xRead - Episodic Vertigo (January 2026)

10976817, 2020, S2, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599820909438 by Mayo Clinic Libraries, Wiley Online Library on [19/09/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

Basura et al

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Benefit-harm assessment: Preponderance of benefit over harms Value judgments: Avoidance of inappropriate therapy Intentional vagueness: None Role of patient preferences: None Exclusions: None Policy level: Recommendation against Differences of opinion: None Supporting Text The purpose of this statement is to define the role of VR/ physical therapy in the management of the severity and fre quency of acute vertiginous attacks with definite or probable MD. Vertigo attacks lasting 20 minutes to 24 hours accom panied by fluctuating low- to midfrequency SNHL, aural fullness, and tinnitus are a typical manifestation of active MD. These attacks are distinct from other MD-associated symptoms, such as chronic imbalance, motion sensitivity, disequilibrium, dizziness, and oscillopsia (eg, ataxia in the dark and inability to maintain stable focus on horizon). Efficient reduction in the severity and frequency of acute vertigo in MD is a vital treatment objective, and it is critical to avoid unnecessary ineffective interventions. VR refers to a compilation of exercises and physical maneuvers to treat chronic balance disorders. The overarch ing goal of VR is to reduce balance-related symptoms while improving postural stability and daily functioning. By com bining active head movements with the integration of other sensory information, VR induces central vestibular compen sation and habituation to alleviate the symptoms of chronic balance disorders. 365 The AAO-HNS has endorsed VR as a ‘‘valid therapeutic modality for the treatment of persistent dizziness and postural instability due to incomplete central vestibular compensation after peripheral vestibular or cen tral nervous system injury.’’ Balance retraining therapy is also of significant benefit for fall prevention in the elderly patient who may experience multiple sensory and motor impairments or for those who have sensory disruption with moving visual information.’’ 366 This therapy has become a primary treatment for patients with stable peripheral and central vestibular hypofunction 360 ; however, for the fluctuat ing nature of vestibular dysfunction manifested in acute MD attacks, the role of VR is undefined. 365 There is strong evidence from a recent CPG demonstrat ing benefit of VR in patients with unilateral and bilateral peripheral vestibular disorders in the acute and subacute set tings who experience ongoing symptoms. 328 This guideline included research among patients with vestibular neuritis, 367 vestibular schwannoma, 368,369 postsurgical peripheral vestib ular hypofunction, 364 and other vestibulopathies; however, there is a lack of evidence to support the use of VR to treat acute vertigo attacks in MD. Despite the documented bene fit of VR in the acute setting, this guideline recommended excluding patients who have compensated vestibular dys function and a ‘‘possible exclusion’’ of patients with active

medical (eg, IT gentamicin) or surgical (eg, labyrinthectomy or VNS) management of refractory episodic vertigo may result in total or near total unilateral peripheral vestibular hypofunction. Patients who receive these treatments may have chronic imbalance if central vestibular compensation has been incomplete; therefore, they are candidates for post treatment VR. A recent clinical guideline 328 identified a level 1 RCT that assessed the role of VR following ablative surgical treatment of MD. When compared with controls, those who received postoperative VR had improved motion sensitivity and subjective improvement of symptoms based on the DHI. 364 VR may also be utilized to treat chronic imbalance symptoms in bilateral MD. These patients face a complicated clinical course and may have limited treatment options due to the potential harm inherent to ablative treat ment. Based on VR clinical guidelines, 328 there is a strong recommendation to use VR for patients with bilateral vestib ular hypofunction. This is based on 4 level 1 RCTs and 5 level 3-4 studies. Despite demonstrating the benefit of VR in alleviating chronic imbalance via objective and subjective measures, these studies are limited by small sample sizes and the utilization of heterogeneous study samples that include a wide range of underlying diseases in addition to MD. Regardless of the limitations in the quality/volume of available research, there is growing evidence showing bene fits versus harm to patients undergoing VR. As such, MD patients should be offered VR as a treatment for chronic imbalance. STATEMENT 14b. ROLE OF VESTIBULAR THERAPY FOR ACUTE VERTIGO: Clinicians should not recom mend vestibular rehabilitation/physical therapy for manag ing acute vertigo attacks in patients with Me´nie`re’s disease. Recommendation against based on RCTs studied that evalu ated acute vertigo but were not specific to MD and a pre ponderance of benefit over harms. Quality improvement opportunity: Avoidance of inappropriate/ineffective therapy. National Quality Strategy domains: Patient Safety, Prevention and Treatment of Leading Causes of Morbidity and Mortality Aggregate evidence quality: Grade B, based on subset analysis of RCTs that failed to identify any studies on the topic as well as expert opinion extra polated from evidence from a CPG Level of confidence in evidence: Medium; the RCTs evaluated acute vertigo but were not specific toMD Benefits: Avoidance of noneffective therapy, pre serving coverage for physical therapy at a later stage of disease, avoidance of potential exacerba tion of symptoms Risk, harm, cost: Delay of treatment in patients with an underlying vestibular hypofunction Action Statement Profile: 14b