CLINICAL CASE PROTOCOL
The following are my objectives for this morning:
1. To present a case of chronic intermitent dizziness
2. To discuss a differential diagnosis for the case
3. To present the current diagnostic and therapeutic approach to dizziness, particularly benign paroxysmal
positional vertigo
4. To present the biomedical and psychosocial problems of a patient with benign paroxysmal positional vertigo.
5. To formulate a wellness plan for the patient
History
This is the case of L.M, 53 year old, female, married, born Again Christian, from Sta. Ana Manila, who came in
because of dizziness
History started 3 month prior to consult, patient experienced on and off dizziness,Is there a particular time of
the day wherein patient would experience this? rotatory in character, aggravated by standing up and moving around or
during sudden changes in position , relieved by rest with accompanying frontal headache, pricking in character, nonradiating, VAS 8/10,( please use NRS-numeric rating scale, severe in intensity with a nrs of 8/10) occuring at no particulat
time of the day, not aggravated by activity, relieved spontaneously.
Please determine your pertinent positives and negatives.She also noted on and off ringing sensation in the ear
with accompaying nausea and bloatedness but no vomiting. She also experienced easy fatigability and patient cannot
hardly perform daily activity of living when she has dizziness attack.
There was no note of hearing loss, ear discharge, fever, chills, confusion, anorexia, weightloss, abdominal pain
and diarrhea. There was no history of trauma.
She immediately sought consult at Local Hospital, random blood sugar was 130mg/dl and patient was prescribed
with charantia and vit B complex tab with no firm diagnosis given.
2 months prior to consult patient has still has on and off dizziness and headache with same characteristic and
severity. Patient sought consult to a private MD and noted to have a BP = 160/100, patient was prescribed with
Amlodipine (Norvasc) 10mg tab, which she took with good compliance.What was the diagnosis of dr at that time? Was
there any work-up done?
On the interim, there was on and off occurence of dizziness, ringing sensation of in the ear with resolution of
headache. She sought several consult at local health center, however with same medication (what medication)was
given. Patient complaint that she cannot perform daily activity of living ( what is patients previous function- betetr to
mention her usual tasks before symptoms manifested)because of her dizziness and has decreased in appetite and noted
weight loss of 5 % in 1 month.
Persistence of above symptoms prompted consult at the ambulatory care unit.
Review of System
(-) palpitation (-) chestpain (-) orthopnea (-) paroxysmal nocturnal dyspnea
(-) difficulty of breathing (-) cough (-) colds (-) sorethroat
(-) dysuria (-) hematuria (-) frequency (-) nocturia
(-) polyuria (-) polydipsia (-) polyphagia
(-) LBM (-) constipation (-) abdominal pain (-) melena (-) hematochezia
(-) body malaise (-)weakness (-) numbness
Past Medical History
(-) Diabetes Mellitus, (-) Heart Disease, (-) Asthma (-) Pulmonary Tuberculosis
(-) Hospitalization, (-) Operations, (-) Accident, (-) Allergies
Family History
(+) Hypertension – siblings (eldest sister and 4th elder sister)
(+) Pulmonary Tuberculosis – 2 younger brother
(+) Diabetes Mellitus – elder sister
(-) Astma, (-) Cancer
OB-Gyne History
Menarche: 12 year old
Menopause: 51 year old
First Sexual Contact: 21 year old
G8P7 (7017) All via normal spontaneous delivery
G3- spontaneous abortion
Personal and Social History
Used to be a store owner (small convenient store), currently a housewife
Non smoker, non-alcohol beverage drinker
Denies any illicit drug use
L.M is the 6th among the 9 siblings. She is married to her husband for 21 years. She has 7 children, 3 of who are
already married and has children. She is current living with her husband and 4 younger, unmarried children. Her
husband work as a messanger while she stays at home as a housewife. For the past 3 months, she was not able to
perform her role as a mother and wife due to the on and off attacks of dizziness. There were no similar symptoms noted
among other family members in the past.
