Has the Pendulum Swung Too Far?
Back in 2013, I did a several part series on BPPV (Benign Paroxysmal Positional Vertigo). My concern was that BPPV was being overlooked, under diagnosed, and not treated often enough in the general medical community. The vast majority of patients complaining of positional vertigo never got a positional test. A reader commented that things seemed to be improving in his community. Over these past three years, I have also noticed an increase in patients being given home exercises for BPPV. Because of this increase in home treatment, I came back in 2014 and did a short series reviewing the most and least effective home treatment techniques.
Jump forward to the end of 2015, and I see the trend to prescribe home exercises for BPPV continuing. My concern is that this is being done without proper examination, solely based on the patient’s description of recurrent vertigo (sometimes positional, sometimes not). Statistically, this makes some sense as BPPV is, by far, the most common cause of recurrent vertigo. But sometimes, it is dangerous to make this assumption and recommend treatment without doing a positional examination. Some examples of this are nicely reviewed by Dr. Tucker Gleason at the University of Virginia.
Two Recent Cases
In just the past month, I have seen two patients that were given home exercises for suspected BPPV. Neither was examined for positional nystagmus. Neither had BPPV.
Patient #1: A young, healthy male with complaints of severe vertigo, nausea and vomiting, provoked by lying flat on his back or with repetitive head motion. On examination by the Physician’s Assistant in our clinic (an important point because the exam was done without the benefit of VNG goggles), persistent down beat nystagmus was noted. The P.A. brought the young man directly over to our lab, where prolonged downbeat positional nystagmus with no latency was observed. The patient was scheduled for MRI scan and an ependymoma of the fourth ventricle was found. Emergency surgery was scheduled and the tumor has already been removed.
Patient #2: A gentleman in his seventies with initial presentation of fluctuating left sided hearing complaints and vague “dizziness.” He was treated with a scopolamine patch and given home exercises for suspected BPPV. Within days, he developed left facial weakness which was initially suspected to be Bell’s Palsy. Less than 24 hours later, he developed ataxia and cranial MRI was ordered. He was found to have suffered a lateral medullary and cerebellar stroke. He was seen in our department due to sudden left sided hearing loss, and persistent left beat nystagmus was noted on examination by the Physician’s Assistant. Under video goggles, it was noted that the left beat nystagmus was less prominent when visual fixation was removed (in total darkness), which is inconsistent with nystagmus of peripheral labyrinthine origin. In view of profound sensorineural hearing loss, Otoacoustic emissions and wave I of his ABR test were present. This is an unusual case of neural hearing loss, as the cochlea on the side of the profound hearing loss was still functional.
Both of these patients would have been identified sooner if a positional test had been performed before home exercise treatment was recommended. Patient #1 had downbeat positional nystagmus, and patient #2 had persistent left beat horizontal nystagmus, both visible without the benefit of video goggles.
Photo courtesy of dev.physicslab.org