Health Dictionary

Overview

The diagnostic study of choice for BPPV is patient history and observing nystagmus on Dix-Hall pike maneuver.

Diagnostic Study of Choice

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Study of choice

The diagnostic study of choice for BPPV is patient history and observing nystagmus on Dix-Hall pike maneuver.^[1]^[2]^[3]

Investigations:

Among the patients who present with clinical signs of BPPV, the Dix-Hallpike maneuver is the most specific test for the diagnosis.

Diagnostic results

The following findings are confirmatory for BPPV:

Recurrent brief vertigo attack which starts with certain head movements.
Nystagmus on Dix-Hallpike maneuver.

Sequence of Diagnostic Studies

The various investigations must be performed in the following order:

If patients doesn’t respond to treatment or doesn’t show the typical nystagmus on Dix-Hall pike maneuver, in order to rule out other abnormalities we may perform some additional test such as:

Electronystagmography (ENG) or video nystagmography (VNG)
Audiometry
Neuroimaging

For more information about these tests, click here.

Diagnostic criteria for posterial canal BPPV

Subtypes	Explanation
History	Brief recurrent vertigo attack starts with change in head position
Physical exam	Vertigo and nystagmus after Dix-Hall pike maneuver Brief delay between performing Dix-Hall pike maneuver and vertigo The vertigo and nystagmus will resolve after 60 seconds

Diagnostic approach

Diagnostic approach to a patient with dizziness:

Patient present with dizziness^[4]^[5]^[6]^[7]

Loss of consciousness?

Yes

No

Sense of motion/
spinning?

Other

Sweating
Heaviness sensation in the legs
“Tunnel” vision
Feeling warm or hot
Nausea
Vomiting

History of seizure
Aura
Post-ictal phase
Uncontrollable muscle spasms
Drooling or frothing at the mouth
Teeth clenching
Tongue biting
Sudden, rapid eye movements

Yes

No

Electrolyte imbalance/
Intracranial process

Syncope

Seizure

Vertigo

Sudden, and generally momentary, loss of consciousness, or blacking out caused by the Central Ischaemic Response

Temporary abnormal electro-physiologic phenomenon of the brain, resulting in abnormal synchronization of electrical neuronal activity

Sudden onset?
Horizental nystagmus?
Auditory symptoms?
No neurological problem?

Causes:
•Hemorrhage
•Hypotension
•Hypoxia
•Pulmonary embolism
•Ruptured abdominal aortic aneurysm
•Ventricular arrhythmia
•Arrhythmia
•Medication
•Orthostatic hypotension
•Vagal stimulation
•Vertebrobasilar insufficiency

Causes:
•Brain damage
•Congenital abnormalities
•Stroke
•Infection
•Genetic syndromes
•Brain tumor
•Epilepsy

Yes

No

Peripheral

Central

BPPV
Vestibular neuritis
HSV oticus
Meniere disease
Labyrinthine concussion
Perilymphatic fistula
Semicircular canal dehiscence syndrome
Vestibular paroxysma
Cogan syndrome
Vestibular schwannoma
Otitis media
Aminoglycoside toxicity
Recurrent vestibulopathy

Vestibular migraine
Epileptic vertigo
Multiple sclerosis
Brain tumors
Crebellar infarction/hemorrhage
Brain stem ischemia
Chiari malformation
Parkinson

Hyperventilation
Psychiatric symptoms

Balance
problem

Sweating
Tunnel Vision
Nausea
Heart palpitations
Abdominal discomfort
Slurred speech

Psychogenic
dizziness

Dysequilibrium

Presyncope

Dizziness which is not characterized by true vertigo and it can be replicated by hyperventilation and psychiatric symptoms that usually precede its onset.

Impaired sense or absence of balance or equilibrioception that primarily occurs during standing or walking

Feeling of lightheadedness that can lead to syncope

Causes:
•Alcohol dependence
•Conversion disorder
•Fibromyalgia
•Generalized anxiety
•Hyperventilation
•Major depression
•Panic disorder

Causes:
•Arrhythmia
•Asthma exacerbation
•Cerebellar hemorrhage
•Compartment syndrome
•Endophthalmitis
•Epilepsy
•Hypoglycemia
•Organophosphates
•Cerebellar disorders
•Gait abnormality
•Hypoglycemia
•Paralysis
•Peripheral neuropathy
•Vestibular disorders
•Visual impairment