Physical Examination
On Physical examination – she was conscious, coherent, ambulatory, not in cardiorespiratory distress with
BP 140/90 PR 88 RR 20 Temp 36.8C Ht 156cm Wt 58kg BMI 23.8kg/m2 (overweight) CBG: 80mg/dl; There was a
note of pink lips and palms, warm, moist skin, no active dermatoses; pink palpebral conjunctivae, anicteric sclera, moist
buccal mucosa, no tonsillopharyngeal congestion; supple neck, no anterior neck mass, no cervical lymphadenopathies;
Symmetric chest expansion, no retractions, clear and equal breath sounds, no wheezes, no crackles; Adynamic
precordium, Apex beat 5th LICS, MCL, no murmurs; Flabby abdomen, NABS, soft, non-tender, no palpable masses, no
organomegaly noted; full and equal pulses, no edema; Otoscopy: Intact tympanic membrane, no erythema, no
discharge; Neuro: oriented to 3 sphere, CN I- XII Normal, Motor 5/5 in all extremities, sensory 5/5 in all extremities,
reflexes ++ in all extremities, (-) Dix-Hillpike maneuver, (-) romberg sign (-) babinski reflex, (-) nuchal rigidity (-) pronator
drift (-) gait disturbance (-) finger to nose test (-) heel to knee test ( where is your optha exam?)
Weber: Right = Left
Rhine: AS: AC>BC
AD: AC>BC
Repeating Dix-Hillpike maneuver on the follow-up consult after 1 week, it was positive
Approach to Diagnosis
After history and PE, my initial concern was: What’s causing the dizziness?
When L.M. told me that she came in because of intermittent dizziness for 3 months, my initial considerations
were: Benign paroxysmal Positional Vertigo, Hypertension Stage 2, poorly controlled. These conditions commonly
present with intermittent dizziness and are commonly encountered in the ambulatory care unit. ( what about
ophthalmologic etiologies?)
Dizziness accounts for an estimated 5 percent of primary care clinic visits (Post,2010). Although it is a common
problem the assessment and management of dizziness in the elderly is challenging for family physicians.
When assessing dizziness, what concerns a family physician most are: 1) how to distinguish serious causes of
dizziness from less urgent ones; 2) how to manage patients with chronic but yet debilitating dizziness; and 3) how to
decide on the right timing and the appropriate specialty for referral. However, according to Bailey et.al, many family
doctors describe dizziness as "confusing" and "discouraging" problem and expensive investigations like electronystagmography and MRI are rarely helpful.
It is important to first focus our history on what type of sensation the patient is feeling. The main categories of
dizziness includes:
Category
Description
Vertigo
False sense of motion, possibly Otolaryngical conditions
spinning sensation
Off-balance or wobbly
Orthopedic, neurologic or Up to 16
sensory problem
Feeling of losing consciousness or Cardiac or vasomotor Up to 14
blacking out
condition
Vague symptoms, possibly feeling Psychiatric problems
Approximately 10
disconnected
with
the
environment
Disequilibrium
Presyncope
Lightheadedness
*Post, 2010
Main Cause
Percentage of patients with
dizziness
45 to 54
L.M. dizziness was described as rotatory (spinning sensation), therefore it can be categorized as vertigo. In this
case I considered L.M. dizziness as Otolytic or vestibular in origin. Otolytic causes of vertigo are the most common
causes of dizziness and include benign paroxysmal positional vertigo (BPPV), vestibular neuritis (viral infection of the
vestibular nerve), labyrinthitis (infection of the labyrinthine organs), and Meniere disease (increased endolymphatic fluid
in the inner ear) as differential diagnosis (Hoffman, 1999).
