Benign paroxysmal positional vertigo diagnostic study of choice

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Fahimeh Shojaei, M.D.

Overview

The diagnostic study of choice for BPPV is patient history and observing nystagmus on Dix-Hall pike maneuver.

Diagnostic Study of Choice

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Study of choice

The diagnostic study of choice for BPPV is patient history and observing nystagmus on Dix-Hall pike maneuver.

Investigations:

• Among the patients who present with clinical signs of BPPV, the Dix-Hallpike maneuver is the most specific test for the diagnosis.

Diagnostic results

The following findings are confirmatory for BPPV:

• Recurrent brief vertigo attack which starts with certain head movements.
• Nystagmus on Dix-Hallpike maneuver.

Sequence of Diagnostic Studies

The various investigations must be performed in the following order:

• Patient history
• Physical examination (Dix-Hall pike maneuver)

If patients doesn't respond to treatment or doesn't show the typical nystagmus on Dix-Hall pike maneuver, in order to rule out other abnormalities we may perform some additional test such as:

• Electronystagmography (ENG) or video nystagmography (VNG)
• Audiometry
• Neuroimaging

For more information about these tests, click here.

Diagnostic criteria for posterial canal BPPV

Subtypes	Explanation
History	Brief recurrent vertigo attack starts with change in head position
Physical exam	Vertigo and nystagmus after Dix-Hall pike maneuver Brief delay between performing Dix-Hall pike maneuver and vertigo The vertigo and nystagmus will resolve after 60 seconds

Diagnostic approach

Diagnostic approach to a patient with dizziness:

Patient present with dizziness

Loss of consciousness?

Yes

No

Sense of motion/ spinning?

Other

Sweating Heaviness sensation in the legs "Tunnel" vision Feeling warm or hot Nausea Vomiting

History of seizure Aura Post-ictal phase Uncontrollable muscle spasms Drooling or frothing at the mouth Teeth clenching Tongue biting Sudden, rapid eye movements

Yes

No

Electrolyte imbalance/ Intracranial process

Syncope

Seizure

Vertigo

Sudden, and generally momentary, loss of consciousness, or blacking out caused by the Central Ischaemic Response

Temporary abnormal electro-physiologic phenomenon of the brain, resulting in abnormal synchronization of electrical neuronal activity

Sudden onset? Horizental nystagmus? Auditory symptoms? No neurological problem?

Causes: •Hemorrhage •Hypotension •Hypoxia •Pulmonary embolism •Ruptured abdominal aortic aneurysm •Ventricular arrhythmia •Arrhythmia •Medication •Orthostatic hypotension •Vagal stimulation •Vertebrobasilar insufficiency

Causes: •Brain damage •Congenital abnormalities •Stroke •Infection •Genetic syndromes •Brain tumor •Epilepsy

Yes

No

Peripheral

Central

BPPV Vestibular neuritis HSV oticus Meniere disease Labyrinthine concussion Perilymphatic fistula Semicircular canal dehiscence syndrome Vestibular paroxysma Cogan syndrome Vestibular schwannoma Otitis media Aminoglycoside toxicity Recurrent vestibulopathy

Vestibular migraine Epileptic vertigo Multiple sclerosis Brain tumors Crebellar infarction/hemorrhage Brain stem ischemia Chiari malformation Parkinson

Hyperventilation Psychiatric symptoms

Balance problem

Sweating Tunnel Vision Nausea Heart palpitations Abdominal discomfort Slurred speech

Psychogenic dizziness

Dysequilibrium

Presyncope

Dizziness which is not characterized by true vertigo and it can be replicated by hyperventilation and psychiatric symptoms that usually precede its onset.

Impaired sense or absence of balance or equilibrioception that primarily occurs during standing or walking

Feeling of lightheadedness that can lead to syncope

Causes: •Alcohol dependence •Conversion disorder •Fibromyalgia •Generalized anxiety •Hyperventilation •Major depression •Panic disorder

Causes: •Arrhythmia •Asthma exacerbation •Cerebellar hemorrhage •Compartment syndrome •Endophthalmitis •Epilepsy •Hypoglycemia •Organophosphates •Cerebellar disorders •Gait abnormality •Hypoglycemia •Paralysis •Peripheral neuropathy •Vestibular disorders •Visual impairment

Causes: •Hemorrhage •Hypotension •Hypoxia •Pulmonary embolism •Ruptured abdominal aortic aneurysm •Ventricular arrhythmia •Arrhythmia •Medication •Orthostatic hypotension •Vagal stimulation •Vertebrobasilar insufficiency