Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + BRONCHITIS, ACUTE Download Section PDF Listen +++ +++ Population ++ –Adults age ≥18 y. +++ Recommendations ++ CDC—October 3, 2017 ++ –Recommends against a chest x-ray if all the following are present: Heart rate <100 beats/min. Respiratory rate <24 breaths/min. Temperature <100.4°F (38°C). No exam findings consistent with pneumonia (consolidation, egophony, fremitus). –Recommends against routine use of antibiotics regardless of duration of cough. ++ Source ++ –https://www.cdc.gov/antibiotic-use/community/for-hcp/outpatient-hcp/adult-treatment-rec.html +++ Comments ++ Primary clinical goal is to exclude pneumonia. Consider antitussive agents for short-term relief of coughing. β2 agonists or mucolytic agents should not be used routinely to alleviate cough. + CATARACT Download Section PDF Listen +++ ++ FIGURE 28-1 Cataract in Adults: Evaluation and Management Algorithm Graphic Jump LocationView Full Size||Download Slide (.ppt) + ++ aBegin evaluation only when patients complain of a vision problem or impairment.Identifying impairment in visual function during routine history and physical examination constitutes sound medical practice. ++ bEssential elements of the comprehensive eye and vision exam: Patient history: Consider cataract if acute or gradual onset of vision loss; vision problems under special conditions (eg, low contrast, glare); difficulties performing various visual tasks. Ask about refractive history, previous ocular disease, amblyopia, eye surgery, trauma, general health history, medications, and allergies. It is critical to describe the actual impact of the cataract on the person’s function and quality of life. There are several instruments available for assessing functional impairment related to cataract, including VF-14, Activities of Daily Vision Scale, and Visual Activities Questionnaire. Ocular examination includes Snellen acuity and refraction; measurement of intraocular pressure; assessment of pupillary function; external exam; slit-lamp exam; and dilated exam of fundus. Supplemental testing: May be necessary to assess and document the extent of the functional disability and to determine whether other diseases may limit preoperative or postoperative vision. Most elderly patients presenting with visual problems do not have a cataract that causes functional impairment. Refractive error, macular degeneration, and glaucoma are common alternative etiologies for visual impairment. ++ cOnce cataract has been identified as the cause of visual disability, patients should be counseled concerning the nature of the problem, its natural history, and the existence of both surgical and nonsurgical approaches to management. The principal factor that should guide decision making with regard to surgery is the extent to which the cataract impairs the ability to function in daily life. The findings of the physical examination should corroborate that the cataract is the major contributing cause of the functional impairment, and that there is a reasonable expectation that managing the cataract will positively impact the patient’s functional activity. Preoperative visual acuity is a poor predictor of postoperative functional improvement: The decision to recommend cataract surgery should not be made solely on the basis of visual acuity. ++ dPatients who complain of mild-to-moderate limitation in activities due to a visual problem, those whose corrected acuities are near 20/40, and those who do not yet wish to undergo surgery may be offered nonsurgical measures for improving visual function. Treatment with nutritional supplements is not recommended. Smoking cessation retards cataract progression. Indications for surgery: Cataract-impaired vision no longer meets the patient’s needs; evidence of lens-induced disease (eg, phacomorphic glaucoma, phacolytic glaucoma); necessary to visualize the fundus in an eye that has the potential for sight (eg, diabetic patient at risk of diabetic retinopathy). ++ eContraindications to surgery: The patient does not desire surgery; glasses or vision aids provide satisfactory functional vision; surgery will not improve visual function; the patient’s quality of life is not compromised; the patient is unable to