However, taking in consideration her being a newly diagnosed hypertensive and presently taking her
hypertensive medication for 2 months, as said by Post in 2010, I must distinguish serious causes of dizziness from less
urgent ones. According to Kwong et.al in 2005, the quality indicators specific to disequilibrium which as said earlier point
to neurologic problem I should assess in my patient the following:
Pertinent to assess
History of fall
Neurologic examination
Cerebellar sign
Gait examination
Romberg’s sign
Visual acuity
Patient History and sign and symptoms
No
Normal
Normal/ Negative
Normal
Negative
OD 20/50 OS 20/100 with corrective lenses
In terms of quality indicators specific to presyncope which is more pointing to cardiac disease I should assess in
my patient the following:
Pertinent to assess
Relationship to postural change
Cardiac symptom
Syncope
Orthostatic blood pressure
changes
Patient History and sign and symptoms
Yes but no feeling of loss of consciousness
None
None
None
After obtaining the patient history, the physician can tailor the physical examination to best fit the differential
diagnosis. One approach to the initial evaluation of patients with dizziness is presented in this algorithm.
Using this algorithm we can better approach patient with complaint of dizziness *
Patient presents with dizziness
Ask about medication regimen; caffeine, nicotine and alcohol
Intake; and history of head trauma or whiplash
What sensation does the patient describe?
False sense of motion
Or spinning sensation
Off-Balance or wobbly
Vertigo
Feeling of losing
consciousness
Or blacking out
Vague symptoms
possibly feeling
disconnected with
The environment
Presyncope
Lightheadedness
Dysequilibrium
Ask about migraine symptom
Migrainous vertigo is
episodic vertigo with a
current migraine or history
of migraine and one
of the following symptoms
during at least two episodes
of vertigo: migraine headache,
photophobia, phonophobia,
aura
Consider possible underlying
conditions, such as
peripheral neuropathy
and Parkinson disease
Recheck medication regimen,
especially in older patients
Examine gait and vision,
perform Romberg test,
screen for neuropathy
Ask about history
of arrhythmia and
myocardial infarction
Recheck medication
regimen, especially
in older patients
Measure orthostatic
blood pressures
Consider cardiac
testing in patients
with relevant history
Hearing loss?
Yes
No
Episodic vertigo?
Yes
Meniere
Disease
No
Labyrinthitis
Episodic vertigo?
Yes
Benign paroxysmal
positional vertigo
No
Vestibular
neuritis
Perform Dix-Hallpike maneuver
* Dros, J, Maarsingh O et.al. Tests used to evaluate dizziness in primary care
Ask about history of
anxiety or depression
Perform hyperventilation
provocation test
Using the above algorithm for my patient I should determine if my patient has history of medication regimen,
caffeine, nicotine and alcohol Intake and history of head trauma or whiplash. May patient is currently taking amlodipine
5 mg tab once a day for 2 months and this could be contributory to her dizziness since amlodipine has a dizziness as an
adverse effect. ( please clarify-patient patient has been experiencing dizziness prior to intake of medication? Did her
dizziness got worse after intake of drug?)She has coffee intake of once a day in the morning with meals, a no-smoker
and non-alcohol beverage drinker. She has no history of any head trauma and whiplash injury.
L.M. dizziness can be categorized as vertigo since she described her dizziness as “rotatory or spinning” in
character. Following the above algorithm, I should ask migraine symptom to rule out migrainous vertigo. In the case of
my patient, her previous headache is described as pricking, on and off with no other associated symptoms like nausea,
vomiting or sensitivity to light. According to ICSI Health Care Guideline on diagnosis and treatment of headache 2011,
migraine headache is throbbing or pulsating in character, often are accompanied by nausea, vomiting, or sensitivity to
light or sound, may affect only one side of your head, may include pain that worsens with routine activity, if untreated,
typically last from four to 72 hours which is not present in my patient.
Following the algorithm, after ruling out migrainous headache, I therefore determined if my patient has hearing
loss. My patient can follow command and performing weber and rhine test, both shows no lateralization and therefore
no hearing loss.
Hence, I follow the Right arm of the algorithm which determine next if the vertigo is episodic or not. This better
differentiate between Benign Paroxysmal Positional Vertigo and Meniere’s disease. In the case of my patient, her vertigo
is episodic and therefore point more in the diagnosis of Benign Paroxysmal Positional Vertigo.
