In-office diagnosis of common type of vertigo

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Two simple head-movement techniques can be used to identify patients with benign paroxysmal positional vertigo (BPPV), the most common equilibrium-related disorder in adults. BPPV, which can be traced to the inner ear, is marked by repeated episodes of positional vertigo—a spinning sensation caused by changes in head position relative to gravity.

A new guideline put forth by the American Academy of Otolaryngology—Head and Neck Surgery recommends that practitioners use the Dix-Hallpike maneuver to diagnose BPPV (Otolaryngol Head Neck Surg. 2008;139[5 Suppl 4]:S47-S81). This test involves moving the patient from a sitting to a reclining position and rotating the head and neck in specific ways (described in the guideline) to check for the onset of dizziness as well as nystagmus (the involuntary and usually rapid movement of the eyeballs that often accompanies dizziness occurring during or after bodily rotation).

If the patient completes the Dix-Hallpike test without any difficulty but BPPV is still suspected, a supine roll test should be performed. This maneuver, also described in the guideline, basically calls for turning the patient's head rapidly to the right and left, then checking for the presence of nystagmus.

The guideline panel recommends against radiographic imaging and/or vestibular testing in patients who have BPPV unless the patient exhibits unrelated symptoms or signs that warrant such testing. In addition, clinicians should not use antihistamines, benzodiazepines, or other vestibular suppressant medications as a routine treatment for BPPV. Better options include various head-positioning moves, known as particle repositioning maneuvers, to eliminate the vertigo; vestibular rehabilitation (balance retraining); and observation as initial management.
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