undergo surgery because of coexisting medical or ocular conditions; a legal consent cannot be obtained; or the patient is unable to obtain adequate postoperative care. Routine preoperative medical testing (12-lead EKG, CBC, measurement of serum electrolytes, BUN, creatinine, and glucose), while commonly performed in patients scheduled to undergo cataract surgery, does not appear to measurably increase the safety of the surgery. ++ fPatients with significant functional and visual impairment due to cataract who have no contraindications to surgery should be counseled regarding the expected risks and benefits of and alternatives to surgery. ++ Sources: American Academy of Ophthalmology Preferred Practice Pattern: Cataract in the Adult Eye. 2006. (http://www.aao.org); American Optometric Association Consensus Panel on Care of the Adult Patient with Cataract. Optometric Clinical Practice Guideline: Care of the Adult Patient with Cataract. 2004. (http://www.aoa.org). + CERUMEN IMPACTION Download Section PDF Listen +++ +++ Population ++ –Children and adults. +++ Recommendations ++ AAO-HNS 2017 ++ –Strongly recommended treating cerumen impaction when it is symptomatic or prevents a needed clinical examination. –Clinicians should treat the patient with cerumen impaction with an appropriate intervention: Ceruminolytic agents. Irrigation. Manual removal. ++ Source –https://www.entnet.org//content/clinical-practice-guideline-cerumen-impaction +++ Comments ++ Ceruminolytic agents include water or saline, Cerumenex, addax, Debrox, or dilute solutions of acetic acid, hydrogen peroxide, or sodium bicarbonate. Ear candling is not recommended for treatment or prevention of cerumen impaction. Removal of cerumen is not necessary if the patient is asymptomatic and adequate clinical exam is possible. + HEADACHE Download Section PDF Listen +++ +++ Population ++ –Adults +++ Recommendation ++ ACR 2012 ++ –Do perform imaging for uncomplicated headaches. +++ Comments ++ Diagnosis and NeuroImaging Indications for imaging or specialty consultation/emergent urgent evaluation. Emergent Red Flag Symptoms Onset of severe headache that is sudden (seconds to a minute to a peak onset of intensity)—obtain emergent CT scan in ER setting. Headache with fever and neck stiffness. Papilledema with altered level of consciousness and/or focal neurological signs. Urgent Red Flag symptoms Signs of systemic Illness in the patient with new onset headache. New headache in patients over 50 y of age with symptoms of temporal arteritis. Papilledema in an alert patient without focal neurological signs. Elderly patient with new headache and sub-acute cognitive change. Consider Imaging or Specialty Consultation Atypical headaches and changes in headache pattern. Unexplained focal signs in the patient with a headache. Headache precipitated by exertion, postural change, cough, or valsalva. New onset cluster headache or another trigeminal autonomic cephalgia, hemicrania continua, or new daily persistent headache. ++ Sources ++ –https://www.guidelinecentral.com/summaries/guideline-for-primary-care-management-of-headache-in-adults/#section-society. –http://www.choosingwisely.org/societies/american-college-of-radiology/ + HEADACHE, MIGRAINE PROPHYLAXIS Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendations ++ AAN 2012 ++ –The following medications have established efficacy for migraine prophylaxis: Divalproex sodium. Sodium valproate. Topiramate. Metoprolol. Propranolol. Timolol. –Frovatriptan is effective for menstrual migraine prophylaxis. –The following medications are probably effective for migraine prophylaxis: Amitriptyline. Venlafaxine. Atenolol. Nadolol. ++ Source ++ –http://www.neurology.org/content/78/17/1337.full.pdf+html +++ Comment ++ Lamotrigine and clomipramine are ineffective for migraine prevention. ++ FIGURE 28-2 Headache Diagnosis Algorithm—Icsi 2011 Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 28-3 Migraine Treatment Algorithm—Icsi 2011 Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 28-4 Tension-Type Headache Algorithm—Icsi 2011 Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 28-5 Cluster Headache Algorithm—Icsi 2011 Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 28-6 Menstrual-Associated