In the last part of the algorithm since I am considering Benign Paroxysmal Positional Vertigo, I should then
perform Dix-Hallpike Maneuver to better support my diagnosis of Benign Paroxysmal Positional Vertigo. Therefore, with
the repeat of my Dix-Hallpike test which turned out to be positive, I can better support my diagnosis of Benign
Paroxysmal Positional Vertigo.
According to Fife et.al, the Dix-Hillpike maneuver is considered the gold standard test for the diagnosis of
posterior canal Benign Paroxysmal Positional Vertigo. In the primary care setting, they have reported a positive
predictive value for a positive Dix-Hallpike test of 83 percent and a negative predictive value of 52 percent for the
diagnosis of BPPV. Therefore, a negative Dix-Hallpike maneuver does not necessarily rule out a diagnosis of posterior
canal BPPV. Because of the lower negative predictive values of the Dix-Hallpike maneuver, it has been suggested that
this maneuver may need to be repeated at a separate visit to confirm the diagnosis and avoid a false-negative result.
In my patient, though it fits the description of dizziness related to BPPV, my initial test for Dix-Hillpike is
negative, then I need to repeat the maneuver on separate visits. After 1 week on follow-up, may patient still have
dizziness with same quality and but lesser frequency hence I performed again the Dix-Hallpike test which turned out this
time to be positive.
My learning point with Dix-Hallpike test is that the nystagmus produced by the Dix-Hallpike maneuvers in
posterior canal BPPV typically displays two important diagnostic characteristics according to Bhattacharyya et.al, 2008.
First, there is a latency period between the completion of the maneuver, and the onset of subjective rotational vertigo
and the objective nystagmus. The latency period for the onset of the nystagmus with this maneuver is largely
unspecified in the literature, but the panel felt that a typical latency period would range from 5 to 20 seconds, although
it may be as long as 1 minute in rare cases. Second, the provoked subjective vertigo and the nystagmus increase, and
then resolve within a time period of 60 seconds from the onset of nystagmus. In my first test, I thought the nystagmus
should appear right away after turning the patient to supine position, after my reading, i learned that I need to wait for
few seconds and rarely a minute to elicit the nystagmus. In my patient I elicited nystagmus in the right after 30 seconds.
If the patient has a history compatible with BPPV an the Dix-Hallpike test is negative, the clinician should
perform a supine roll test to assess for lateral semicircular canal BPPV. According to Imai et.al, lateral canal BPPV (also
called horizontal canal BPPV) is the second most common type of BPPV. The supine roll test is the preferred maneuver
to diagnose lateral canal BPPV. The supine roll test has not received as much widespread use or diagnostic validation as
the Dix-Hallpike maneuver. But according to Steenerson et.al., a positive supine roll test, however, is the most
commonly required and consistent diagnostic entry criterion for therapeutic trials of lateral canal BPPV. Unfortunately in
my patient I wasn’t able to this during the first consult and first follow-up and when I performed this when I learned
about it on the third follow-up, it was negative.
According to review conducted by Dros et.al, practice guidelines advocate the use of several diagnostic
tests in the evaluation of dizziness, including history taking, pulse measurement, carotid sinus massage, nystagmus tests
and the Dix-Hallpike maneuver. However, these recommendations are based more on opinion than on evidence.
Despite being the most common cause of peripheral vertigo, BPPV is still often underdiagnosed or
misdiagnosed.
Other causes of vertigo that may be confused with BPPV can be divided into otological, neurological, and
other entities.
To further assess the dizziness, here are the most common differential diagnosis of dizziness.
