Vertigo is a common problem observed in patients who visit the emergency department and primary care. It is presented as a sensation of motion, usually rotational motion. This article will guide physicians to manage vertigo with the proper diagnosis. 

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Vertigo is a familiar situation presented as a sensation of motion, usually rotational motion. Benign paroxysmal positional vertigo is a commonly encountered cause of episodic vertigo in neurology clinics and general care settings. Careful assessment of associated nystagmus during positional testing can lead to a proper diagnosis of BPPV in most patients.

Vertigo is caused by vestibular dysfunction arising due to a peripheral or non-vestibular/central lesion. Nearly 80% of vertigo is peripheral whereas 20% is central.

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Peripheral vertigo and central vertigo

1. Peripheral vertigo is caused by issues in the peripheral vestibular system from the inner ear to the vestibular division of the VIIIth cranial nerve. While central vertigo takes place when there are lesions or dysfunction of the brainstem vestibular apparatus.
2. It is an acute severe form that occurs in an episodic manner. On the contrary, central vertigo is associated with less severe symptoms and occurs over a longer period.
3. Peripheral vertigo involves severe episodes which become worse with head movements. It is usually associated with horizontal or rotary nystagmus, which is fatigable and unidirectional. In central vertigo, nystagmus is not fatigable and typically multi-directional.
4. Benign paroxysmal positional vertigo (BPPV) is the most prevalent form of peripheral vertigo observed during clinical practice.

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Peripheral vertigo – Diagnosis and workup

1. The diagnostic approach for peripheral vertigo starts with a detailed medical history which is correlated with the symptoms and other clinical findings.
2. The Dix-Hallpike test is used to diagnose peripheral vertigo. This test makes the symptoms worse and nystagmus more obvious. Electro/ videonystagmography, sinusoidal harmonic acceleration (rotating-chair test), computerised dynamic posturography, and vestibular-evoked myogenic potential are some other procedures that can be used to diagnose peripheral vertigo.

Clinical practice guidelines on BPPV by the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF)

In 2017, an updated clinical practice guideline on BPPV has been put forth by the AAO-HNSF intending to help physicians make decisions more efficiently by offering an updated evidence-based framework.

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Diagnosis of posterior semicircular canal BPPV

The Dix-Hallpike test is the gold standard test for evaluating posterior semicircular canal BPPV. However, the accuracy of the test depends on the clinician’s expertise. Hence, a negative Dix-Hallpike test does not always rule out the diagnosis of posterior semicircular canal BPPV. As the negative predictive value for the Dix-Hallpike test is low, it is suggested to repeat the test at a separate visit to confirm the diagnosis and to avoid a false-negative result.

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Diagnosis of lateral (horizontal) semicircular canal BPPV

1. Patients with symptoms suggestive of BPPV but are negative for posterior semicircular canal BPPV (when the Dix-Hallpike test is done) should be tested for lateral semicircular canal BPPV by performing a supine roll test.
2. Some stark differences between lateral semicircular canal BPPV and posterior semicircular canal BPPV are mentioned below:
3. Nystagmus elicited by the supine roll test in lateral semicircular canal BPPV is predominantly horizontal, but nystagmus elicited by the Dix-Hallpike test in posterior semicircular canal BPPV is upbeat and torsional.
4. In the lateral semicircular canal BPPV, vertigo, and nystagmus are evoked by turning the head side to side while supine. However, in the posterior semicircular canal BPPV, vertigo, and nystagmus are induced by the Dix-Hallpike manoeuvre.

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Differential diagnosis

BPPV is frequently either underdiagnosed or misdiagnosed. Other causes of vertigo that may be confused with BPPV can be divided into otologic, neurologic, and other entities.

Radiographic imaging and Vestibular testing

BPPV is mainly diagnosed using the clinical history and physical examination. Routine radiographic imaging is not required in patients who meet the clinical criteria for the diagnosis of BPPV.

Radiographic imaging can be used in the following cases:

• Atypical clinical presentation
• The Dix-Hallpike test elicits findings with equivocal or unusual nystagmus
• The presence of additional symptoms suggests an accompanying modifying central nervous system (CNS) or otologic disorder

Similar to radiographic imaging, routine vestibular testing is not recommended in patients with a history and symptoms consistent with BPPV.

Vestibular testing can be used in the following cases:

• Atypical clinical presentation
• The Dix-Hallpike test elicits findings with equivocal or unusual nystagmus
• Unclear diagnosis
• The presence of additional symptoms suggests an accompanying modifying CNS or otologic disorder
• Suspicion of multiple concurrent peripheral vestibular disorders

Repositioning procedures as initial therapy

Evidence suggests that patients diagnosed with posterior or lateral semicircular canal BPPV should be treated with CRP. Consistent treatment with CRP can help eliminate disabling vertigo, which in turn can improve the quality of life and reduce the risk of falls.

Postprocedural restrictions

Currently, there is no evidence to recommend post-manoeuvre restrictions for most patients with posterior semicircular canal BPPV who are treated with a CRP.

Observation as initial therapy

1. Observation in BPPV means treatments such as vestibular rehabilitation (VR) and CRP will be withheld to check if the symptoms and the severity of BPPV will improve naturally and spontaneously.
2. During the observation period, patients should be instructed to avoid activities that may increase the risk of injury. There is no recommendation regarding the optimal period of observation for patients with symptomatic BPPV.

Medical therapy

Psychotropic medications such as benzodiazepines can be used as vestibular suppressants, but they have the potential to harm significantly. These suppressants may cause drowsiness, cognitive deficits, and interference with driving or operating machinery. They are also associated with a significant independent risk factor for falls. Polypharmacy is another challenge, especially in the elderly.

Outcome assessment

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Disclaimer- The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of M3 India.