Vertigo Makes the World Go Round – A Case of BPPV: Medical Student Clinical Pearl

Johnathan Rose, Med III

Class of 2022

Dalhousie Medical School New Brunswick (DMNB)

Reviewed by Dr. Maria Kovalik

Copyedited by Dr. Mandy Peach

Case:

A 73-year-old female presented to the emergency department via EMS with a three-day history of dizziness and associated nausea. On further questioning she stated that the dizziness began suddenly when she awoke three days prior. It felt like her environment was spinning and was made worse with movements. Episodes lasted about 30-60 seconds and would resolve if she stayed still. Her mobility was impaired due to feeling unsteady on her feet. She felt nauseous when dizzy but had no emesis; Gravol provided mild relief. She denied any headaches, vision/hearing changes, chest pain, shortness of breath, bowel/bladder changes, recent infections, muscle weakness, paresthesia, or constitutional symptoms.

 

She was an otherwise healthy 73-year-old with no past medical or surgical history. She was taking no medications. She did not smoke, drink alcohol, or use any recreational drugs.

 

Physical Exam:

 

The patient’s vital signs were all within normal limits and stable. Upon inspection, she appeared her stated age, was well kempt, and was laying very still with her eyes closed. She was alert and oriented x3. Her cranial nerve exam II-XII was normal. She had 5/5 strength in upper and lower limbs bilaterally. Tympanic membranes were normal bilaterally.

 

Upon sitting up, she had mixed horizontal and torsional nystagmus in her eyes bilaterally, as well as when she laid back down (Figure 1). When performing the Dix-Hallpike manoeuvre, she had mixed horizontal and torsional nystagmus when her head was tilted both left and right.

From: https://icrcat.com/en/nystagmus/

Figure 1. Types of Nystagmus. Diagram showing the 3 major forms of nystagmus: horizontal, vertical, and rotary.

 

 

What is vertigo?

 

There are four main types of dizziness: vertigo, light-headedness, presyncope, and disequilibrium. Vertigo is the most common, accounting for 54% of presentations¹. Vertigo is the sensation of dizziness or illusory movement. Some people may perceive it as the environment moving while others perceive self-motion. It is often caused because of asymmetry in the vestibular system or dysfunction of the labyrinth, vestibular nerve, or central vestibular structures located in the brainstem². Vertigo is a symptom, not a diagnosis, and the causes can be broken into two broad categories: central and peripheral³.

 

 

Does this patient have a central or peripheral cause of vertigo?

 

The history alone from a patient presenting with vertigo is able to correctly reveal the diagnosis in ¾ patients¹. Therefore, it is necessary to ask questions that will help differentiate the causes of vertigo, as further investigations may not be helpful in doing so (Table 1).

 

Table 1. Distinguishing features between central and peripheral causes of vertigo^{1, 4}.

	Peripheral	Central
Onset	Sudden	Gradual
Intensity	Severe	Mild
Duration	Seconds	Continuous
Nystagmus	Horizontal and torsional; can be inhibited by fixation of gaze	Purely vertical, horizontal, or torsional; cannot be inhibited by fixation of gaze
Associated neuro findings	Rare	Common
Tinnitus	Common	Rare
Nausea/Vomitting	Frequent, severe	Infrequent, mild

 

Physical exam for differentiating between central and peripheral vertigo should include a HINTS exam

Interpretation of the HINTS

“A benign HINTS exam is defined as abnormal HIT + direction-fixed horizontal nystagmus + absent skew.

A dangerous HINTS exam is defined as any one of:

• Normal/untestable HIT
• or direction-changing horizontal nystagmus present/untestable
• or skew deviation present/untestable

(Untestable refers to those patients with obvious oculomotor pathology or lethargy in whom the tests were unable to be completed).

 

The acronym INFARCT can be used to remember what constitutes a dangerous HINTS exam:

Impulse Normal

Fast-phase Alternating

Refixation on Cover Test.”⁸

 

Based on her history and physical exam findings, it is likely that our patient has peripheral vertigo.

 

What is the differential diagnosis for central vertigo¹?

• Multiple sclerosis
• Migraine
• Transient ischemic attack or stroke
• Brain tumor

 

What is the differential diagnosis for peripheral vertigo¹?

• Benign positional paroxysmal vertigo (BPPV)
• Ménière’s disease
• Vestibular neuronitis
• Acute labyrinthitis
• Otosclerosis

 

What type of peripheral vertigo does our patient have?

The most common causes of peripheral vertigo are BPPV, Ménière’s disease, and vestibular neuronitis⁵. Table 2 illustrates some of the features that can be used to distinguish the causes of peripheral vertigo.

