilo A. Poblete, M.D.
Bicol Philip Dionisio M. Roa, M.D.
Central Eastern Visayas Eduardo R. Arcenas, M.D.
Western Visayas Teodoro L. Jardeleza, M.D.
Southeast Mindanao Gil A. Yarra, M.D.
Northwest Mindanao Jesus M. Jardin, M.D.

233
Vertigo
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
*Ear Study Group,
The Philippine National Ear Institute

234
 Vertigo

The recommendations presented in this report

are intended as a guide for ENT practitioners
in the diagnosis and management of periph­
eral 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
recommendations 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, otolo-
gists 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 knowl-
edge.

Ruzanne Magiba-Caro, M.D.

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

235
Vertigo
Algorithm for the Treatment of Meniere's Disease

Meniere's
Disease


2


Y
Symptomatic Give vestibular
treatment?
 suppressants

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


Y
Positive  Discontinue and
response? observe

N
8


Refer

236
 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


Y
Positive End of treatment
response?  and follow-up

7


Refer

237
Vertigo
Algorithm for the Treatment of Vestibular Neuronitis/Viral Labyrinthitis

Vestibular
Neuronitis/Viral
Labyrinthitis

2 3


Give vestibular  Steroids

suppressants +/-
Antiviral Agent

4


Y
Positive Vestibular
response?  rehabilitation

N
6 7



Refer Y
Positive
 Continue
response?

