Vertigo, Benign Paroxysmal Positional Case File
Eugene C. Toy, MD, Ericka Simpson, MD, Pedro Mancias, MD, Erin E. Furr-Stimming, MD
CASE 37
A 63-year-old otherwise healthy man presents with a 3-month history of intermittent “dizziness.” He describes the episodes as a sensation of “room spinning” and notes that they are brought on or exacerbated by change in position, particularly when rolling out of bed in the morning. Episodes are generally self-limiting, lasting from 10 to 15 seconds on average. He denies associated nausea, vomiting, blurry or double-vision, hearing loss, tinnitus, ear pain, or headache. He does not take any medications. On examination, he is a well-nourished, healthy-appearing man. Vital signs are within normal limits, and he is afebrile. There are no lesions or masses on his face or head. His voice is normal, and speech is fluent. His ear canals and tympanic membranes are normal-appearing. His symptoms can be provoked by lying down and changing position of his head. While symptomatic, he also develops rotational nystagmus. The nystagmus is self-limiting, with the fast phase occurring counterclockwise (from patient’s perspective) as his head is tilted 45-degrees to the left (geotropic nystagmus). He improves a few seconds after sitting up, and nystagmus is no longer noted. The remainder of his general and neurologic examination is unremarkable.
▶ What is the most likely diagnosis?
▶ What is the next diagnostic step?
▶ What is the next step in therapy?
ANSWERS TO CASE 37:
Vertigo, Benign Paroxysmal Positional
Summary: A 63-year-old man with brief episodes of dizziness that are brought on by different positions, not associated with hearing loss, tinnitus, or headache.
- Most likely diagnosis: Benign paroxysmal positional vertigo (BPPV).
- Next diagnostic step: Perform a Dix-Hallpike maneuver (as described later) and consider neuroimaging if a central cause is suspected.
- Next therapeutic step: Canalith repositioning maneuvers and/or vestibular rehabilitation.
ANALYSIS
Objectives
- Define vertigo and understand its common causes.
- Learn to discern the prominent symptoms of vertigo.
- Learn about the important physical examination findings in patients with vestibular disorders.
- Learn about ancillary tests that can be performed to evaluate vertigo.
- Learn about the appropriate treatments for vertigo.
Considerations
This patient has brief (<30 seconds) episodes of vertigo that are brought out by position changes. This vertigo is not associated with any other inner ear symptom or other neurologic symptoms. His physical examination does not indicate evidence of middle ear disease. A positive Dix-Hallpike maneuver (described below) is highly suggestive of BPPV, with estimated sensitivity and specificity of 75% and 79%, respectively. Of all causes of vertigo, BPPV is most common and is due to otolith (calcium stone) impaction in the semicircular canal (SCC) of the inner ear. Abnormal SCC activation produces the false sensation of rotational movement in or about space.
APPROACH TO:
Vertigo
DEFINITIONS
DIZZINESS: A disturbed sense of relationship to space or feeling of disequilibrium.
VERTIGO: The false perception of rotational movement, either of oneself in space, or of space relative to oneself.
BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV): Recurrent abnormal sensation of vertiginous movement provoked by certain positions, secondary to otolith impaction in the inner ear.
NYSTAGMUS: An involuntary, rapid, rhythmic movement of the eye, which may be horizontal, vertical, rotatory, or mixed.
GEOTROPIC NYSTAGMUS: A subset of rotatory nystagmus in which the fast phase of rotation is coincident with direction of head turning (ie, counterclockwise with head turned left, clockwise with head turned right).
ELECTRONYSTAGMOGRAM (ENG): A recording of eye movements that provides objective documentation of induced and spontaneous nystagmus. These tests include recordings of the following: spontaneous nystagmus, positional nystagmus, gaze-induced nystagmus, smooth pursuit, random saccades, optokinetic stimulation, Dix-Hallpike testing, and caloric stimulation.
OTOLITH: Small calciferous granules within the gelatinous membrane of the saccule and utricle.
DIX-HALLPIKE MANEUVER: Sequential head position and turning test with high positive predictive value for BPPV. A positive test may occur if symptoms are elicited and/or nystagmus is reproduced.
