A couple of years ago, I did a four part series here discussing the potential benefits of developing a Clinical Practice Guideline for Acute Vertigo. This would be most applicable to Emergency Department (ED) and Primary Care Physicians (PCP), as very few patients are still in the acute phase by the time they make it to a vestibular lab. There is much evidence to suggest that there may be more efficient ways to evaluate patients that present with acute, recent onset vertigo. There is also evidence that ED physicians recognize this, but also have concerns about adopting new protocols.

 Several months after I concluded my series, the article “Emergency Physician Attitudes, Preferences, and Risk Tolerance for Stroke as a Potential Cause of Dizziness Symptoms” was published. The authors of this article surveyed ED physicians to get an idea how they felt about a new practice guideline replacing their current methods of assessing a patient with acute vertigo. Here are a few highlights from that article:

Less than half of ED physicians use the Epley maneuver to treat BPPV, and less than one out of three use the HINTs protocol to examine for nystagmus, skew deviation, or abnormal head thrust. Both of these techniques have a better than 90% success rate at treating BPPV effectively, and separating peripheral from central vertigo when performed by experienced specialists. That level of confidence has not carried over to the ED.

The majority  of ED physicians (74%) routinely use cranial CT scan when stroke is suspected. Although an equal number of physicians (75%) agreed that CT scan was overused in the evaluation of vertigo. Read about CT scans for dizziness here.

The majority rely on patient medical history and quality of symptoms in establishing risk of stroke. ED physicians express confidence in using cranial nerve exam and limb weakness to separate stoke from benign vertigo. One out of four routinely request neurology consult when stroke is suspected.

ED physicians surveyed agreed that a decision guideline would have to reduce the risk of missed stroke to .05% for them to feel comfortable using it as an alternative to current techniques.

The authors recognize that the risk of stroke as a cause for acute vertigo is quite low (2 to 4%), so any technique to help identify those with stroke more efficiently will only apply to a small group of patients.

 

 

BPPV is a common disorder, typically easily treated once identified.  The vast majority (over 90%) of cases of BPPV involve free floating debris in the posterior canal on one side. The type of BPPV responds well to the Epley maneuver. There are other, less common and less easily treated variants of BPPV.

Occasionally, the debris will settle in the horizontal canal. The most likely complaint that would indicate horizontal canal rather than typical posterior canal is that horizontal canal is triggered more by rolling over in bed, and the vertigo is triggered ON BOTH SIDES. Diagnostically, the nystagmus elicited is horizontal rather than the rotary nystagmus seen in posterior canal BPPV.

There are two forms of horizontal canal BPPV, typically referred to as the GEOTROPIC (towards earth) or AGEOTROPIC (away from earth) form. This refers to the direction of the fast phase of the nystagmus elicited. For the GEOTROPIC form, the Epley maneuver performed with the head tilted up at 30 degrees is very effective. For the AGEOTROPIC form, we are still looking for an effective fix. This was a topic of discussion at the recent course I attended at Johns Hopkins.

During an excellent presentation by Michael Schubert, DPT on canalith repositioning, he demonstrated the Gufoni Manuever for AGEOTROPIC horizontal positional nystagmus. This pattern of nystagmus has generally been thought to be the result of cupulolithiasis of the horizontal canal, located on the side demonstrating the less intense nystagmus. Cupulolithiasis is a variant of BPPV where the debris is not free floating, but has adhered to the cupula at the end of the canal.

Others believe this pattern may suggest canalithiasis, with free floating debris located close to the cupula in the horizontal canal. The Gufoni maneuver is based on this second theory, with a series of head movements intended to move the debris closer to the canal opening to the vestibule.

Dr. Schubert reported Gufoni’s same day success rate at around 80%. I asked him if he achieved similar results, as I have used the Gufoni maneuver on these patients with far less than 80% success rate. He smiled, and acknowledged that 80% was probably optimistic (maybe not for Gufoni himself). A quick survey across the room found that others were frustrated with the low success rate in re-positioning patients with ageotropic horizontal positional nystagmus. It was suggested that maybe those that do not respond to repositioning may have something  other than, or in addition to, BPPV going on. The good news was that most people I talked to found that the vast majority of these patients would return after one week of home BBQ roll exercises with reduced nystagmus and improved symptoms.