N
9


Refer

238

Clinical Practice Guidelines for
Peripheral Vertigo in Adults
Scope of the Practice Guideline
This clinical practice guideline is for use by general
otorhinolaryngologists and resident trainees in otorhi-
nolaryngology. It covers the diagnosis and management
of peripheral vertigo in adults (19 years old and above)
in an ambulatory care setting.
Objectives
The objectives of the guideline are (1) to assist general
ENT practitioners to determine true peripheral vertigo in
adults; (2) to evaluate current diagnostic techniques; and
(3) to describe treatment options.
Definition
Vertigo is defined as an illusion of movement of self
or of the environment. Peripheral vertigo is defined as
vertigo arising from disorders of the 8th cranial nerve
and inner ear.
Prevalence
According to the United States National Institutes of
Health (NIH) national report, 40% of all Americans seek
consult for dizziness at one point in time. How­ever, the
real prevalence of vertigo is yet undetermined.
At the Philippine General Hospital Department of Otorhi-
nolaryngology, there were 103 cases of vertigo 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 were
528 new consults for dizziness and vertigo (prevalence
of 2.5%). In the Department of Neuro­sciences, out of
4547 patients, there were 42 consults for vertigo and
dizziness (18 new, 24 referrals) in 2001, and 39 (7 new,
32 referrals) in 2002. In the outpatient department of
the University of Sto. Tomas Hospital, there were 688
patient visits for dizziness from 1999-2002.
STatements of evidence Grades of recommendations
Ia Obtained from meta-analysis of randomized
controlled trials
Ib Obtained from at least one randomized controlled
trial
IIa Obtained from at least one well-designed control-
led study without randomization
Iib Obtained from at least one other type of well-
designed quasi-experimental study
III Obtained from well-designed non-experimen-
tal descriptive studies, such as comparative
studies, correlation studies and case studies
IV Obtained from expert committee reports or
opinions and/or clinical experience of respected
authorities
Vertigo
Literature Search
The National Library of Medicine's PubMed database
was searched for literature using the keyword vertigo.
The search was limited to articles involving humans and
those published in English in the last fifteen years, WHO
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 the
guideline. One hundred ninety three (193) abstracts were
chosen and results were further assessed for relevance.
Full text articles were obtained when possible. The cho-
sen articles were divided as follows:
Randomized Controlled Trials 11
Non-Randomized Controlled Study 5
Case Series 3
Descriptive Study 3
Review of Literature 1
Committee Report 1
All literature were classified according to levels of
evidence and grades of recommendations based on
guidelines from the US Agency for Health Care Policy
and Research and were set out as follows:
RECOMMENDATIONS ON THE DIAGNOSIS OF
VERTIGO
1. A carefully obtained medical history is the most
important part in the evaluation of a patient with
vertigo. The history alone may be very suggest­
ive of a diagnosis. It guides the examination and
work-up.
Grade C Recommendation
The history should include the following:
1.1 chief complaint
1.2 history of the present illness (recent history of
viral infections, colds, co-morbid symp­toms)
1.3 past medical history (previous head trauma,
medications, medical and surgical illnesses)
1.4 pertinent family, personal and social history
1.5 brief review of systems
Requires at least one randomized controlled
A trial as part of a body of literature of overall good
quality and consistency addressing the specific
recommendation
Requires the availability of well conducted
B clinical trials but no randomized clinical trials on
the topic of recommendation
C Requires evidence obtained from expert commit­
tee reports or opinions and/or clinical expe­­riences
of respected authorities. Indicates an ab­sence of
directly applicable clinical studies of good quality
239
Vertigo
To guide the examination and work-up, it is proposed
that a simple dizziness questionnaire validated in
the local dialect should be filled up by the patient.
Based on the prospective blinded study by Kentala,
questionnaire can correctly classify 60% of patients
with otogenic causes of vertigo.
2. The chief complaint of vertigo should be evalu­
