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Benign Positional Vertigo in Emergency Medicine Clinical Presentation

  • Author: Andrew K Chang, MD; Chief Editor: Robert E O'Connor, MD, MPH  more...
 
Updated: May 28, 2015
 

History

When asked about their dizziness, patients with benign positional vertigo (BPV) characteristically describe that the room or world is spinning. However, other descriptions, such as rocking, tilting, somersaulting, and the like, are also possible. All that matters is that an illusion of motion is caused by a misperception of a stimulus (the otoliths). Diagnosis of BPV is based on a characteristic history and a positive Hallpike test.

Episodic vertigo may occur with the following head movements:

  • Rolling over in bed
  • Lying down
  • Sitting up
  • Leaning forward
  • Turning the head in a horizontal plane

Symptoms of BPV are usually worse in the morning (the otoliths are more likely to clump together as the patient sleeps and exert a greater effect when the patient gets up in the morning) and mitigate as the day progresses (the otoliths become more dispersed with head movement).

Nausea is typically present (vomiting is less common).

A history of head trauma may be present, especially in young patients with BPV. The head trauma may dislodge the otoliths off the hair cells within the utricle, allowing them the opportunity to enter the semicircular canals.

Eliciting that the individual episodes of vertigo in BPV last for seconds at a time is important. Patients may describe that they are having continuous vertigo, when in reality, they are having repeated episodes (with each episode typically lasting seconds or less than a minute). Patients with vestibular neuritis and labyrinthitis have continuous vertigo, often for hours to days.

During the interview, if patient states that the "room is spinning" while the patient's head is still and prior to any manipulative tests, then it is highly unlikely that the patient has BPV because the vertigo in BPV lasts for seconds at a time and occurs only after head movement.

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Physical

In addition to the patient's history, a diagnosis of benign positional vertigo (BPV) is confirmed by a positive Hallpike test (see video below).[2, 3]

Hallpike test. In this example, the right posterior semicircular canal is being tested. Note that the head extends over the edge of the gurney. The thumb can be used to help keep the eyelids open since noting the direction of the nystagmus is important.

In this test, the patient is placed in the head-hanging position after turning the head 45 degrees to one side. After a short delay of a few seconds, nystagmus and reproduction of the vertigo occurs and typically resolves within 30-60 seconds. In general, the Hallpike test will be positive on one side (the side with the otoliths in the posterior semicircular canal) and negative on the other side. The neurologic examination is otherwise unremarkable.

Nystagmus (an involuntary rhythmic oscillation of the eyes) is described in terms of the fast-phase component.

Classic nystagmus occurs when the patient's head is dependent and turned to the affected side.

The nystagmus is torsional or rotatory. In the head-hanging position, the fast phase should beat toward the forehead (upbeat) and in the same direction as the affected side (ipsilateral). Although some describe the fast phase in terms of being clockwise or counterclockwise, most experts avoid this terminology because it can be unclear if the clock is being viewed from the patient's or physician's perspective.

Nystagmus usually occurs within 10 seconds after positioning but may present as late as 40 seconds. Hence, if the history is classic, observe the patient for at least 40 seconds while he or she is in the head-hanging position during the Hallpike test.

The duration of the observed nystagmus varies from a few seconds to a minute and parallels the sensation of vertigo.

Response fatigues if the patient is repeatedly placed into the provoking position (due to dispersion of the otoliths).

Note: If the patient has a classic history of BPV (after a short delay, the room spins, but then revolves in 20-30 seconds, and then the rooms spins in the opposite direction when he or she sits back up) but no nystagmus is seen during the Hallpike test, most experts would agree to treat the patient with the modified Epley maneuver because nystagmus may be blocked by fixation suppression and emergency physicians do not have access to Frenzel lenses that specialists use to block fixation suppression (see Treatment).

One study showed that treating such patients with the Epley maneuver is still effective (despite the lack of nystagmus). Again, these patients should have a classic history and be symptomatic during Hallpike testing.

Perform the Hallpike test as follows (Caution: For patients with cervical spondylosis, it may not be advisable to extend the neck. However, because having the head dependent is important, the same effect can be achieved if the gurney is placed in the Trendelenburg position for such patients).

First, warn the patient that symptoms of vertigo will likely be reproduced but will resolve after a few seconds.