Migraine Algorithm—Icsi 2011 Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 28-7 Perimenopausal or Menopausal Migraine Algorithm—Icsi 2011 Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 28-8 On Estrogen-Containing Contraceptives or Considering Estrogen-Containing Contraceptives with Migraine Algorithm—Icsi 2011 Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ FIGURE 28-9 Migraine Prophylactic Treatment Algorithm—Icsi 2011 Graphic Jump LocationView Full Size||Download Slide (.ppt) + HEARING LOSS, SUDDEN Download Section PDF Listen +++ +++ Population ++ –Adults age 18 y and older. +++ Recommendations ++ AAO-HNS 2012 ++ –Distinguish hearing loss between sensorineural and conductive hearing loss. –Diagnosis of idiopathic sudden sensorineural hearing loss (ISSNHL) is made when audiometry confirms a 30 decibel hearing loss at three consecutive frequencies and an underlying condition cannot be identified by history and physical. –Evaluate patients with ISSNHL for retrocochlear pathology by obtaining an MRI of the internal auditory canal, auditory brainstem responses, and an audiology exam. –Consider treatment of ISSNHL with incomplete hearing recovery with systemic or intratympanic steroids or hyperbaric oxygen therapy. –In patients with ISSNHL, recommend against antivirals, thrombolytics, vasodilators, or antioxidants for treatment and against CT scanning of the head or routine lab testing. +++ Comments ++ Prompt diagnosis is important. Counsel patients with incomplete recovery of hearing about the benefits of hearing aids. ++ Source ++ –https://www.entnet.org//content/aao-hnsf-clinical-practice-guideline-sudden-hearing-loss + HOARSENESS Download Section PDF Listen +++ +++ Population ++ –Persons with hoarseness. +++ Recommendations ++ AAO-HNS 2018 ++ –Most but not all hoarseness is benign or self-limited; some of the most common causes are URI and voice overuse. –Begin assessment with history and physical to identify underlying causes and factors that may modify management. –All patients with hoarseness that fails to resolve or improve within 4 wk should undergo laryngoscopy. –Recommends against screening neck imaging (CT or MRI scanning) for chronic hoarseness prior to laryngoscopy. –Recommends against the routine use of antibiotics or steroids to treat hoarseness. – Recommends against routine use of antireflux medications unless the patient exhibits signs or symptoms of gastroesophageal reflux disease. –Recommends voice therapy for all patients with hoarseness and a decreased voice-related quality of life. –Consider surgery for possible laryngeal CA, benign laryngeal soft-tissue lesions, or glottis insufficiency. –Consider botulinum toxin injections for spasmodic dysphonia. ++ Source ++ –https://www.entnet.org//content/clinical-practice-guideline-hoarseness-dysphonia +++ Comment ++ Nearly one-third of Americans will have hoarseness at some point in their lives. + LARYNGITIS, ACUTE Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendation ++ Cochrane Database Systematic Reviews 2015 ++ –Insufficient evidence to support the use of antibiotics for acute laryngitis. ++ Source ++ –http://www.cochrane.org/CD004783/ARI_antibiotics-to-treat-adults-with-acute-laryngitis +++ Comment ++ Many methodological flaws in studies evaluated. + OTITIS EXTERNA, ACUTE (AOE) Download Section PDF Listen +++ +++ Population ++ –Children age 2 y or older and adults. +++ Recommendations ++ AAO-HNS 2014 ++ –Recommends against systemic antimicrobials as initial therapy for diffuse, uncomplicated acute otitis externa (AOE). –Recommends topical antibiotics for initial therapy of AOE. –In the presence of a perforated tympanic membrane or tympanostomy tubes, prescribe a non-ototoxic topical antibiotic. ++ Source ++ –https://www.entnet.org//content/clinical-practice-guideline-acute-otitis-externa +++ Comment ++ Recommends reassessment of the diagnosis if the patient fails to respond within 72 h of topical antibiotics. + OTITIS MEDIA, ACUTE (AOM) Download Section PDF Listen +++ +++ Population ++ –Children age 3 mo to 18 y. +++ Recommendations ++ AAP 2013 ++ –Diagnosis should be made with pneumatic otoscopy –Children at low riska should use a wait-and-see approach for 48–72 h with oral analgesics. –Recommends