TINNITUS: Perception of sound in one or both ears when no external sound exists. Often described as “ringing” in the ear(s).
CLINICAL APPROACH
Dizziness is perhaps the most common chief complaint encountered in the field of neurology, but it is unfortunately also among the most difficult for patients to describe or characterize. Clinical history and physical examination are critically important, as the differential diagnoses span the gamut of dehydration to BPPV to emergent brainstem stroke. “Dizziness” alone provides little localizing value and also has poor triaging value with regard to establishing urgency. Dizziness may refer to light-headedness, ataxia, somnolence, or vertigo, among many other symptoms. Dizziness, as a vague subjective complaint, should always be clarified and characterized by the clinician. Vertigo refers to the abnormal sensation of rotation or spinning, either self-spinning or room-spinning. In general, vertigo localizes to the inner ear, including the SCC and vestibular apparatus (peripheral vertigo), or to the brainstem and associated structures that receive and/or process vestibular input (central vertigo).
With regard to peripheral causes of vertigo, duration of symptoms provides some guidance in diagnosis, though it is by no means absolute. Very brief vertigo, lasting only one or two seconds, sometimes brought on by rapid head movements, should raise suspicion for a vestibular etiology. Such patients may report a prior history of prolonged vertigo in the setting of a viral infection, indicating prior vestibular neuronitis or labyrinthitis with residual dysfunction. Vertigo that lasts 10 to 30 seconds and recurs when the patient assumes a particular position, such as rolling to one side while lying in bed, is consistent with BPPV. Prolonged vertigo lasting for hours or days should raise suspicion for central causes, though acute labyrinthitis may also produce prolonged symptoms due to inflammatory changes.
Associated symptoms also provide important diagnostic and localizing information. Nausea or vomiting, especially in the setting of altered mental status or focal neurologic deficits, should raise suspicion for central vertigo with localization to brainstem structures. When vertigo is associated with aural pressure/fullness, hearing loss (low frequency), and tinnitus, Ménière disease (endolymphatic hydrops) should be suspected. Aural pressure or pain, along with fever, may also be seen in patients with serous or suppurative otitis media with secondary labyrinthitis.
Cholesteatomas are benign tumors that occur within the middle ear and are caused by ingrowth of skin from the eardrum. Depending on location and size, these may affect inner ear structures and produce vertigo. Classic symptoms of cholesteatoma include conductive hearing loss and foul-smelling otorrhea, and examination may reveal a whitish mass in the middle ear. If the patient has vertigo in the setting of unilateral headache, visual scintillations, and family history of migraine headaches, migraine with brainstem aura (MBA, previously called basilar-type migraine) should be considered. However, potentially emergent causes of central vertigo should be evaluated prior to making this diagnosis during a first-time presentation.
BPPV is the most common cause of vertigo, accounting for an estimated 20% of patients who present with vertigo. Although symptoms can be severe, it is called benign because it often is self-limited. It is paroxysmal due to its episodic nature. It is called positional due to the ability to produce symptoms in particular positions. For example, looking upward as one would while trying to reach for a top shelf can provoke this vertigo, giving rise to the synonym of top shelf syndrome (Table 37–1).
Clinical Evaluation
For many patients with vertigo, the physical examination is normal. The ears, cranial nerve function, and neurologic examination should be carefully assessed, with careful assessment of vestibular nerve function and neurologic examination. BPPV is associated with a geotropic rotatory nystagmus, indicating that fast phase rotation occurs toward the problematic inner ear when the head is tilted toward that side. For instance, if left-sided SCC otolithic disease exists, the expected finding would be counterclockwise (leftward) fast phase nystagmus when the head is tilted to the left. These findings can be produced during Dix-Hallpike testing. Starting in a sitting position, the patient is asked to turn their head 45 degrees to one side and then lies back while maintaining head position. The examiner looks for a rotatory nystagmus, which typically appears after 1 to 5 seconds, but can sometimes take up to 30 seconds to appear. Next, the patient is returned to seated position, the head is turned the opposite direction, and lies back once more. Frequently, the nystagmus will return, although in this circumstance its direction will be opposite of that seen before.