Table 2. Distinguishing features between common causes of peripheral vertigo⁵.

Ddx	Duration	Provoking Factors	Special features	Physical exam findings
Labyrinthitis	Seconds – Minutes	Change in position	Hearing loss and tinnitus	Hearing loss
Vestibular neuronitis	Seconds – Minutes	URTI	Imbalance	Normal hearing
BPPV	Seconds – Minutes	Change in position	Positional	Positive Dix-Hallpike
Ménière’s disease	Hours	Spontaneous	Hearing loss and tinnitus	Hearing loss

 

 

 

Taking into account both the history and physical exam, our patient has clear case of BPPV. She had a sudden onset of dizziness that is worse with changes in position and lasts 30-60 seconds before resolving if still. She had associated nausea and no other neurological signs. This, along with a positive Dix-Hallpike, is enough to secure the diagnosis.

 

BPPV Pathophysiology

BPPV is caused by canalithiasis, often calcium carbonate crystals, within the semicircular canals (Figure 2). The semicircular canals normally function to detect angular movements of the head. However, these heavy stones can cause inappropriate movement of the endolymph within the canals during times of linear accelerations, such as with gravity. Ultimately, this causes the improper sensation of spinning when the head shifts with respect to gravity⁶.

From: https://balanceanddizziness.org/disorders/vestibular-disorders/bppv/

Figure 2. Mechanism of BPPV. Calcium crystals normally found within the utricular cavity are displaced and fall into the semicircular canals. Once displaced, they then cause the erroneous sensation of spinning when the head moves⁶.

 

Treatment

 Although episodes of dizziness last seconds to minutes, the symptoms may persist for up to two weeks, and will often resolve spontaneously⁶. Symptoms may recur after remission⁵.

Treatment options are limited for those with BPPV. Medications are often not helpful, and treatment with vestibular suppressant medications such as antihistamines and/or benzodiazepines should be avoided⁷. For those who find the symptoms to be too distressing, the Epley maneuver may be performed to try and dislodge the otoliths from the semicircular canals (Figure 3)⁶. This maneuver has roughly a 77% success rate in the literature, but anecdotally seems to be less while also making patients more nauseous⁵.

Figure 3. Epley Maneuver. Steps involved in trying to reposition the calcium debris within the semicircular canals to migrate toward the common crus and exit into the utricular cavity⁶.

 

Our Case

Our patient ended up having BPPV that would likely resolve on its own within 2 weeks. No further diagnostic workup was required. Treatment options were limited; she was disappointed when she learned we had no medications that would provide her relief of her spinning world. The Epley maneuver was offered with the premise that it may or may not help relieve symptoms but will likely make her more nauseous, which she declined.

 

Clinical Pearls

 

• Vertigo is a symptom, not a diagnosis.
• A detailed history is required to elicit features of central or peripheral causes of vertigo.
• Serious causes of central vertigo need to be considered.
• Physical examination should include a neurological, cardiovascular, eye, and ear exam.
• Rule out orthostatic hypotension by seeing if the patient feels dizzy when they sit up as well as when they lay down.
• Treatment with vestibular suppressant medications such as antihistamines and/or benzodiazepines should be avoided⁷.
• The Epley maneuver may be useful in some patients but will likely increase their nausea.

 

References

1. Labuguen RH. Initial Evaluation of Vertigo. Am Fam Physician. 2006;73(2):244-251.
2. Evaluation of the patient with vertigo. https://www.uptodate.com/contents/evaluation-of-the-patient-with-vertigo?search=vertigo&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H1
3. Baumgartner B, Taylor RS. Peripheral Vertigo. StatPearls. 2020. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430797/
4. Chang AK. Dizziness and vertigo. In: Mahadevan SV, Garmel GM, editors. An Introduction to Clinical Emergency Medicine. 2nd ed. Cambridge: Cambridge University Press; 2012. p. 289–300.
5. Dommaraju S, Perea E. An approach to vertigo in general practice. Australian Family Physician. 2016;45(4):190-194.
6. Benign paroxysmal positional vertigo. https://www.uptodate.com/contents/benign-paroxysmal-positional-vertigo?search=vertigo&source=search_result&selectedTitle=5~150&usage_type=default&display_rank=5#H4
7. Stanton M, Freeman AM. Vertigo. StatPearls. 2021. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482356/
8. MacKay, J. HINTS exam in Acute Vestibular Syndrome. 2016. Retrieved Oct 26, 2021 from https://sjrhem.ca/resident-clinical-pearl-hints-exam-in-acute-vestibular-syndrome/