BPPV Diagnosis and Management

• 45/M civil engineer from Binanuahan, Legazpi City presented with dizziness
• HR: 75 bpm
• RR: 18 cpm
• Temperature: 36.7°C
• BMI: 32 kg/m²

Subjective Data

• Experiences recurrent episodes of dizziness, lasting less than a minute; and triggered by head movements
• Reports nausea and vomiting
• Diagnosed with BPPV by GP
• Temporary relief from Betahistine 25 mg BID x 2 weeks
• Dizziness episodes prolonged (lasting 30 minutes to hours), not necessarily triggered by positional changes
• Left intermittent ear fullness and tinnitus are present
• Left persistent ear fullness and intermittent dizziness and tinnitus
• Hypertension for 6 years, managed with Amlodipine 5 mg OD
• No previous vertigo episodes before current onset
• Social history includes occasional alcohol intake and working around machinery noise
• No history of chronic sinusitis/congestion, fever, headache, ear issues, trauma, or upper respiratory infection, viral illness, visual disturbance, neurologic deficits, or gait instability/loss of consciousness

Objective Data

• Awake, alert, well-nourished, not in distress
• Skin warm/dry with no rashes, cyanosis, or pallor
• Normocephalic, atraumatic head
• Pupils are equal, round, and reactive to light; extraocular movements intact; no nystagmus at rest
• Normal external ears
• Tympanic membranes intact with no erythema, bulging, or retraction
• Weber Test lateralizes to the right ear
• Rinne Test AC > BC bilaterally, but reduced on the left
• Nasal mucosa pink with no discharge or congestion
• Oral mucosa moist with no erythema or exudates
• Neck is supple with no lymphadenopathy or thyroid enlargement
• Cardiovascular, respiratory, and abdomen are normal
• Extremities show no abnormalities with palpable and equal peripheral pulses
• Alert and oriented neurologically
• Cranial nerves II-XII intact - spontaneous horizontal nystagmus to the right (left ear affected), positive head thrust test on the left
• Motor strength 5/5 in all extremities
• Sensory intact to light touch, pain, and temperature
• Reflexes 2+ bilaterally and symmetrical
• Coordination normal on finger-to-nose and heel-to-shin testing
• Gait with slight unsteadiness when walking, worsened with eyes closed
• Romberg Test: Positive
• Dix-Hallpike Maneuver: Negative for nystagmus
• Low-frequency sensorineural hearing loss in the left ear (PTA)
• Reduced caloric response on the left side (VNG)
• Increased summating potential/action potential (SP/AP) ratio suggesting endolymphatic hydrops (ECochG)
• Negative MRI with Contrast for acoustic neuroma/central pathology

Pertinent Data from History

• Consistent with Meniere's Disease but initially mimicked BPPV
• Transition from brief, positional vertigo to prolonged, spontaneous vertigo
• Unilateral aural fullness, tinnitus, and hearing loss
• Initial response to Epley maneuver but eventual lack of efficacy
• No associated systemic or neurologic symptoms

Dizziness

• Refer to the appendix for Table 5 for information on Dizziness (Vertigo), Presyncope, and Disequilibrium

Benign Paroxysmal Positional Vertigo (BPPV)

• Caused by dislodged otoconia (calcium carbonate crystals) from the utricle migrating into the semicircular canals

Pathophysiology

• Free-floating particles (canaliths) stimulate the endolymph and deflect the cupula
• Abnormal activation of the vestibular system leads to vertigo
• Gold standard test: Dix-Hallpike Maneuver
• Treatment of choice: Epley Maneuver
• Adjunct therapy: Medications (Betahistine)