Neuroscience · Year 2 · from Neuroscience
Case 2: Benign Paroxysmal Positional Vertigo (BPPV)
Patient Presentation
Demographics: 55-year-old female
Chief Complaint: Spinning dizziness when lying down or turning over in bed
History of Present Illness: A 55-year-old woman presents with episodes of intense spinning sensation (vertigo) for 2 weeks. Episodes are triggered by specific movements, particularly when she lies down, gets out of bed, or turns over in bed. Each episode lasts about 30 seconds and is accompanied by nausea. She feels perfectly normal between episodes. She denies hearing loss, tinnitus, ear pain, or fullness. She reports no recent head trauma or ear infections. She has been avoiding lying flat due to symptom severity.
Physical Examination:
- Vital signs: Normal
- General: Comfortable at rest in sitting position
- HEENT: Ears normal; hearing grossly intact bilaterally
- Neurological:
- Mental status: Normal
- Cranial nerves: Intact including facial strength and hearing
- Cerebellar: Normal finger-to-nose, heel-to-shin; no dysmetria
- Gait: Normal, no ataxia
- Dix-Hallpike maneuver: Positive on RIGHT side - after latency of 2 seconds, torsional upbeating nystagmus develops lasting 25 seconds; patient reports vertigo; nystagmus fatigues with repeated testing
- Dix-Hallpike maneuver: Negative on LEFT side
Workup:
- Clinical diagnosis based on classic Dix-Hallpike findings
- No imaging required for classic presentation
- Audiometry: Normal (not mandatory but performed to exclude other vestibular disorders)
Diagnosis: Right posterior canal benign paroxysmal positional vertigo (BPPV)
Treatment:
- Epley repositioning maneuver (canalith repositioning procedure) performed in clinic for right posterior canal
- Resolution of symptoms after single treatment
- Epley maneuver repeated once for residual mild symptoms
- Patient educated on Brandt-Daroff exercises for home use if symptoms recur
- Vestibular suppressants (meclizine) prescribed for as-needed use only
- Symptoms resolved completely at 4-week follow-up
Clinical Pearl: BPPV is the most common cause of vertigo, resulting from displacement of otoconia (calcium carbonate crystals) from the utricle into the semicircular canals, most commonly the posterior canal. Head movements cause the crystals to shift, creating abnormal endolymph flow and cupular deflection, which the brain interprets as rotation. The Dix-Hallpike maneuver provokes the characteristic geotropic, torsional, upbeating nystagmus with latency and fatigue. The Epley maneuver repositions the crystals back to the utricle and has >80% efficacy with a single treatment. BPPV is distinguished from central vertigo by brief duration, positional triggers, characteristic nystagmus pattern, and absence of other neurological signs.