ated and described thoroughly.
Grade C Recommendation
The vertigo episode must be described as to the fol-
lowing:
2.1 what the patient actually felt in his own words
2.2 mode of onset
2.3 frequency, severity, intensity and duration of
individual and succeeding episodes (diminishing
or increasing) and in compa­rison with the initial
episode
2.4 triggering and alleviating factors
2.5 associated auditory symptoms (hearing loss,
tinnitus or ear fullness)
2.6 effects of medication
3. The physical examination should include the­
­following:
3.1 vital signs - blood pressure (lying, sitting
and standing position to rule out orthostatic
hypotension), heart rate, respiratory rate
3.2 ORL examination (otoscopy, fistula test and
tuning fork tests)
3.3 evaluation of the vestibular system (at the
least, observation for spontaneous nystag­
mus should be included and the Dix-Hallpike
maneuver should be performed)
3.4 neurological testing (with emphasis on the
cranial nerves and vestibulospinal tests e.g.
Romberg's test.)
Grade C Recommendation
The Romberg's test detects impaired pro­prio­ception
by demonstrating loss of postural control in darkness.
It is present when a patient is able to stand with feet
together and eyes open, but sways or falls with eyes
closed. The anatomic basis of the sign as an indica-
tion of proprioceptive sensory deficits solidified, so
that patients with cerebellar, vestibular, pyramidal,
and muscle diseases were generally excluded by a
positive Romberg's sign.
4. Pure tone audiometry and speech testing must
be performed.
Grade C Recommendation
Conventional pure tone and speech audiometry re-
mains to be the most useful and cost effective screen­
ing tool in defining patients who should undergo
further testing with an auditory brainstem response
testing and/or an imaging study. The PTA-ST helps
identify the population of patients with vertigo who
are at risk of having an acoustic neuroma.
The panel is cognizant of the fact that speech test-
ing may be difficult in some situations e.g. language
240
barriers, and in these cases a pure tone audiometry
may suffice.
5. Abnormal PTA-ST results that would warrant
further diagnostic testing (e.g. ABR or MRI) are
the following:
a) more than 15 dB difference in 2 kHz alone or
in the threshold average (1,2,4, & 8 kHz),
b) more than or equal to 15% SDS difference.
Grade B Recommendation
Allowing for inter-test variability that can range from
5 to 10 dB, the consensus panel decided on the >15
dB difference as a prudent threshold.
In a study by Mangham et.al, it was observed that
the most effective threshold difference, (in terms of
cost-effectiveness and in reducing the false negatives
and positives), that can be used for referring patients
for ABR testing is 5 to 20 dB. In the same study, the
authors recommended that a more than 20 dB dif-
ference warranted further evaluation with magnetic
resonance imaging.
5.1 For PTA-ST results that are highly sugges­tive
of an acoustic neuroma, the clinician may opt
to have an immediate imaging study. How­
ever, if the clinical findings and PTA-ST result
remain equi­vocal, an ABR may be requested.
Grade C Recommendation.
Abnormal PTA-ST results that are highly suggestive
of acoustic neuroma include (1) more than 20 dB dif-
ference in 2 kHz alone or in the threshold average (1,
2, 4, 8 kHz) and (2) more than 15% SDS difference.
Signs and symptoms that may point to an acoustic
schwannoma are (1) unsteadiness more than vertigo;
(2) unilateral tinnitus or progressive hearing loss; (3)
associated cranial nerve abnormalities - trigeminal
nerve abnormality (specifically decreased corneal
reflex) and facial nerve palsies.
Overall sensitivity of ABRs in diagnosing acoustic
neuromas is 90%. However, only 58% of tumors 1
cm or smaller in greatest diameter were detected by
ABR. Thus, the clinician should be aware of the ABR's
limitation in diagnosing smaller tumors.
To this date, magnetic resonance imaging with gado-
linium remains to be the gold standard in diagnosing
acoustic neuroma.
5.2 Auditory brainstem response findings that
are suggestive of acoustic neuroma include
at least one or more of the following:
5.2.1 abnormal interaural wave V latency
diffe­rence >0.2 ms
5.2.2 abnormally prolonged wave V
5.2.3 I-V interpeak interval interaural differ­
ence > 0.2 ms
5.2.4 presence of wave I and absence of later
waves (III, IV, V)
5.2.5 absent wave response in the involved ear.

