Applied Evidence

Standardizing your approach to dizziness and vertigo

J Fam Pract. 2018 August;67(8):490-492,495-498

From The Journal of Family Practice | 2018;67(8):490-492,495-498.

References

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More worrisome suspicions. Patients suspected of cardiac causes should have a full cardiac work-up performed.²²For suspected stroke, brain tumor, or head trauma, specific computed tomography or magnetic resonance imaging can be arranged.²² Carotid doppler can be used if dizziness is suspected to be caused by orthostatic hypotension or a vascular cause.²³

Audiologic and vestibular testing. Audiologic testing is not routinely recommended and is only warranted in instances when patients report hearing loss or changes. Referral to an otolaryngologist for vestibular testing is warranted once life-threatening and alternate etiologies have been ruled out, and a vestibular disorder remains at the top of the differential.²⁴

Treatment hinges on cause and may be multifaceted

Treatment hinges on the specific cause of the patient’s dizziness and may involve useful maneuvers, medication, physiotherapy, or perhaps even surgery.

Employ a particle repositioning maneuver for BPPV

A positive Dix-Hallpike test should prompt the use of a particle repositioning maneuver (PRM) to treat BPPV.²¹ The goal of PRMs, such as the Epley maneuver (see https://www.youtube.com/watch?v=9SLm76jQg3g for a demonstration of this maneuver), is to move the head in such a way as to return displaced otoliths in the semicircular canal back to the utricle. The Epley maneuver is specific for treating posterior semicircular canal BPPV, which is the most common variant.

Identifying true vertigo from among other sensations helps to limit the differential because true vertigo is caused by vestibular etiologies only.

Performing the Epley maneuver. To perform the Epley PRM for correction of an otolith in the left posterior semicircular canal, ask the patient to sit and look straight ahead. Lay the patient back, while asking the patient to turn his/her head 45 degrees to the left side. Then ask the patient to turn his/her head 45 degrees to the right side. Instruct the patient to maintain the same 45-degree head orientation, while rolling over to his/her right shoulder, ending in the right decubitus position. Conclude the maneuver by having the patient sit up.

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