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Vertigo - Gufoni manoeuvre

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Indications

Vertigo or dizziness lasting less than two minutes initiated by head movements (e.g. turning while standing)

and

No nystagmus (prior to assessment)

and

Horizontal nystagmus on supine roll test (diagnosing horizontal canal BPPV)

Contraindications (absolute in bold)

Cervical spine pathology (known or suspected)

Vascular insufficiency (carotid or vertebrobasilar)

Limited mobility

Alternatives

None

Informed consent

Verbal consent

Less complex non-emergency procedure with low risk of complications

Potential complications

Vertigo

Vomiting

Procedural hygiene

Standard precautions

PPE: non-sterile gloves

Area

Any bed space

Staff

Procedural clinician

Equipment

Bed with access on both sides

Positioning

Sit patient upright on the edge of the bed

Medication

Medications are not useful for the brief episodes of vertigo associated with BPPV

Consider ondansetron 4mg sublingual or IV, if unable to tolerate positional testing

Sequence (geotrophic horizontal canal BPPV)

Explain the manoeuvre to the patient, warning it may cause brief vertigo and nausea

Lie the patient on their side, with the good ear down for one minute

Turn the patients head 45 degrees towards the ground

Hold this position for two minutes

Sit the patient up

Sequence (apogeotrophic horizontal canal BPPV)

Explain the manoeuvre to the patient, warning it may cause brief vertigo and nausea

Lie the patient on their side with their affected ear down for one minute

Turn the patients head 45 degrees away from the ground

Hold this position for two minutes

Sit the patient up

Post-procedure care

Further assessment:

Repeat the supine roll test (repositioning successful if patient asymptomatic)

If nystagmus noted or the patient is symptomatic, repeat the Gufoni manoeuvre (repeat up to three times)

If unable to resolve vertigo, discuss with specialist for follow-up (neurology, ENT or vestibular physiotherapy)

It is not uncommon for the Gufoni manoeuvre to convert horizontal canal BPPV from apogeotropic to geotropic (or the other way around) which then requires another Gufoni manoeuvre to correct

Discharge advice:

Assess for impaired balance, falls risk and home support

Educate patient on BPPV (explain pathology, possibility of recurrence)

Recommend that new episodes of vertigo should always be reassessed to exclude central causes

In confirmed horizontal canal BPPV, sleeping on the affected side may improve symptoms while awaiting follow-up

Tips

Performing the Gufoni repositioning manoeuvre quickly lowers the chances of success

Repeating the Gufoni manoeuvres may cure BPPV even after a failed attempt

Symptoms recur in 30% over the next several years

Recurrence can occur in a difference canal, home treatment without re-diagnosis is not recommended

Sleeping on the affected side is a modification of the forced prolonged positioning rehabilitation manoeuvre

Discussion

BPPV is caused by calcium carbonate otoliths in the semi-circular canals of the inner ear. The posterior (70%) and the lateral canals (25%) are most affected by this pathology.

The Dix-Hallpike test diagnoses BPPV caused by posterior canal otoliths. Typically, after a 5-20 seconds latency, vertical upwards and rotatory nystagmus will be seen which resolves within one minute. The otoliths in the posterior canal BPPV can be repositioned by the Epley manoeuvre which is effective with one application in 80%.

If no nystagmus or horizontal nystagmus is seen on Dix-Hallpike testing, we perform a supine roll test looking for horizontal canal BPPV. Typically, after a 5-20 seconds latency, horizontal nystagmus will be seen on testing both sides which resolves within one minute. The nystagmus will either beat towards the ground on both sides, termed geotropic nystagmus, or away from the ground, which is termed apogeotropic. The otolith in the lateral canal can be repositioned by the Gufoni manoeuvre (the Epley manoeuvre will not cure these patients).

The supine roll test and Gufoni manoeuvre may be unknown to many emergency physicians. Practice of these techniques will expand the range of BPPV you can cure in the emergency department.

Patterns of movement-initiated vertigo we cannot diagnosis as posterior or horizontal canal BPPV or do not resolve with the Epley or other manoeuvres in the emergency department require specialist review (ENT, neurology or vestibular physiotherapy) or follow-up to exclude rarer central causes.

Peer review

This guideline has been reviewed and approved by the following:

Emergency Care Institute

Dr Peter Johns, Assistant Professor, Department of Emergency Medicine, University of Ottawa

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Produced with and reviewed by Dr Peter Johns, Assistant Professor, Department of emergency medicine, University of Ottawa.

Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol head neck surg. 2017;156(3_suppl):S1-S47. doi:10.1177/0194599816689667

Nuti D et al (2020): Benign Paroxysmal Positional Vertigo: What We Do and Do Not Know: Semin Neurol 2020 Feb;40(1):49-58.

Roberts JR, Hedges JR (eds), Clinical Procedures in Emergency Medicine 7th Edition, WB Saunders Company

Dunn R et al (eds), The Emergency Medicine Manual: Venom Publishing (Online April 2019)

UpToDate (2019) - Benign paroxysmal positional vertigo (Updated December 2017)

eTG complete therapeutic guidelines - Benign paroxysmal positional vertigo

Sumner A (2012): The Dix-Hallpike Test: J Physiotherapy. 2012;58(2):131.

You P et al (2018): Benign paroxysmal positional vertigo: Laryngoscope Investig Otolaryngol. 2018 Dec 14;4(1):116-123.

Omron R et al (2019): Peripheral Vertigo: Emerg Med Clin North Am. 2019 Feb;37(1):11-28

Dix & Hallpike (1952): The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann. Otol. Rhinol. Laryngol. 1952 Dec;61(4):987-1016

Kerber et al (2017): Barriers and facilitators to ED physician use of the test and treatment for BPPV. Neurol Clin Pract. 2017 Jun;7(3):214-224.

Agency for Clinical Innovation (2012): Emergency Care Institute: Patient Factsheet: Benign Paroxysmal Positional Vertigo

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