eMedicine Specialties > Emergency Medicine > Neurology
Benign Positional Vertigo: Differential Diagnoses & Workup
Updated: Aug 24, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
| Headache, Migraine | Stroke, Hemorrhagic |
| Labyrinthitis | Stroke, Ischemic |
| Meniere Disease | Systemic Lupus Erythematosus |
| Multiple Sclerosis | Vestibular Neuronitis |
Other Problems to Be Considered
Acoustic schwannoma
Chronic otomastoiditis
Congenital malformation (inner ear)
Medications (alcohol, phenytoin, diuretics, salicylates, quinidine, quinine, barbiturates, antibiotics)
Otosclerosis
Ototoxicity
Polyarteritis nodosa
Posttraumatic injuries
Posterior fossa neurosurgery
Postsurgery (general)
Postsurgery (ear)
Vertebrobasilar insufficiency
Workup
Laboratory Studies
- No pathognomonic laboratory test for benign positional vertigo (BPV) exists. Laboratory tests may be performed to rule out other pathology.
Imaging Studies
- Currently, no imaging study can demonstrate the presence of otoliths.
- Head CT scanning or MRI is indicated if the diagnosis is in doubt.
Other Tests
- Although most patients with benign positional vertigo (BPV) have posterior semicircular canal involvement, some patients have horizontal canal involvement. This canal should be suspected if the patient has bilateral symptoms during the Hallpike test. Use the Roll test to formally diagnose horizontal canal BPV, and use the bar-b-que treatment to treat horizontal canal BPV.
- Roll test: Have the patient lie in the supine position on the gurney. Unlike the Hallpike test, the head does not need to hang over the edge of the gurney.
- Turn the patient's head 90° to one side. The patient should experience a reproduction of symptoms and the presence of horizontal nystagmus. The fast phase should beat toward the earth (geotropic).
- Now, turn the patient's head 180° (or 90° to the opposite side). The patient should again experience a reproduction of symptoms and the presence of horizontal nystagmus. The fast phase again beats toward the earth (note that it has changed direction). This is known as direction-changing nystagmus (nystagmus that changes direction based on turning the head) and is different from gaze-evoked nystagmus (which is nystagmus that changes direction depending on where the patient is looking, as in Dilantin toxicity).
- Note that both sides will have nystagmus and a reproduction of symptoms, but one side will be much more symptomatic (and demonstrate stronger nystagmus) than the other side. This is considered the involved side.
- A positive Roll test should be treated with the bar-b-que treatment (see Treatment).
- Head-thrust test
- When the Epley maneuver does not work, it may be because it is being applied inappropriately to patients with vestibular neuritis and labyrinthitis.
- The head-thrust test is used to diagnose vestibular neuritis and labyrinthitis.
- In this test, the patient is told to look at the examiner's nose. The examiner places both his or her hands on the patient's head and rapidly turns it approximately 10-15° to one side. If the vestibular apparatus is functioning properly, the patient will be able to maintain his or her focus on the examiner's nose. If the vestibular apparatus is not working properly, the patient's eyes will deviate to the side and then quickly jerk back to view the examiner's nose. This jerking eye movement is called a saccade and indicates a positive head-thrust test.
Procedures
- The Hallpike test, along with the patient's history, confirms the diagnosis of BPV. See Physical for details of this procedure.
- The modified Epley maneuver is used to treat posterior canal BPV (see Treatment as well as Media file 15 for a video demonstration).
More on Benign Positional Vertigo |
| Overview: Benign Positional Vertigo |
 Differential Diagnoses & Workup: Benign Positional Vertigo |
| Treatment & Medication: Benign Positional Vertigo |
| Follow-up: Benign Positional Vertigo |
| Multimedia: Benign Positional Vertigo |
| References |
| « Previous Page | Next Page » |
References
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. Jun 1991;66(6):596-601. [Medline].
[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. Nov 2008;139(5 Suppl 4):S47-81. [Medline]. [Full Text].
Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med. Nov 18 1999;341(21):1590-6. [Medline].
[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. May 27 2008;70(22):2067-74. [Medline]. [Full Text].
Epley JM. Particle repositioning for benign paroxysmal positional vertigo. Otolaryngol Clin North Am. Apr 1996;29(2):323-31. [Medline].
Baloh RW. Dizziness and vertigo. In: Samuels MA, Feske S. Office Practice of Neurology. London: Churchill Livingstone; 1996:83-91.
Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol. Aug 1980;106(8):484-5. [Medline].
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. Sep 2004;11(9):918-24. [Medline].
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. Jul 2000;75(7):695-700. [Medline].
Lempert T, Gresty MA, Bronstein AM. Benign positional vertigo: recognition and treatment. BMJ. Aug 19 1995;311(7003):489-91. [Medline].
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. Oct 2000;36(4):310-9. [Medline].
Massoud EA, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol. Apr 1996;25(2):121-5. [Medline].
Troost BT, Patton JM. Exercise therapy for positional vertigo. Neurology. Aug 1992;42(8):1441-4. [Medline].
Further Reading
Keywords
benign positional vertigo, benign paroxysmal positional vertigo, BPV, vertigo, dizziness, dizziness symptoms, dizziness treatment, inner ear, Hallpike test, Epley maneuver, lightheadedness, canalolithiasis theory, otoliths, Brandt exercise, Daroff exercise
near-syncope, dysequilibrium, disequilibrium, orthostatic hypotension, vasovagal episode, neurocardiogenic syncope, disorder of thevestibular proprioceptive system, labyrinthitis, vestibular neuronitis, nystagmus, torsional nystagmus, rotatory nystagmus, dizzy, head-hanging maneuvers, labyrinthine disease, otoconia, psychophysiologic dizziness