Grade B Recommendation
Kanzaki et al compared various ABR para­meters
in 2 groups of patients, those with acoustic neu-
romas, and those without acoustic neuromas but
with sensorineural hearing loss. The value of
each parameter was adjusted so that the false
positive rate would be less than 20%, whereas
the false negative rate would be less than 10%.
They found out that a prolonged interaural wave
V latency difference is the most useful param-
eter. This was also validated by a separate study
by Selters et. al.
5.3 Abnormal pure tone audiometry result
suggestive of Meniere's disease is a low
frequency sensorineural hearing loss.
Grade B Recommendation
In Stage I of Meniere's disease, when the first ver-
tiginous episodes occur, it is the presence of a low-
tone hearing loss that indicates the onset of the
disease and the beginning of the disabling state.
In a prospective cohort study by Mateijsen et.
al, they found out that affected ears significantly
show low frequency hearing losses. The hearing
loss, however, does not correlate with the dura-
tion of the disease.
6. The history, physical examination and diagnostic
tests should be correlated to arrive at a logical­
­diagnosis.
Grade C recommendation
The table below provides a simple tabulation of the
history, PE and diagnostic tests results of the most
common peripheral causes of vertigo that can help
the clinician have a quick working impression.
7. In case of doubtful diagnosis or high suspicion
of acoustic neuroma, a neurotologic consult is
recommended
Grade C recommendation.
recommendations on the treatment of
specific causes of vertigo
Treatment Recommendations for Meniere's ­Disease
1. For acute attacks of vertigo associated with
Meniere's disease, vestibular suppressants may
be given.
Grade B Recommendation
Intramuscular droperidol or dimenhydrinate are both
effective in reducing the acute symptoms of peripheral
vertigo.
The panel, however, is cognizant that droperidol is
not available locally.
Diazepam is widely used as a vestibular suppres-
sant because of its additional tranquilizing effect.
Vertigo
Dimenhydrinate, meclizine and diphenhydramine
have been studied in double - blind trials in humans
and have been found to be more effective compared
with placebo.
Anti-vertiginous medications, anti-emetics, sedatives,
antidepressants, and psychiatric management have
been reported to be beneficial in reducing the severity
of vertigo and vegetative symptoms and in improving
tolerance of Meniere's symptoms.
2. Because of the episodic nature of Meniere's
­disease, a trial of treatment to prevent the attacks
should be instituted for 2-3 months.
2.1 Betahistine dihydrochloride, at 16 mg tablet
BID for 2-3 months, is recommended.
Grade A Recommendation
Betahistine dihydrochloride significantly reduced
the number of vertigo attacks, their intensity
score and duration both in Meniere's and PPV.
Dosage was at 16 mg twice per day for 3 months.
In a double-blind crossover study in 88 patients,
both betahistine and cinnarizine were shown
to be equally effective in reducing the duration
and severity of symptoms of peripheral vertigo
of unknown origin. Significantly fewer attacks
of vertigo, however, occurred during betahis-
tine therapy. Side effects (e.g. drow­si­ness or
lethargy) were most common in cinnarizine.
In a double-blind, randomized, multicenter
study comparing betahistine dihydrochloride
(16 mg tab TID) and flunarizine (10 mg tab OD)
on patients with recurrent vestibular vertigo,
betahistine was found to be signi­ficantly more
effective than flunarizine. Meniere's disease
was diagnosed in 38/69 cases (55%). Both
treatments were administered for 8 weeks.
In a randomized controlled trial comparing be-
tahistine dihydrochloride (16 mg tablet TID) and
acetazolamide (125 mg tablet OD) on 95 pa-
tients with Meniere's disease, betahistine was
significantly more effective than acetazolamide
in reducing the severity and frequency of vertigo
spells. Treatment duration was 6 months.
2.2 The use of diuretics (with potassium monito­
ring) in Meniere's disease is likewise recom­
mended.
Grade A Recommendation
In a cross-over placebo - controlled study of 33
patients with Meniere's disease, dyazide (50 mg
triamterene and 25 mg hydrochloro­thiazide) was
found to decrease significantly the vestibular com-
plaints, but had no effect on hearing and tinnitus.
The panel, however, is aware that the above
drug preparation is not available locally.
2.3 Calcium antagonists, e.g. nimodipine and
cinnarizine, may also be helpful.
241
Vertigo
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 thres-
• Recurrent, spontaneous, holds at 0.25, 0.5 and 1.0 kHz is
episodic vertigo 15 dB or more higher than the
(~30 min-to less than average of 1, 2 and 3 kHz;
24 hours) 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) • >15 dB 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