Basic differential diagnosis of Dizziness
Otological disorders
Neurological disorders
(Vertigo)
(Dysequilibrium)
Ménière’s disease
Migraine-associated dizziness
Vestibular neuritis
Vertebrobasilar insufficiency
Labyrinthitis
Demyelinating diseases
Superior canal dehiscence
CNS lesions
syndrome
Posttraumatic vertigo
Cardiac Disorder
(Presyncope)
Arrythmia
Myocardial Infarction
Carotid artery stenosis
Orthostatic hypotension
Other entities
(Lightheadedness)
Anxiety or panic disorder
Cervicogenic vertigo
Medication side effects
Postural hypotension
Applying to my patient in rule in and out of disorder associated with first otologic disorders
Patient Salient
Features
Benign
Paroxysmal
Vertigo
Meniere’s
Disease
Vestibular
neuritis
Labyrinthitis
Dizziness
(Vertigo)
Episodic
Vertigo
Episodic
vertigo
sudden,
unanticipated,
severe vertigo
(-)
sudden,
unanticipated,
severe vertigo
(-)
Dizziness
triggered by
change in
position
Headache
Tinnitus
Not present in
patient
(+)
(-)
(+)
(-)
(-)
(+)
(+) hearing
loss
(-)
(-)
(+)
(+)
(+) hearing loss
(+/-) hearingloss
(+) preceded by (+) preceded by
a viral prodrome a viral prodrome
Superior
canal
Dehiscence
syndrome
Attacks of
vertigo
Posttraumatic
vertigo
Triggered by
pressure
changes
(-)
(-)
(+)
(+) oscillopsia
(+) hearing
loss
(+)
(+)
Vertigo
(+)
disequilibrium
As opposed to BPPV, the duration of vertigo in an episode of Ménière’s disease typically lasts longer (usually on
the order of hours) and is typically more disabling owing to both severity and duration. In addition, an associated
contemporaneous decline in sensorineural hearing is required for the diagnosis of a Ménière’s attack, whereas acute
hearing loss should not occur with an episode of BPPV.
In vestibular neuritis or labyrinthitis, the vertigo is of gradual onset, developing over several hours, followed by a
sustained level of vertigo lasting days to weeks. The vertigo is present at rest (not requiring positional change for its
onset), but it may be subjectively exacerbated by positional changes.
Applying to my patient in rule in and out of disorder associated with second with neurologic disorder
Patient Salient
Migraine-associated vertigo
Vestibular Insufficiency
Intracranial Tumor
features
Dizziness
Episodic dizziness
Isolated transient dizziness
(+/-)
(off-balance or wobbly)
(off-balance or wobbly)
Headache
(+)
(-)
(+/-)
Tinnitus
(-)
(-)
(+)
Not present in
least two of the following
( + ) aural fullness, new-onset
my patient
migraine symptoms
hearing loss, and/or
during at least two vertiginous
other neurological symptoms
episodes: migrainous
headache, photophobia,
phonophobia, or visual or
other aura;
Applying to my patient in rule in and out of disorder associated with third with cardiac disorder, my patient do
have dizziness but it not described as “feeling of losing consciousness or blacking out”.
Several other non-otological and non-neurological disorders may present similarly to BPPV. Patients with panic
disorder, anxiety disorder, or agoraphobia may complain of symptoms of lightheadedness and dizziness. Although these
symptoms are usually attributed to hyperventilation, other studies have shown high prevalences of vestibular
dysfunction in these patients. These conditions may also mimic BPPV.
Applying to my patient though my patient has dizziness it is not described as lightheadedness more common
seen in patient with anxiety and depression.
Several medications, such as Mysoline, carbamazepine, phenytoin, antihypertensive medications, and
cardiovascular medications, may produce side effects of dizziness and/or vertigo and should be considered in the
differential diagnosis.
Although the differential diagnosis of BPPV is vast, most of these other disorders can be further distinguished
from BPPV on the basis of responses to the Dix-Hallpike maneuver and the supine roll test. Clinicians should still remain
alert for concurrent diagnoses accompanying BPPV, especially in patients with a mixed clinical presentation.
Biomedical aspect
In terms of my third objective which is to present the current diagnostic and therapeutic approach to dizziness,
particularly benign paroxysmal positional vertigo.
Benign Paroxysmal Positional Vertigo is the most common vestibular disorder in adults, a lifetime prevalence of
2.4 percent (Battcharyya, 2008). Although, BPPV age of onset is most commonly between the fifth and seventh decades
of life.