TREATMENT
Pharmacologic therapy for BPPV is limited. The first choice for many clinicians is canalith repositioning procedures, which include the Epley and Semont maneuvers. Both are noninvasive, office-based positioning maneuvers that aim to reposition displaced otoliths to their proper position, from the SCC back to the saccule. Vestibular rehabilitation may also provide benefit over longer periods of time.
CASE CORRELATION
- See Case 35 (Facial Paralysis)
COMPREHENSION QUESTIONS
37.1 A 33-year-old man is complaining of the room spinning. Which of the following tests is used to diagnose BPPV?
A. Weber test
B. Rinne test
C. Dix-Hallpike maneuver
D. Brandt-Daroff maneuver
E. Epley maneuver
37.2 A 40-year-old woman has recurring 30-minute episodes of disabling vertigo. The episodes are accompanied by roaring tinnitus, aural pressure, and low-frequency hearing loss. Her physical examination is normal. What is the most likely diagnosis?
A. BPPV
B. Acute suppurative labyrinthitis
C. Acute serous labyrinthitis
D. Ménière disease
E. Vertebrobasilar insufficiency
37.3 A 45-year-old woman complains of recurring episodes of vertigo. Her spells last 10 to 15 seconds and occur mostly when rolling out of bed (and once when changing a light bulb). She denies hearing loss or tinnitus. Her physical examination is normal except for rotatory nystagmus when she is lying with the right ear down. What is the most likely diagnosis?
A. Acute serous labyrinthitis
B. BPPV
C. Vestibular migraine
D. Ménière disease
E. Viral vestibular neuronitis
ANSWERS
37.1 C. The Dix-Hallpike maneuver is used to diagnose BPPV. It consists of positioning the patient from a sitting position to that of lying down with one ear down. The important findings of this test are a latent, geotropic, rotatory nystagmus. Frequently, a reverse of the nystagmus is found on return to a sitting position. The Weber and Rinne test are tuning fork tests for hearing assessment. The Epley maneuver and Brandt-Daroff exercises are used in the treatment of BPPV.
37.2 D. The symptoms described are the classic findings in Ménière disease. BPPV is characterized by rotatory nystagmus and has no associated hearing loss or tinnitus. Acute serous labyrinthitis and acute suppurative labyrinthitis produce vertigo that usually lasts for more than 1 day. Vertebrobasilar insufficiency is generally associated with other cranial nerve or central nervous system symptoms in the setting of risk factors for atherosclerosis.
37.3 B. The symptoms and physical findings are those of BPPV. Acute serous labyrinthitis and viral vestibular neuronitis have vertigo that lasts for more than 1 day. Vestibular migraine is more likely when the vertigo is associated with headache, especially when other neurologic symptoms and a family history are suggestive of migraine. Ménière disease has vertigo that lasts at least 20 minutes and is usually associated with hearing loss, roaring tinnitus, and aural pressure.
CLINICAL PEARLS
|
▶ BPPV is associated with geotropic
rotary nystagmus, which can help isolate the side of the problem and can be
observed during Dix-Hallpike testing.
▶ Nausea, altered mental status,
cranial nerve findings, or focal motor or sensory symptoms should raise
suspicion for central vertigo. Any of these symptoms warrants rapid
evaluation for posterior circulation stroke.
▶ BPPV usually is self-limited or resolves
with proper treatment maneuvers. If BPPV continues after the maneuvers have
been tried, a specialist such as an otolaryngologist, a head and neck
surgeon, or a neurologist should be involved. |
REFERENCES
Dorland’s Illustrated Medical Dictionary. 27th ed. Philadelphia, PA: WB Saunders; 1988.
Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992;107(3):399-404.
Faralli M, Cipriani L, Del zompo MR, Panichi R, Calzolaro L, Ricci G. Benign paroxysmal positional vertigo and migraine: analysis of 186 cases. B-ENT. 2014;10(2):133-139.
Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008;70(22):2067-2074.
Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014;(12):CD003162.
Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med. 2014; 370(12):1138-1147.
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