Seat the patient close enough to the end of the gurney so that when he or she lies supine, the head can extend backward an additional 30-45°.

Instruct the patient to keep his or her eyes open because you want to observe the direction of the nystagmus. The examiner may need to use his thumb to hold the eyelid open because patients may involuntarily close their eyes even when instructed to keep them open.

To test the left posterior canal, follow these steps:

  • Turn the patient's head 45° to the left. This position orients the head such that the left posterior semicircular canal is going to be in the same plane as the upcoming head movement (next step). This is the most provocative way to move the otoliths (if they are indeed in the posterior semicircular canal) which will result in a positive test.
  • With your hands on either side of the patient's head, lay the patient down until the head is dependent (hanging over the edge of the gurney). Note that this step does not need to be performed rapidly.
  • Check for reproduction of symptoms and nystagmus. In most cases, the fast phase of the nystagmus should be upbeat (toward the forehead) and ipsilateral (in this example, toward the patient's left).
  • Return the patient to the upright position. Nystagmus may be observed in the opposite direction, and the patient may describe that the world is spinning in the opposite direction.

To test the right posterior canal, repeat the Hallpike test with the head turned 45° to the right side. In general, if the patient has BPV, only one side should test positive during the Hallpike test. Although having bilateral posterior semicircular canal BPV is possible, it is unlikely and should suggest horizontal canal involvement, vestibular neuritis/labyrinthitis, or a central cause.

Note that many patients experience mild dizziness when being brought up from the head-hanging position to the sitting position. It is important not to confuse this dizziness (which is more lightheaded in character) with true vertigo.

If the patient's head cannot be extended over the edge of the gurney, 2 additional options exist. The first is to place the patient in the Trendelenburg position if a gurney that allows this position is available. The other alternative is to use the side-lying test; the patient sits with his or her legs over one side of the gurney. To test the left posterior semicircular canal, turn the patient's head 90° to the opposite side (in this case, the right side). Then, lay the patient on his or her left side. By turning the patient's head to the right, the left posterior semicircular canal is aligned in the same plane as the sideways movement. As in the Hallpike test, this will allow the greatest chance for otoliths to move if they are indeed located in the posterior semicircular canal.

The neurologic examination findings should be otherwise normal; if not, strongly consider alternative diagnoses.

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Causes

Several disorders affecting the peripheral vestibular system may precede the onset of benign positional vertigo (BPV).

  • Idiopathic (50-60%)
  • Infection (viral neuronitis)
  • Head trauma, especially in younger patients
  • Degeneration of the peripheral end organ
  • Surgical damage to the labyrinth
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Contributor Information and Disclosures
Author

Andrew K Chang, MD Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center

Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

J Stephen Huff, MD, FACEP Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD, FACEP is a member of the following medical societies: American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Association for Physician Leadership, American Heart Association, Medical Society of Delaware, Society for Academic Emergency Medicine, Wilderness Medical Society, American Medical Association, National Association of EMS Physicians

Disclosure: Nothing to disclose.

Additional Contributors

Edward Bessman, MD, MBA Chairman and Clinical Director, Department of Emergency Medicine, John Hopkins Bayview Medical Center; Assistant Professor, Department of Emergency Medicine, Johns Hopkins University School of Medicine

Edward Bessman, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. Froehling DA, Silverstein MD, Mohr DN, Beatty CW, Offord KP, Ballard DJ. Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota. Mayo Clin Proc. 1991 Jun. 66(6):596-601. [Medline].

  2. [Guideline] Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov. 139(5 Suppl 4):S47-81. [Medline]. [Full Text].

  3. Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med. 1999 Nov 18. 341(21):1590-6. [Medline].

  4. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014 Dec 8. 12:CD003162. [Medline].

  5. [Guideline] Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, 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 May 27. 70(22):2067-74. [Medline]. [Full Text].

  6. Epley JM. Particle repositioning for benign paroxysmal positional vertigo. Otolaryngol Clin North Am. 1996 Apr. 29(2):323-31. [Medline].

  7. Kim AS, Fullerton HJ, Johnston SC. Risk of vascular events in emergency department patients discharged home with diagnosis of dizziness or vertigo. Ann Emerg Med. 2011 Jan. 57(1):34-41. [Medline].