symptomatic relief with acetaminophen or ibuprofen and warm compresses to the ear. –Educate caregivers about prevention of otitis media: encourage breast-feeding, feed child upright if bottle fed, avoid passive smoke exposure, limit exposure to groups of children, careful handwashing prior to handling child, avoid pacifier use >10 mo, ensure immunizations are up to date. –Amoxicillin is the first-line antibiotic for low-risk children. –Alternative medication if failure to respond to initial treatment within 72 h; penicillin allergy; presence of a resistant organism found on culture. –Recommends referral to an ear, nose, and throat (ENT) specialist for a complication of otitis media: mastoiditis, facial nerve palsy, lateral sinus thrombosis, meningitis, brain abscess, or labyrinthitis. –Recommends against routine recheck at 10–14 d in children feeling well. –Management of otitis media with effusion: Educate that effusion will resolve on its own. Recommends against antihistamines or decongestants. Recommends a trial of antibiotics for 10–14 d prior to referral for tympanostomy tubes. ++ Source ++ –Pediatrics. 2013;131:e964-e999. ++ AAFP 2013 ++ –Do not prescribe antibiotics to children age 2–12 y with nonsevere AOM when observation is an option. ++ Source ++ –http://www.choosingwisely.org/societies/american-academy-of-family-physicians/ +++ Comments ++ Amoxicillin is first-line therapy for low-risk children: 40 mg/kg/d if no antibiotics used in last 3 mo. 80 mg/kg/d if child is not low risk. Alternative antibiotics: Amoxicillin-clavulanate. Cefuroxime axetil. Ceftriaxone. Cefprozil. Loracarbef. Cefdinir. Cefixime. Cefpodoxime. Clarithromycin. Azithromycin. Erythromycin. +++ Population ++ –Children 6 mo to 12 y. +++ Recommendations ++ AAP 2013 ++ –Diagnosis of AOM Moderate-to-severe bulging of the tympanic membrane. New-onset otorrhea not due to otitis externa. Mild bulging of an intensely red tympanic membrane and new otalgia <48 h duration. –Treatment of AOM Analgesics and antipyretics. Indications for antibiotics. Children <24 mo old with bilateral AOM. Symptoms that are not improving or worsening during a 48-h to 72-h observation period. AOM associated with severe symptoms (extreme fussiness or severe otalgia). Observation for 48–72 h is recommended in the absence of severe symptoms and fever <102.2°F. –Consider tympanostomy tubes for recurrent AOM (3 episodes in 6 mo or 4 episodes in 1 y). ++ Source ++ –http://www.guidelines.gov/content.aspx?id=43892 +++ Comments ++ AOM is not present in the absence of a middle ear effusion based on pneumatic otoscopy or tympanometry. Amoxicillin is the preferred antibiotics if the child has not received amoxicillin in the last 30 d. Augmentin is the preferred antibiotic if the child has received amoxicillin in the last 30 d. + ++ aChildren older than age 2 y without severe disease (temperature >102°F [39°C] and moderate-to-severe otalgia), otherwise healthy, do not attend daycare, and have had no prior ear infections within the last month. + PHARYNGITIS, ACUTE Download Section PDF Listen +++ ++ FIGURE 28-10 Approach to Acute Pharyngitis Graphic Jump LocationView Full Size||Download Slide (.ppt) + ++ Source: IDSA 2012 guidelines on group A Streptococcus (GAS) pharyngitis. + RHINITIS Download Section PDF Listen +++ ++ FIGURE 28-11 Management of Noninfectious Rhinitis Graphic Jump LocationView Full Size||Download Slide (.ppt) ++ Sources ++ –ICSI, JAN 2011; AAO-HNSF, FEB 2015. –https://www.entnet.org//content/clinical-practice-guideline-allergic-rhinitis + SINUSITIS Download Section PDF Listen +++ +++ Population ++ –Children age 1–18 y. +++ Recommendation ++ ACEP 2013 ++ –Avoid prescribing antibiotics in the ER for patients presenting with uncomplicated acute sinusitis. ++ Source ++ –http://www.choosingwisely.org/societies/american-college-of-emergency-physicians/ +++ Comment ++ Improvement of symptoms should occur within 72 h of antibiotic initiation. + SINUSITIS, ACUTE BACTERIAL Download Section PDF Listen +++ +++ Population ++ –Children age 1–18 y with acute bacterial sinusitis. +++ Recommendations ++ AAP 2013 ++ –Presumptive acute sinusitis if child with acute URI and one of the following: Nasal discharge or persistent cough lasting more than 10 