Diagnostic and therapy gaps in BPPV care: a retrospective analysis and feasibility evaluation across a London NHS trust

Benign paroxysmal positional vertigo (BPPV) is the most prevalent cause of peripheral dizziness, yet it remains poorly assessed and treated in acute settings. Despite the availability of validated bedside tools such as the Dix-Hallpike test (DHT) and canal repositioning manoeuvres (CRM) such as the Epley, diagnostic variability is high, neuroimaging is overused, and vestibular suppressants are frequently prescribed. This two-part evaluation characterised BPPV assessment and management across a London NHS Trust and assessed the feasibility of incorporating DHT into an existing AHP-led falls pathway within the emergency department (ED).

A two-part evaluation was conducted across a large London NHS teaching hospital. Part 1 comprised a retrospective review of electronic patient records to characterise current BPPV assessment and management practices and identify potential service gaps. Part 2 was a prospective feasibility study evaluating the incorporation of AHP-led DHT screening into routine falls assessments for patients aged ≥65 years presenting to the ED.

Part 1 identified 128 cases (mean age 63.4 years; 61.7% female). BPPV was the most common discharge diagnosis, 45.3% (95% CI 37.0-53.9%), yet full assessment and treatment were documented in only 14.8% of cases (95% CI 9.7-22.0%). Vestibular suppressants were prescribed in 43.8%, neuroimaging performed in 71.9 and 18.8% left without a definitive diagnosis. Readmission for dizziness within three months occurred in 13.3% (95% CI 8.5-20.2%). Part 2 included 102 patients, 79 with complete records (mean age 84.6 years; 54% female). DHT was completed in 62% (63/102 attempts; 95% CI 52.1-70.6%); BPPV was identified in 8% (95% CI 4.0-14.7%) and all received CRM. No dizziness-related readmissions occurred at three months.

This evaluation identifies consistent gaps in acute BPPV assessment and management, including overuse of neuroimaging and vestibular suppressants alongside underutilisation of validated bedside tools. Physiotherapy led DHT screening is feasible in a busy ED setting, even in older adults with multiple comorbidities, and the absence of readmissions in this small feasibility cohort is an encouraging finding that warrants evaluation in a larger, controlled cohort.