  8. Baloh RW. Dizziness and vertigo. Samuels MA, Feske S. Office Practice of Neurology. London: Churchill Livingstone; 1996. 83-91.

  9. Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol. 1980 Aug. 106(8):484-5. [Medline].

  10. Chang AK, Schoeman G, Hill M. A randomized clinical trial to assess the efficacy of the Epley maneuver in the treatment of acute benign positional vertigo. Acad Emerg Med. 2004 Sep. 11(9):918-24. [Medline].

  11. Froehling DA, Bowen JM, Mohr DN, et al. The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc. 2000 Jul. 75(7):695-700. [Medline].

  12. Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med. 2014 Mar 20. 370(12):1138-47. [Medline].

  13. Lempert T, Gresty MA, Bronstein AM. Benign positional vertigo: recognition and treatment. BMJ. 1995 Aug 19. 311(7003):489-91. [Medline].

  14. Marill KA, Walsh MJ, Nelson BK. Intravenous Lorazepam versus dimenhydrinate for treatment of vertigo in the emergency department: a randomized clinical trial. Ann Emerg Med. 2000 Oct. 36(4):310-9. [Medline].

  15. Massoud EA, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol. 1996 Apr. 25(2):121-5. [Medline].

  16. Troost BT, Patton JM. Exercise therapy for positional vertigo. Neurology. 1992 Aug. 42(8):1441-4. [Medline].

 
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Anatomy of the semicircular canals.
Epley maneuver. Move the patient back in the gurney such that when he lies down, his or her head will hang over the edge of the gurney. Emphasize to the patient to keep his or her eyes open during each position so that nystagmus can be observed. Lower the guardrails of the gurney on the opposite side from which the patient's head is turned.
Epley maneuver. Turn the patient's head 45° to the side that had the most prominent symptoms during the Hallpike test. In this example, the patient's head is turned 45° to the left. With both hands holding the patient's head, gently lay the patient down in the supine position with the head hanging over the edge of the bed. Note: Each maneuver does not need to be performed rapidly. The Epley maneuver is positional, not positioning.
Epley maneuver. The patient's head should be at 45° and hanging off the edge of the bed. Observe the patient's eyes and look for torsional nystagmus. Keep the patient in this position for at least 30 seconds or until the nystagmus or symptoms resolve.
Epley maneuver. Because the patient's head will be turned 90° in the other direction, the physician needs to move to the head of the gurney and regrip the patient's head so that the fingers are pointing toward the patient's feet.
Epley maneuver. Turn the patient's head 90° in the opposite direction (in this case, the patient's head is now facing to the right). Again, observe for nystagmus and hold this position for at least 30 seconds or until nystagmus or symptoms resolve.
Epley maneuver. Close-up view of step shown in Media file 6.
Epley maneuver. Ask the patient to turn onto his or her shoulder.
Epley maneuver. Guide the patient's head down so that he or she is looking at the ground. Again, wait for at least 30 seconds.
Epley maneuver. Close-up of view shown in Media file 9.
Epley maneuver. The patient's head needs to be regripped again. Then, the patient needs to sit up with the legs hanging over the side of the gurney (which is why the guardrails need to be lowered before the start of the procedure).
Epley maneuver. The patient is now sitting upright.
Epley maneuver. Move the patient's head slightly forward. This completes the Epley maneuver. The maneuver may be performed multiple times.
Hallpike test. In this example, the right posterior semicircular canal is being tested. Note that the head extends over the edge of the gurney. The thumb can be used to help keep the eyelids open since noting the direction of the nystagmus is important.
Epley maneuver. In this example, the left posterior semicircular canal is being treated. In this clip, the maneuvers are performed quickly. In a real patient, each position should be held for at least 30 seconds or until resolution of the nystagmus and vertigo.
Semont maneuver. Generally reserved for the cupulolithiasis form of benign positional vertigo, in which the otoliths are attached to the cupula of the semicircular canal. This maneuver has to be performed rapidly to be effective, and it is not recommended in elderly persons. In this example, the right posterior semicircular canal is being treated.
Bar-b-que maneuver. This maneuver is used to treat horizontal canal benign positional vertigo. In this example, the right horizontal canal is being treated. Each position should be held at least 20-30 seconds.
 
 
 
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