242

Grade B Recommendation
In a comparative double blind study involving
181 subjects, two calcium antagonists, namely
nimodipine and cinnarizine, were found to be
equally effective in the symptomatic treatment
of vestibular vertigo. The dosages were at 30
mg nimodipine tablet taken TID and 150 mg
cinnarizine tablet taken OD for 12 weeks. Both
had similar safety profiles.
2.4 Non-pharmacologic treatment options in­
clude lifestyle modifications, i.e. salt restric­
tion.
Grade C Recommendation
Salt restriction and diuresis are believed by
many to be the best medical therapy for those
with Meniere's disease. The goal is to reduce
endolymph volume by fluid removal or reduced
production.
2.5 The panel is cognizant of other treatments
reported for Meniere's disease, including
hyperbaric oxygen therapy, pressure therapy
(Meniett device). It is recommen­ded that
these be considered only within the limits
of a well-controlled clinical trial.
Grade C Recommendation
Treatment Recommendations for Benign Paroxys­mal
Positional Vertigo
1. Epley's or Semont's maneuver done at weekly
intervals, maximum of 4 maneuvers per side, is
recommended.
Grade A Recommendation
In the randomized controlled trial by Soto et al., a total
of 106 BPPV patients were randomly assigned to
three treatment groups: Brandt and Daroff habituation
exercises, Semont maneuver, and Epley maneuver.
Their results indicate that: 1) the Epley and Semont
maneuver are more effective than Brandt and Daroff
habituation exercises, 2) the initial response to the
Epley maneuver was similar to the Semont maneuver,
and 3) after 3 months of treatment, better results
were obtained with the Epley maneuver than with the
Semont maneuver.
In another randomized controlled trial by Cohen et
al., 87 subjects diagnosed with posterior canal BPPV
were randomly assigned to three treatment groups:
modified Epley maneuver, modified Epley maneuver
with augmented head rotations, and modified Semont
maneuver. Their data suggested that augmented
head rotations are unnecessary and that the modified
Epley and modified Semont maneuvers are equally
effective.
Grade B Recommendation
In the retrospective chart review by Haynes et al, 127
cases of objective BPPV and 35 cases of subjective
BPPV underwent the Semont liberatory maneuver
Vertigo
and was assessed after 3 weeks for complete, partial,
and failure of resolution. There was 90% improvement
after an average of 1.5 maneuvers, 91% with objec-
tive BPPV after 1.6 maneuvers and 86% of subjective
BPPV after 1.13 maneuvers had improvements. 29%
recurrence after first maneuver, where 96% of the re-
maining responded to the succeeding maneuvers.
Prospective cohort study of 86 patients with BPPV
who was treated with the Epley maneuver and evalu-
ated within the 2 weeks following treatment. Seventy
per­cent (70%) had complete resolution within 2 days
after first maneuver. Additional 9% had complete
resolution within 2 days after first maneuver. Addi-
tional 9% had complete resolution after 1 week after
first maneuver.
More than 90% of patients were cured after a maxi-
mum of 4 Semont's maneuvers, and 83.5% were
cured after 2 maneuvers. The efficacy decreased
each time it was repeated.
Grade C Recommendation
Current therapy of BPPV organized around reposi­
tioning maneuvers that use gravity to move canalith
debris out of the affected semicircular canal and into
the vestibule.
When these patients were managed with customized
vestibular rehabilitation therapy, 100% had complete
resolution of their symptoms.
2. Repeated repositioning maneuvers may be at­
tempted on recurrent attacks of BPPV. However, re­
current attacks may warrant further investigation.
Grade C Recommendation
Treatment Recommendations on Vestibular Neuro­
nitis or Viral Labyrinthitis
1. In the acute attack of vertigo associated with ves­
tibular neuronitis or viral labyrinthitis, vesti­bular
suppressants may be given. However, prolonged
administration of vestibular suppres­sants may
delay central compensation.
Grade C Recommendation
In a case series involving 23 subjects with vestibular
neuritis, oral flunarizine at 5 mg tablet daily in a single
dose was taken together with physical exercises.
Flunarizine appears to be useful in the treatment
of vertigo caused by vestibular neuritis. However, it
could not be determined whether the portion of the
change was obtained by flunarizine and exercises
and what was due to spontaneous evolution.
2. Vestibular rehabilitation initiated as early as
possible to improve balance function is recom­
mended.
Grade B Recommendation
In the randomized controlled trial by Strupp et al,
thirty-nine patients (20 in the control group, 19 in
the physiotherapy group) diagnosed with vestibular
243
Vertigo
neuronitis were analyzed. Vestibular exercises were
found to improve vestibulo-spinal compensation in
these patients, thereby improving balance function.
It seems best to start as early as possible with the
exercises after symptom onset.

3. Steroids, plus an antiviral agent, may be useful

for improving peripheral vestibular function in
vestibular neuritis.

Grade C Recommendation

A preliminary interim analysis on the data of 51

patients shows that the recovery rate was 31% in
the placebo group, 46% in the valacyclovir group,
61% in the methylprednisolone group, and 67% in
the methyl­prednisolone plus valacyclovir group.
However, this has to be further evaluated in an
ongoing randomized, prospective study with a
larger group of patients.

244
 Vertigo
Appendix

Figure 1. Dix-Hallpike Maneuver

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

245
Vertigo
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.

Excerpted from the article “The canalith repositioning procedure: For treatment of benign paroxysmal positional
vertigo.”

