Teleconsultation and Teletreatment Protocol to Diagnose and Manage Patients with Benign Paroxysmal Positional Vertigo (BPPV) during the COVID-19 Pandemic

Abstract

Introduction Telehealth consists in the application of technology to provide remote health service. This resource is considered safe and effective and has attracted an exponential interest in the context of the COVID pandemic. Expanded to dizzy patients, it would be able to provide diagnosis and treatment, minimizing the risk of disease transmission. Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder. The diagnosis typically rests on the description of the symptoms along with the nystagmus observed at a well-established positional testing. Objectives The aim of the present study was to propose a teleconsultation and teletreatment protocol to manage patients with BPPV during the COVID-19 pandemic. Methods Specialists in the vestibular field met through remote access technologies to discuss the best strategy to manage BPPV patients by teleconsultation and teletreatment system. Additionally, several scientific sources were consulted. Technical issues, patient safety, and clinical assessment were independently analyzed. All relevant information was considered in order to design a clinical protocol to manage BPPV patients in the pandemic context. Results Teleconsultation for BPPV patients requires a double way (video and audio) digital system. An adapted informed consent to follow good clinical practice statements must be considered. The time, trigger and target eye bedside examination (TiTRaTe) protocol has proven to be a valuable first approach. The bow and lean test is the most rational screening maneuver for patients with suspected positional vertigo, followed by most specific maneuvers to diagnostic the sub-variants of BPPV. Conclusion Although with limited evidence, teleconsultation and teletreatment are both reasonable and feasible strategies for the management of patients with BPPV in adverse situations for face-to-face consultation.

Keywords: COVID-19; dizziness; telemedicine; therapeutics; vertigo.

Fig. 1

Flowchart of otoneurological management for BPPV patients by means of teleassistance.

Fig. 2

Bow and Lean Test procedure– Left to right: Straight ahead, flexion and extension of the head while the eyes movements are recorded with a cellphone. Each position should be maintained for at least 30 seconds according to the tolerance of the patient (adapted from the original)

Fig. 3

Supine Roll Test (adapted from the original) procedure. The patient lies supine on an examination couch. The subject turns his head 90° to either side, while the nystagmus is recorded. The head should be maintained for 45 to 60 seconds in each position. A slight elevation of the head from the table (∼ 20°) (i.e head resting on the pillow), is recomended.

Fig. 4

Side Lying Test (adapted from the original). The patient sits sideways in the middle of an examination couch. The subject turns his/her head 45° away from the test ear and lies sideways so that they maintain the 45° head turn looking upwards toward the ceiling while the nystagmus is recorded. Bring the patients feet up onto the couch to be more comfortable. An external support (i.e caregiver) is commonly required.

Fig. 5

Modified Dix Hallpike test procedure. Left picture: The patient's head is turned 45° toward the test ear. Then, he/she is brought from sitting to a supine position, with the head extended ∼ 20° backward with the back resting on the pillow (middle picture). The patient should be instructed to fix his/her eyes on a point directly in front of him/her to let the nystagmus be recorded throughout the test (right picture) (adapted from the original)