d. Worsening course. Severe onset with fever ≥102.2°F and purulent nasal discharge for at least 3 d. –Recommend against imaging studies for uncomplicated sinusitis. –Contrast-enhanced CT scan of sinuses for any suspicion of orbital or CNS involvement. –Recommend antibiotics for any sinusitis with a severe onset or worsening course. Amoxicillin +/– clavulanate is first-line therapy. Persistent cough or rhinorrhea in the absence of severe symptoms may be managed with ongoing observation. ++ Source ++ –https://guidelines.gov/summaries/summary/46939 + SINUSITIS Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendations ++ AAO-HNS APRIL 2015 ++ –ACUTE RHINOSINUSITIS (ARS) Up to 4 wk of purulent nasal drainage (anterior, posterior, or both) accompanied by nasal obstruction, facial pain/pressure/fullness, or both ++ –VIRAL RHINOSINUSITIS (VRS) Acute rhinosinusitis that is caused by, or is presumed to be caused by, viral infection. A clinician should diagnose viral rhinosinusitis when symptoms or signs of acute rhinosinusitis are present <10 d and the symptoms are not worsening. ++ –SYMPTOMATIC RELIEF OF VRS Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of VRS. ++ –ACUTE BACTERIAL RHINOSINUSITIS (ABRS) Acute rhinosinusitis that is caused by, or is presumed to be caused by, bacterial infection. A clinician should diagnose acute bacterial rhinosinusitis when Symptoms or signs of acute rhinosinusitis fail to improve within 10 d or more beyond the onset of upper respiratory symptoms. Symptoms or signs of acute rhinosinusitis worsen within 10 d after an initial improvement (double worsening). ++ –ABRS—INITIAL MANAGEMENT Clinicians should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS. Watchful waiting should be offered only when there is assurance of follow-up such that antibiotic therapy is started if the patient’s condition fails to improve by 7 d after ABRS diagnosis or if it worsens at any time. ++ –ABRS—CHOICE OF ANTIBIOTIC If a decision is made to treat ABRS with an antibiotic agent, the clinician should prescribe amoxicillin with or without clavulanate as first-line therapy for 5–10 d for most adults. ++ –ABRS—TREATMENT FAILURE If the patient’s condition worsens or fails to improve with the initial management option by 7 d after diagnosis or worsens during the initial management, the clinician should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications. If ABRS is confirmed in the patient initially managed with observation, the clinician should begin antibiotic therapy. If the patient was initially managed with an antibiotic, the clinician should change the antibiotic. ++ –ABRS—SYMPTOMATIC RELIEF Clinicians may recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of ABRS. ++ –DIFFERENTIAL DIAGNOSIS Clinicians should distinguish presumed ABRS from ARS caused by viral upper respiratory infections and noninfectious conditions. A clinician should diagnose ABRS when Symptoms or signs of ARS (purulent nasal drainage accompanied by nasal obstruction, facial pain/pressure/fullness, or both) persist without evidence of improvement for at least 10 d beyond the onset of upper respiratory symptoms. Symptoms or signs of ARS worsen within 10 d after an initial improvement (double worsening). –RADIOGRAPHIC IMAGING Clinicians should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected. ++ –CHRONIC RHINOSINUSITIS (CRS) Twelve weeks or longer of 2 or more of the following signs and symptoms: Mucopurulent drainage (anterior, posterior, or both). Nasal obstruction (congestion). Facial pain/pressure/fullness. Decreased sense of smell. AND inflammation is documented by one or more of the following findings: Purulent (not clear) mucus or edema in the middle meatus or anterior ethmoid region. Polyps in nasal cavity or the middle meatus. Radiographic imaging showing inflammation of the paranasal sinuses. ++ –RECURRENT ACUTE RHINOSINUSITIS Four or more episodes per year of acute bacterial rhinosinusitis without signs or symptoms of rhinosinusitis between episodes. Each episode of acute bacterial rhinosinusitis should meet diagnostic criteria for ARS. ++ –CRS OR RECURRENT ARS—DIAGNOSIS Clinicians should distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms. ++ –CRS—OBJECTIVE CONFIRMATION