246

Figure 3. Semont's Maneuver
"The patient is laid on the ipsilateral side to the sick
ear with his head slightly declined. The nystagmus can
appear in this condition one must wait until it stops. If
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, the
paroxysmal rotatory nystagmus rolling toward the ex-
amination table appears. One wait until it has completely
stopped and then the patient is left in this position for 2
or 3 minutes."
"Then, holding patient's head and neck with two hands,
he is swung quickly to the opposite side. The speed of
the head must be zero moment the head touches the ex-
amination table. Then a rotatory nystagmus appears still
rolling toward the sick ear, which is now the higher one.
It must not be an inverted nystagmus. The nystagmus is
slightly different: wide amplitude, slower frequency, not
so paroxysmal as the original one."
"If nothing happens, the head is slowly turned nearly 90
degrees facing up and then quickly turned to 45 degrees
facing down. Then the nystagmus occurs. The patient
must stay in this last position for at least 5 minutes and
is brought back to orthostatism very, very slowly."
"The patient is then asked to keep his head absolutely
vertical in space during at least 48 hours day and night.
He is asked to avoid fast head movements upward or
downward and not to sleep on the vertigo-generating
side for a week. If the maneuver is not successful, it is
performed again a week later."
Excerpted from the article “Curing the BPPV with a Libera-
tory Maneuver” by A. Semont et al, Adv Oto-Rhino-Laryngl, Vol
42:290-293.
References:
1. Otolaryngology, Head and Neck Surgery, 3rd edition, volume
4, 1998, edited by Cummings et al., p. 2681 and p. 2748
2. Department of Otorhinolaryngology OPD-PGH Census 2002
3. Department of Family Medicine OPD-PGH Census 2002
4. Department of Neurosciences OPD-PGH Census 2002
5. Outpatient Department Census Santo Tomas University Hospital
2002
6. El-Kashlan & Telian, S. Diagnosis and initiating treatment for peripheral
system Disorders. Otolaryngol Clin of North America 2000, 33:563-
577.
7. Davidson, TM. Ambulatory healthcare pathways for ear, nose, and
throat disorders.
8. Kentala, E & Rauch, S. A practical assessment algorithm for diagnosis
of dizziness. Otolaryngol Head Neck Surg 2003, 128:54-59.
9. Lanska, DJ and Goetz, CG. Romberg's sign: Development, adoption
and adaptation in the 19th century. Neurology 2000; 55:1201-1206.
10. Jackler, R. K. and Brackmann, DE. Neurotology. Mosby Year Books
Publisher, 1994.
11. Mangham, C. Hearing threshold differences between ears and risk of
acoustic neuroma. Otolaryngol Head Neck Surg 1991, 105:814.
12. Lee, KJ. Essential Otolaryngology. Appleton and Lange, 1999.
13. Schmidt, R., et al. The sensitivity of ABR testing for the diagnosis 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.
Vertigo
16. Filipino R., Barbara M. Natural History of Meniere's Disease: Staging
the patients or their symptoms? Acta Otolaryngol 1997; Suppl 526:10-
13.
17. Mateijsen, DJ, et. al. Pure tone and speech audiometry in patients with
Meniere's Disease. Clin Otolaryngol 2001 Oct;26(5):379-87.
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): 181-5.
19. Irving, Carol, et al. June 2002. Intramuscular Droperidol versus
Intramuscular Dimenhydrinate for the Treatment of Acute Peripheral
Vertigo in the Emergency Department: A Randomized Clinical Trial.
Acad Emerg Med, Vol. 9, No. 6, pp 650-653.
20. Claes, J and Van De Heyning, PH. Medical Treatment of Meniere's
Disease: A Review of Literature. 1997. Acta Otolaryngol (Stockh)
Suppl 526:37-42.
21. Mira, Eugenio, et al. September 2002. Betahistine dihydrochloride in
the treatment of peripheral vestibular vertigo. Eur Arch Otorhinolaryngol
260: 73-77.
22. Deering, RB et al. A double -blind crossover study comparing betahistine
dihydrochloride and cinnarizine in the treatment of recurrent vertigo in
patients in general practice. 1986, June 11. Curr. Med. Res. Opin. 10: 209-14.
23. Albera, Roberto, et al. December 2002. Double -blind, Randomized,
Multicenter Study Comparing the Effect of Betahistine dihydrochloride
and Flunarizine on the The Dizziness Handicap Inventory Scores in
Patients with Recurrent Vestibular Vertigo. Acta Otolaryngol 2003; 00:1-6.
24. Colletti, V. Medical Treatment in Meniere's Disease: Avoiding
Vestibular Neurectomy and Facilitating Postoperative
Compensation. Acta Otolaryngol 2000; Suppl 544:27-33.
25. Van Deelen, GW and Huizing, EH. Use of Diuretic (Dyazide) in the
Treatment of Meniere's Disease. A Double Blind Cross-over Placebo-
controlled Study. ORL J Otorhinolaryngol Relat Spec. 1986 48(5):
287-92.
26. Pianese, CP, et al. New Approaches to the Management
of Peripheral Vertigo: Efficacy and Safety of Two Calcium
Antagonists 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 prospective
study of the efficacy of Brandt and Daroff exercises, Semont and Epley
maneuvers. Rev Laryngol Otol Rhinol 2001; 122,3:179-183.
28. Cohen, HS et al. Efficacy of treatments for posterior canal benign
paroxysmal positional vertigo. The Laryngoscope 109: April 1999:
584-590.
29. Resser, Haynes D., et al. The treatment of benign positional vertigo
using the Semont maneuver: Efficacy in patients presenting without
nystagmus. Laryngoscope 2002 112:796-801
30. Ruckenstein, M. Therapeutic efficacy of the Epley canalith
repositioning maneuver. Laryngoscope 2001 111:940-945.
31. Levrat, E., et al. June 2003. Efficacy of the Sermont Maneuver in
Benign Paroxysmal Positional Vertigo. Arch Otolaryngol Head Neck
Surg, vol 129, pp. 629-633.
32. Corvera, et al. Objective Evaluation of the Effect of Flunarizine on
Vestibular Neuritis. Otology & Neurotology 2002, 23:933-937.
33. Strupp, et al. 1998. Vestibular exercises improve central vestibulospinal
compensation after vestibular neuritis. Neurology 51:838-844.
34. Strupp, et al. Exercise and Drug Therapy Alter Recovery from Labyrinth
Lesion in Humans. Annals New York Academy of Sciences .
247
Vertigo
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.

