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A 61-year-old man is evaluated for dizziness that started about 2 days ago while he was looking over his shoulder. He describes the symptoms as “room spinning” dizziness and mild nausea. The symptoms resolved within several minutes when he lay back on the couch and was perfectly still. They recurred several hours later while turning in bed and the next day while backing out of his driveway. He denies diplopia, slurred speech, confusion, motor weakness, paresthesias, tinnitus, antecedent infection, or hearing loss. He has no other medical problems and takes no medications.
Vital signs are normal. The cardiopulmonary examination is normal. Peripheral nystagmus and reproduction of symptoms on the Dix-Hallpike maneuver when the head is turned right are demonstrated. There are no focal neurologic defects. Visual acuity and hearing are normal.
Which of the following management options is the best choice for this patient?
B. Brain MRI with magnetic resonance angiography
C. Cardiac event monitor recording
D. Epley canalith repositioning maneuver
Answer: D, Epley canalith repositioning maneuver.
Educational Objective: Manage benign paroxysmal positional vertigo.
Critique: The patient has benign paroxysmal positional vertigo. Key diagnostic features are precipitation with head movement; recurrent episodes over days to weeks that last for several minutes each; reproduction of symptoms and peripheral nystagmus with a Dix-Hallpike maneuver; and a lack of associated hearing loss, tinnitus, or neurologic findings. The disease typically is self-limited and may recur months to years later. The Epley maneuver to reposition otolith debris within the patient’s semicircular canal is effective in eliminating symptoms and has minimal adverse effects.
Audiometry is most useful in patients with signs and symptoms suggestive of Meniere disease or acoustic neuroma and is not routinely indicated in most patients with vertigo. Meniere disease is usually associated with unilateral tinnitus, ear fullness, and hearing loss. An acoustic neuroma most often presents with unilateral hearing loss or tinnitus and nonspecific feelings of imbalance. Severe acute vertigo as a presenting symptom is unusual for an acoustic neuroma.
Neuroimaging should usually be reserved for patients with cerebellar or focal neurologic symptoms or vertical nystagmus; brain MRI with magnetic resonance angiography is not indicated in this patient.
Methylprednisolone is an effective therapy for acute vestibular neuronitis. However, this patient does not have persistent symptoms, severe symptoms, or a history of antecedent infection that would be more characteristic of vestibular neuronitis. Therefore, treatment with methylprednisolone is not indicated.
A cardiac dysrhythmia could cause episodic symptoms lasting for minutes spread out over days to weeks and may be detected by an event monitor. However, this patient has positive findings on a Dix-Hallpike maneuver, and the last three episodes all occurred in the context of head-turning.
Key Point: The Epley maneuver is effective at relieving short-term symptoms of benign paroxysmal positional vertigo and has minimal adverse effects.
Hilton M, Pinder D. The Epley (canalith repositioning) maneuver for benign paroxysmal positional vertigo. Cochrane Database of Syst Rev. 2004;(2):CD003162. [PMID:15106194] - See PubMedTable of Contents
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