The clinician should confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography. ++ –CRS—TOPICAL INTRANASAL THERAPY Clinicians should recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS. ++ –CRS—ANTIFUNGAL THERAPY Clinicians should not prescribe topical or systemic antifungal therapy for patients with CRS. ++ Source ++ –https://www.entnet.org//content/clinical-practice-guideline-adult-sinusitis + TINNITUS Download Section PDF Listen +++ +++ Population ++ –Adults and children. +++ Recommendations ++ AAO-HNS Oct. 2014 ++ –Recommend a thorough history and exam on patients with tinnitus. –Recommend a comprehensive audiologic examination for unilateral or persistent tinnitus or any associated hearing impairment. –Recommend imaging studies only for unilateral tinnitus, pulsatile tinnitus, asymmetric hearing loss, or focal neurological abnormalities. –Recommend a hearing aid for tinnitus with hearing loss. –Consider cognitive behavioral training or sound therapy for persistent, bothersome tinnitus. –Recommend against medical or herbal therapy or transcranial magnetic stimulation for tinnitus. ++ Source ++ –https://www.entnet.org//content/clinical-practice-guideline-tinnitus + TONSILLECTOMY Download Section PDF Listen +++ +++ Population ++ –Children. +++ Recommendations ++ AAO-HNS 2011 ++ –Recommends against routine perioperative antibiotics for tonsillectomy. –Tonsillectomy indicated for: Tonsillar hypertrophy with sleep-disordered breathing. Recurrent throat infections for ≥7 episodes of recurrent throat infection in last year; ≥5 episodes of recurrent throat infection per year in last 2 y; or ≥3 episodes of recurrent throat infection per year in last 3 y. –Recommends posttonsillectomy pain control. ++ Source ++ –http://www.entnet.org/HealthInformation/upload/CPG-TonsillectomyInChildren.pdf + TYMPANOSTOMY TUBES Download Section PDF Listen +++ +++ Population ++ –Children 6 mo to 12 y. +++ Recommendations ++ AAO 2013 ++ –Clinicians should not perform tympanostomy tube insertion for children with: A single episode of otitis media with effusion (OME) of <3 mo duration. Recurrent acute otitis media without effusion. –Clinicians should obtain a hearing test if OME persists for at least 3 mo or if tympanostomy tube insertion is being considered. –Clinicians should offer bilateral tympanostomy tube insertion to children with: Bilateral OME for at least 3 mo AND documented hearing impairment. Recurrent acute otitis media with effusions. Tympanostomy tube insertion is an option for chronic symptomatic OME associated with balance problems, poor school performance, behavioral problems, or ear discomfort thought to be due to OME. ++ Source ++ –http://www.guideline.gov/content.aspx?id=46909 +++ Comment ++ No need for prophylactic water precautions (avoidance of swimming or water sports or use of earplugs) for children with tympanostomy tubes. + VERTIGO, BENIGN PAROXYSMAL POSITIONAL (BPPV) Download Section PDF Listen +++ +++ Population ++ –Adults. +++ Recommendations ++ AAO-HNS March, 2017 ++ –Recommends the Dix–Hallpike maneuver to diagnose posterior semicircular canal BPPV. –Recommends treatment of posterior semicircular canal BPPV with a particle repositioning maneuver. –If the Dix–Hallpike test result is negative, recommends a supine roll test to diagnose lateral semicircular canal BPPV. –Recommends offering vestibular repositioning exercises such as the Epley maneuver for the initial treatment of BPPV. –Observation is an acceptable initial management for patients with BPPV. –Recommends against post-procedural postural restrictions for posterior canal BPPV. –Recommends evaluating patients for an underlying peripheral vestibular or central nervous system disorder if they have an initial treatment failure of presumed BPPV. –Recommends against routine radiologic imaging for patients with BPPV. –Recommends against routine vestibular testing for patients with BPPV. –Recommends against routine use of antihistamines or benzodiazepines for patients with BPPV. ++ Source ++ –https://www.entnet.org//content/clinical-practice-guideline-benign-paroxysmal-positional-vertigo-bppv +++ Comment ++ BPPV is the most common vestibular disorder in adults, afflicting 2.4% of adults at some point during their lives.