BPPV is most commonly clinically encountered as one of two variants: BPPV of the posterior semicircular canal
(posterior canal BPPV) or BPPV of lateral semicircular canal (also known as horizontal canal BPPV). Posterior canal BPPV
is more common than horizontal canal BPPV, constituting approximately 85 to 95 percent of BPPV cases.
Although debated, posterior canal BPPV is most commonly thought to be due to canalithiasis. Debris (thought to
be fragmented endolymph particles) entering the posterior canal becomes “trapped” and causes inertial changes in the
canal, thereby resulting in abnormal nystagmus and vertigo with head motion in the plane of the canal.
Although BPPV arises from dysfunction of the vestibular end organ, patients with BPPV often concurrently suffer
from comorbidities, limitations, and risks that may affect the diagnosis and treatment outcome of BPPV.
Many tests can only be performed in secondary and tertiary care settings, although most patients are first seen
in primary care. The main problem for primary care physicians is to decide which patients need additional testing, which
should be referred to secondary care, which require immediate therapy, and which should receive an explanation,
reassurance, advice and a “wait and see” approach. Primary care physicians need to know the characteristics of the
diagnostic tests that can be used as point-of-care tests for the diagnosis of the more common conditions.
Accurate evaluation of diagnostic tests should be based on the results of more than one study. Therefore, we
describe four tests, all targeted for neuro-otologic conditions, that were evaluated in more than one study (Dros et.al,
2011)
Dix-Hallpike manoeuvre
Both studies of the use of the Dix-Hallpike manoeuvre to diagnose benign paroxysmal positional vertigo used
multiple vestibular tests as reference standards. Data from 114 patients were available, and we calculated a mean
sensitivity of 80% (95% confidence interval [CI] 71%–87%).
Head-shaking nystagmus test
All nine studies of the use of the head-shaking nystagmus test used caloric measurement as part of the
reference standard. In these studies done by Dron, the pooled probability of peripheral vestibular dysfunction after a
positive head-shaking nystagmus test result increased from 27% to 48%, and the probability after a negative result
decreased from 27% to 25%. Using an estimated prevalence of 33% for peripheral vestibular dysfunction in primary care
patients with dizziness, the post-test probability of a positive head-shaking nystagmus test result was 55% and the posttest probability of a negative result was 25%.
Head and Impulse Test
In these studies, the probability of peripheral vestibular dysfunction after a positive test result increased from
33% to 82%, and the probability after a negative result decreased from 33% to 17%. Because the estimated prevalence
in primary care matched the prevalence in the studied population (both 33%), the posttest probabilities were the same.
The probability of central vestibular dysfunction after a positive head impulse test result decreased from 62% to 31%,
and the probability after a negative result increased from 62% to 95%.
Vibration-induced nystagmus test
We calculated specificity based only on one study, with a positive result of the vibration-induced nystagmus test
increasing the probability of peripheral vestibular dysfunction from 13% to 59%. Using the estimated prevalence of 33%
for peripheral vestibular dysfunction in primary care patients with dizziness, we estimated the post-test probability of a
positive vibration-induced nystagmus test result to be 83%.
Diagnostic criteria for posterior canal BPPV
History
Patient reports repeated episodes of vertigo with changes in head position.
Physical
examination
Each of the following criteria are fulfilled:
● Vertigo associated with nystagmus is provoked by the Dix-Hallpike test.
● There is a latency period between the completion of the Dix-Hallpike test and the onset of
vertigo and nystagmus.
● The provoked vertigo and nystagmus increase and then resolve within a time period of 60
seconds from onset of nystagmus.
Lateral canal BPPV (also called horizontal canal BPPV) is the second most common type of BPPV. The supine roll
test is the preferred maneuver to diagnose lateral canal BPPV.
The diagnosis of BPPV is based on the clinical history and physical examination. Routine radiographic imaging or
vestibular testing is unnecessary in patients who already meet clinical criteria for the diagnosis of BPPV. Radiographic
imaging of the CNS should be reserved for patients who present with a clinical history compatible with BPPV but who
also demonstrate additional neurological symptoms atypical for BPPV. Such symptoms include abnormal cranial nerve
findings, visual disturbances, and severe headache, among others. It should be noted that intracranial lesions causing
vertigo are rare.