Adrenocorticosteroid hormones Amlodipine camsylate Bumetanide

Methylprednisolone Amvasc Burinex
Depo-Medrol Benidipine Furosemide
Medixon Coniel Am-Europharma Furosemide
Medrol Diltiazem Drugmaker's Biotech
Solu-Cortef Cordazem Furosemide
Solu-Medrol Dilatam Frusema
Dilzem/Dilzem SA/Dilzem SR Lasix
CNS Drugs Drugmaker's Biotech Diltiazem Pharmix
Anti-Emetic/Anti-Vertigo RiteMED Diltiazem Piplen
Betahistine Tildiem Furosemide/Potassium Cl
Merislon Vasmulax Diumide-K Continus Tablet
Serc Zandil Hydrochlorothiazide
Verdiz Felodipine Diuzid
Cinnarizine Dilahex Diuzide
Drugmaker's Biotech Cinnarizine Hytaz
Dilofen ER
Stugeron/Stugeron Forte Indapamide
Felim
Difenidol Natrilix SR
Felop ER Tab
Cephadol Spironolactone
Logimax*
Dimenhydrinate Aldactone
Plendil ER
Drugmaker's Biotech Spironolactone/Butizide
Triapin*
Dimenhydrinate Aldazide
Versant XR
Meclizine
Lacidipine
Bonamine
Lacipil
Nodiz
Lercanidipine
Postadoxine
Zanidip
Metoclopramide
Manidipine
Biclomet
Caldine
Plasil
Nicardipine
Antihistamines Cardepine
Diphenhydramine Nifedipine
Allerin AH Adalat
Am-Europharma Calcheck
Diphenhydramine HCl Calcibloc
Benadryl Calcibloc OD
Drugmaker's Biotech Calcigard-5
Diphenhydramine Denkified
Hizon Diphenhydramine Injection Drugmaker's Biotech Nifedipine
Nebrecon Heblopin
Diphenhydramine/ Nifestad
Phenylpropanolamine Normadil
Allerin Reformulated Nimodipine
Nimotop
Anti-Migraine Verapamil
Flunarizine Isoptin/Isoptin SR
Sibelium Tarka*

Anti-viral Hypnotics/Sedatives
Valacyclovir Clonazepam
Valtrex Rivotril
Diazepam
Calcium antagonists Valium
Amlodipine besylate
Envacar* Diuretics
Norvasc Acetazolamide
Vasalat Diamox

248