Dix-Hallpike Positive, No Red Flags, Now What?

January 23, 2010

dixhallpikeThe Proper Diagnosis and Treatment of Benign Paroxysmal Positional Vertigo

Carly Oboudiyat

Faculty peer reviewed

You finally have the “dizzy” patient whose eyes actually beat torsionally upwards when you do that silly maneuver you have done countless times to no avail. Hallelujah, you think, a positive Dix-Hallpike sign, reassuring you that you have a case of benign paroxysmal positional vertigo (BPPV). But now what? Do you try that other acrobatic maneuver to reposition the canaliths in the posterior canal, or should you give meclizine?

Benign paroxysmal positional vertigo has a lifetime prevalence of 2.4%.[1] It is thought to result from the anomalous position of calcium carbonate otoliths in the inner ear stimulating the ampulla erroneously. The otoliths break off from the macula, and due to its gravitationally privileged position, most commonly end up in the posterior canal becoming canaliths.[2] The movement of the canaliths within the semicircular canal causes stimulation of the ampulla, resulting in central input unidentifiable from actual movement of the head, resulting in vertigo.

BPPV is a diagnosis that can be made by history alone, but is supported by positive exam findings. The patient should describe vertigo provoked by head movements, commonly while lying in bed or standing up from a bent-over position, that lasts 10-30 seconds in the absence of any other neurological symptoms.[2] A positive Dix-Hallpike sign supports the diagnosis and localizes the affected ear. The posterior canal is the most commonly affected canal, and it is this canal that produces upward beating torsional nystagmus upon performing the Dix-Hallpike maneuver. This maneuver also uncovers which ear is the culprit: the nystagmus will be evoked when the affected ear is downwards. When these patients present to the emergency department, 19% undergo imaging studies, constituting a waste of resources.[3]

In a study of 9,472 patients presenting to US emergency departments with the chief complaint of dizziness, 7.4% were diagnosed with a vestibular etiology, either BPPV or acute peripheral vestibular neuropathy.[3] Unfortunately, these patients received very similar treatment despite the very different disease entities. Patients were commonly (58%) prescribed meclizine (trade name Antivert) for BPPV although meclizine does not have utility in this disorder.[3] The treatment guidelines put forth by the American Academy of Neurology in 2008 in fact do not recommend any medication for the treatment of BPPV.[4]

And so it is time for acrobatics: the Epley maneuver is the recommended treatment for BPPV.[4] In fact, having had treatment with the Epley maneuver is the single best prognostic factor in reduced five-year recurrence rates of BPPV.[5] Eighty percent of patients do not have nystagmus on repeat testing 24 hours after the Epley is performed versus 10 percent of patients who received a placebo maneuver, showing immediate and positive results.[6] Restricted movement after the maneuver is not necessary for efficacy, according to a recent study.[7] Restricted movement for 48 hours was compared to no restrictions in movement, and it was found that there was no difference between the two groups, suggesting that patients do not need to be given instructions to restrict movement.[7]

In summary, benign paroxysmal positional vertigo is a diagnosis that can often be made using history and physical exam: vertigo lasting 10-30 seconds upon movements of the head in the absence of other neurological symptoms. The diagnosis is supported by, but does not require, a positive Dix-Hallpike sign. A common misconception that BPPV can be treated with meclizine remains prevalent. The proper treatment consists of performing the Epley maneuver with subsequent follow-up for repositioning when necessary. A nice demonstration of the Epley can be found here.

References
1. von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007;78(7):710-715.

2. Fife TD. Benign paroxysmal positional vertigo. Semin Neurol. 2009;29(5):500-508.

3. Newman-Toker D, Camargo CA Jr, Hsieh YH, Pelletier AJ, Edlow JA. Disconnect between charted vestibular diagnoses and emergency department management decisions: a cross-sectional analysis from a nationally representative sample. Acad Emerg Med. 2009;16(10):970-977.

4. Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008;70(22):2067-2074.

5. Rashad UM. Long-term follow up after Epley’s manoeuvre in patients with benign paroxysmal positional vertigo. J Laryngol Otol. 2009;123(1):69-74.

6. von Brevern M, Seelig T, Radtke A, Tiel-Wilck K, Neuhauser H, Lempert T. Short-term efficacy of Epley’s manoeuvre: a double-blind randomized trial. J Neurol Neurosurg Psychiatr. 2006;77(8):980-982.

7. Fyrmpas G, Rachovitsas D, Haidich AB, et al. Are postural restrictions after an Epley maneuver unnecessary? First results of a controlled study and review of the literature. Auris Nasus Larynx. 2009;36(6):637-643.

Carly Oboudiy is a fourth year medical student at NYU Medical School.

Faculty peer reviewed by Saran Jonas, MD.

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