According to Baloh et.al., when patients meet clinical criteria for the diagnosis of BPPV , no additional diagnostic
benefit is obtained from vestibular function testing. Vestibular function testing is indicated when the diagnosis of a
vertiginous or dizziness syndrome is unclear or possibly when the patient remains symptomatic following treatment. It
may also be beneficial when multiple concurrent peripheral vestibular disorders are suspected.
Patients with a clinical diagnosis of BPPV according to guideline criteria should not routinely undergo vestibular
function testing, because the information provided from such testing adds little to the diagnostic accuracy. Therefore,
vestibular function testing should not be routinely obtained when the diagnosis of BPPV has already been confirmed by
clinical diagnostic criteria. Vestibular function testing, however, may be warranted in patients with 1) atypical
nystagmus, 2) suspected additional vestibular pathology, 3) a failed (or repeatedly failed) response to CRP, or 4)
frequent recurrences of BPPV.
In terms of audiometric testing, No recommendation is made concerning audiometric testing in patients
diagnosed with BPPV. Audiometry is not required to diagnose BPPV; however, audiometry may offer some diagnostic
benefit for patients in whom the clinical diagnosis of BPPV is unclear.
In terms of treatment, Clinicians should treat patients with posterior canal BPPV with a particle repositioning
maneuver (PRM). Two types of PRMs have been found effective for posterior canal BPPV: 1) the canalith repositioning
procedure (CRP, also referred to as the Epley maneuver) and 2) the liberatory maneuver (also called the Semont
maneuver). The Cochrane review identified a statistically significant effect in favor of the CRP compared with controls.
An odds ratio of 4.2 (95% confidence interval, 2.0-9.1) was found in favor of treatment for subjective symptom
resolution in posterior canal BPPV; an odds ratio of 5.1 (95% confidence interval, 2.3-11.4) was found in favor of
treatment for conversion of a positive to negative Dix-Hallpike test (Hilton, 2004)
Another leaning point for me, with this statement, I therefore realized the importance of performing particle
repositioning in my patient. In the 3 consecutive follow-ups of my patient what I did was work-up other metabolic or
cardiac cause of dizziness and continuously prescribing betahistine 16 mg tab TID which gave temporary relief but not
complete resolution of her dizziness.
Clinical trials concerning the treatment effectiveness of the liberatory maneuver are limited. the Semont
maneuver is more effective than no treatment or Brandt-Daroff exercises in relieving symptoms of posterior canal BPPV,
according to studies with small sample sizes and limitations (Bhattacharyya, 2008)
In terms of vestibular rehabilitation, vestibular rehabilitation demonstrates superior treatment outcomes
compared with placebo. In short-term evaluation, vestibular rehabilitation is less effective at producing complete
symptom resolution than PRMs. Vestibular rehabilitation is a form of physical therapy designed to promote habituation,
adaptation, and compensation for deficits related to a wide variety of balance disorders.
In terms of medical therapy, clinicians should not routinely treat BPPV with vestibular suppressant medications
such as antihistamines or benzodiazepines. There is no evidence in the literature to suggest that any of these vestibular
suppressant medications are effective as a definitive, primary treatment for BPPV, or as a substitute for repositioning
maneuvers (Frohman et.al, 2003). A lack of benefit from vestibular suppressants and their inferiority to PRMs indicate
that clinicians should not substitute pharmacological treatment of symptoms associated with BPPV in lieu of other more
effective treatment modalities. Vestibular suppressant medications are not recommended for treatment of BPPV, other
than for the short-term management of vegetative symptoms such as nausea or vomiting in a severely symptomatic
patient.
Hence applying this to my patient, I there should have prioritize doing repositioning maneuvers than
continuously doing medical management.
Clinicians should reassess patients within 1 month after an initial period of observation or treatment to confirm
symptom resolution. Thus, persistence of symptoms after initial management requires clinicians to reassess and
reevaluate patients for other etiologies of vertigo. Conversely, resolution of BPPV symptoms after initial therapy such as
a PRM would corroborate an accurate diagnosis of BPPV.
