Dizziness: Case #1 – Mr. J and BPPV

 

• J is a 32-year-old man who comes to your office complaining of dizziness.
• J reports that when he is dizzy, it feels as though the room is spinning. His first episode occurred 3 days ago when he rolled over in bed. The spinning sensation was very intense, causing nausea and vomiting. It lasted less than 1 minute.
• On further questioning, Mr. J reports that he had a similar episode 5 years ago. Other than nausea, he has no other symptoms. Specifically, he has not had definitive CNS symptoms like new severe headache or neck pain, diplopia, numbness, weakness, dysarthria, or trouble walking. He has no risk factors that increase the likelihood of central vertigo such as diabetes mellitus, hypertension, coronary artery disease or peripheral vascular disease (which increase the likelihood of cerebrovascular disease), no history of active cancer, and he is not taking any anticoagulants (which increase the likelihood of CNS hemorrhage). He has no prior history of neurologic complaints (eg, unilateral vision loss of optic neuritis or motor weakness). On physical exam, he appears anxious. His vital signs are BP, 110/70 mm Hg; RR,16 breaths per minute; pulse, 84 bpm; temperature, 37.0°C. HEENT exam reveals extraocular muscles intact with 15 beats of horizontal nystagmus on left lateral gaze. This stops after repeating the maneuver several times. Optic disks are sharp and visual fields are intact to confrontation. Cardiac, pulmonary, and abdominal exams are normal. On neurologic exam, cranial nerves are intact (except for nystagmus). Hearing is grossly normal. Gait and finger-to-nose testing are normal. Romberg is negative.

• Mr. J’s history is characteristic of BPPV. At this point, the Dix-Hallpike maneuver should be performed to evaluate positional nystagmus.
• Mr. J reports intense vertigo with the maneuver. Horizontal nystagmus with a rotary component is noted, which lasts for 20 seconds. After repeating the maneuver, the nystagmus disappears.
• Mr. J’s history, physical exam, and response to Dix-Hallpike maneuver are entirely consistent with peripheral vertigo. There are no alarm features to suggest central vertigo. The duration of each vertiginous episode suggests BPPV rather than vestibular neuritis or Meniere disease. There is no tinnitus or hearing loss to suggest Meniere disease. Further testing is not indicated.
• An Epley maneuver is performed resulting in resolution of Mr. J’s symptoms. One month later he returns and is feeling well.

S – 32-year-old man complains of dizziness first occurring 3 days ago seeks treatment now for intense spinning sensation, like the room is spinning, that caused nausea and vomiting lasting no longer than 1 minute. These symptoms first occurred when he rolled over in bed. States similar episode occurred 5 years ago. Denies any other symptoms, medical Hx or medication use. He does not have any pertinent risk factors that could lead to cerebrovascular disease.

 

O –  BP 110/70 mm Hg; RR 16 breaths per minute; pulse 84 bpm; temperature 37.0°C.

 

HEENT exam shows extraocular muscles intact with 15 beats of horizontal nystagmus on left lateral gaze, stops after repeating the maneuver several times. Optic disks are sharp and visual fields are intact to confrontation. Gait and finger-to-nose testing are normal. Romberg is negative.

 

On neurologic exam, cranial nerves are intact (except for nystagmus). Hearing is grossly normal. 

 

Dix-Hallpike maneuver performed to evaluate positional nystagmus, intense vertigo reported. Horizontal nystagmus with a rotary component is noted, which lasts for 20 seconds. No tinnitus or hearing loss noted. Maneuver repeated, nystagmus disappeared.

 

Cardiac, pulmonary, and abdominal exams are normal. 

 

Appears anxious.

 

A – Signs/symptoms consistent with peripheral vertigo, likely BPPV (Benign Paroxysmal Positional Vertigo)

 

R/O vestibular neuritis, Meniere’s disease

 

P – Epley maneuver performed resulting in resolution of symptoms

 

One month F/U – Patient reports feeling well.

 

 

            The other differential diagnoses of vestibular neuritis and Meniere’s disease were easily ruled out by further testing and questioning of the patient but were considered in the first place due to their similar symptoms to BPPV. Vestibular neuritis has a sudden onset and vertigo exacerbated by head motion, like in BPPV, but the symptoms are constant rather than in short intermittent spells. Meniere’s disease, like BPPV, has sudden onset vertigo spells that are intermittent. However, these spells usually last for minutes or hours and are accompanied by tinnitus and hearing loss. According to Mr. J’s symptoms and test results, he was described as having textbook BPPV and these other diagnoses were easily ruled out. Most patients seem to recover from BPPV symptoms regardless of treatment but can take weeks to months to resolve on their own. The Epley Maneuver used is a “complex rotational maneuver that repositions the canalith and is 80–95% effective at stopping vertigo.” [1] This was an effective treatment for Mr. J and he remained without symptoms one month after treatment. This maneuver is preferred and used first as medications, such as vestibular suppressants like meclizine and benzodiazepines, tend to cause drowsiness and make imbalance worse. They are only considered when the vertigo spells are frequent and intolerable or if the Epley maneuver doesn’t alleviate vertigo symptoms. There are also surgical options but are rarely ever considered necessary.

 

 

Sources:

[1] https://accessmedicine-mhmedical-com.york.ezproxy.cuny.edu/content.aspx?bookid=1088§ionid=61698199#1102644122

Dizziness. In: Stern SC, Cifu AS, Altkorn D. eds. Symptom to Diagnosis: An Evidence-Based Guide, 3e New York, NY: McGraw-Hill; 2014. http://accessmedicine.mhmedical.com.york.ezproxy.cuny.edu/content.aspx?bookid=1088§ionid=61698199. Accessed October 30, 2018.