Vertigo: Diagnosis and Management
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Expires December 31, 2014
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Benign paroxysmal positional vertigo accounts for approximately 42% of cases of vertigo seen in primary care settings and is the single most common cause of vertigo in the United States. Our expert outlines an evidence-based approach to diagnosis, which results in an increase in desirable patient outcomes and a decrease in unnecessary tests and medications.
LABORATORY WORK-UP AND IMAGING
There is no lab work that assists in making the diagnosis of BPPV. Radiographic imaging21 and laboratory testing are not beneficial and are in fact unnecessary and inappropriate in the patient with probable BPPV.6,8,20 There are no radiologic findings in the patient with BPPV alone.4,22 Clinical practice guidelines recommend against radiologic imaging in patients with BPPV, unless the diagnosis is uncertain or there are additional or unrelated exam findings or symptoms that justify testing.4
DIAGNOSIS
The Dix-Hallpike maneuver is considered the gold standard for diagnosing BPPV,4 although it is possible for the Dix-Hallpike test results to be negative in a patient with BPPV. If the test is negative and there is a strong clinical suspicion for BPPV, the patient may need to come back for a second visit to repeat the maneuver.4 The clinician may also consider referral to a specialist who performs vestibular function testing in order to decrease the time from the onset of symptoms to diagnosis and proper treatment.
According to the AAOHNS guidelines for BPPV, the specific diagnostic criteria for posterior canal BPPV include the patient history of repeated episodes of vertigo related to changes in head position; vertigo and nystagmus elicited on physical exam by the Dix-Hallpike test with a latency period between the onset and completion of the test; and an increase in intensity and then resolution within a minute of onset of the provoked vertigo and nystagmus.4
Patients should be questioned about associated hearing loss. Vertigo accompanied by hearing loss is typically not BPPV, but can be caused by Ménière’s disease or labyrinthitis. Patients presenting with Ménière’s disease commonly have sustained vertigo (lasting for hours), tinnitus, and fluctuating hearing loss.4 Vestibular labyrinthitis typically presents with severe vertigo that lasts from days to weeks (constant and not related to movement), severe nausea and vomiting, hearing loss, and tinnitus.4
Orthostatic hypotension, another cause of dizziness, should always be in the differential. Visual changes, ataxia, confusion, slurred speech, and numbness point to central causes of dizziness such as vertebrobasilar ischemic stroke or vertebrobasilar insufficiency.20
Once the BPPV diagnosis is made, it should be documented in the patient’s medical record. Using a diagnosis code for vertigo or dizziness is insufficient because it only describes the patient’s symptoms and is inadequate for follow-up and continuity of care. Nor does such a code provide the patient with the concise diagnosis needed to engage in self-care. Further, the incidence of the disease remains undocumented for purposes of research on BPPV.
On the next page: Treatment and management >>