Therapeutic trials in BPPV variably report follow-up assessments for treatment outcomes at 40 hours, 2 weeks, 1
month, and up to 6 months, although the most commonly chosen interval for follow-up assessment of treatment
response is within or at 1 month (Hilton, 2004)
In a study by Monobe et al, treatment failure of the PRM was most commonly seen in patients with BPPV
secondary to head trauma or vestibular neuritis.
Patients with symptoms consistent with those of BPPV who do not show improvement or resolution after
undergoing the PRM, especially after two or three attempted maneuvers, or those who describe associated auditory or
neurological symptoms should be evaluated with a thorough neurological examination, additional CNS testing, and/or
MRI of the brain and posterior fossa to identify possible intracranial pathological conditions (Dunniway et.al, 1998).
Psychosocial
On the first follow-up (January 23, 2012), L.M. still has dizziness and tinnitus, with same characteristic but lesser
and shorter attacks. Her BP is 130/80 and her usual BP now is 120-130/80. She has no headache, no weakness, no
nausea and vomiting. She reported that she can move more now but since she still has few attacks of dizziness and she
has fear of falling, her movement is still limited and her full function as a mother and wife is still not attained. I told her
that at this point her hypertension is better controlled and that she should continue taking her betahistine for 1 more
week since the usual duration of treatment is 2 weeks.
On 2nd follow-up (January 30, 2012) L.M. still has dizziness but rarely has tinnitus, with same characteristic and
with fewer duration and frequency of attack even after finishing the medication. At this time, I was not still not aware of
doing the particle repositioning maneuver would be a better of treatment option for my . At this point, I educate my
patient regarding benign paroxysmal positional vertigo and told her to continue taking betahistine 16 mg tab TID.
On 3rd follow-up (February 6, 2012) L.M. still has few attacks of dizziness with the same characteristic, she
sought a consult to a private ophthalmologist( was this pxs initiative to visit optha?) and she was prescribed new
corrective lenses. I also changes her medication from Amlodipine 10mg tab to Losartan 50 mg tab because I noted that
amlodipine has dizziness side effect that could also aggravate her dizziness.
Wellness
Clinicians should question patients with BPPV for factors that modify management including impaired mobility
or balance, CNS disorders, a lack of home support, and increased risk for falling. Assessment of the patient with BPPV for
factors that modify management is essential for improved treatment outcomes and ensuring patient safety with an
underlying diagnosis of BPPV. In a study by Oghalai, 9 percent of patients referred to a geriatric clinic for general
geriatric evaluation had undiagnosed BPPV, and three-fourths of those with BPPV had fallen within the 3 months prior to
referral. Thus, evaluation of patients with a diagnosis of BPPV should also include an assessment of risk for falls. In
particular, elderly patients will be more statistically at risk for falls with BPPV.
In the case of my patient, I advice her the risk of falls and asked her husband to accompany patient when she is
going out and advice the patient to avoid sudden movement and avoid bending and sudden change in head position.
Patients with both osteoporosis and BPPV may be at greater risk for fractures resulting from falls related to
BPPV; therefore, patients with combined osteoporosis and subsequent BPPV should be identified and monitored closely
for fall and fracture risk.
Was there any hypertensive work-up? Counseling on diet? Px is obese and hypertensive.
This supervision may include counseling about the risk of falling at home or a home safety assessment. Hence I
advice my patient and her husband to avoid clutters at home and make their home more safe against fall.
In addition, because recurrence of BPPV may occur as early as 3 months after initial treatment, so I advice the
patient the importance of her follow-up and educate her warning signs that she should monitor or watch out like
increase in severity and duration of dizziness, any weakness and numbness in her body, severe headache, blurring of
visions and chest pain and that if this warning signs appear that she should sought consult right away.
Clinicians should counsel patients regarding the impact of BPPV on their safety, the potential for disease
recurrence, and the importance of follow-up. Hence, this is what I counsel my patient.
HOW IS PATIENT NOW? Present status?
Insights
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