Clinical diagnosis of benign paroxysmal positional vertigo and vestibular neuritis

Article Figures & Tables

Download figure
Open in new tab
Download powerpoint
Figure 1:
Flow chart of the initial approach to the diagnosis of acute vertigo. With permission from Tintinalli JE, Ma OJ, Yealy DM, et al. Tintinalli’s emergency medicine: a comprehensive study guide, 9th edition. New York: McGraw Hill; 2020. Note: BPPV = benign paroxysmal positional vertigo; HINTS plus = head impulse, nystagmus and test of skew, with plus refering to a test of recent hearing loss; HIT = head impulse test.

Box 1: Clinical presentation and guide to bedside testing for benign paroxysmal positional vertigo, vestibular neuritis and cerebellar stroke

Symptom	BPPV	Vestibular neuritis	Cerebellar stroke
Vertigo when patient is still	No	Yes	Yes
Patient is able to stand unaided	Yes	Yes	May not be able to
Spontaneous and/or gaze-evoked nystagmus	No	Yes	Yes
Typical spontaneous or gaze-evoked nystagmus observed	Not present	Undirectional horizontal/rotatory Not purely vertical	Various, including bidirectional horizonal/rotatory; sometimes vertical
Worse when patient moves their head	Yes	Yes	Yes
Other neurologic symptoms or findings	No	No	Often but not always present
New hearing loss	No	No	Can occur
Appropriate to perform Dix–Hallpike test	Yes	No	No
Nystagmus produced during Dix–Hallpike test	Vertical upward and rotatory	Do not perform Dix–Hallpike test	Do not perform Dix–Hallpike test
Appropriate to perform HINTS plus examination	No	Yes	Yes
Results from HINTS plus examination	Do not perform HINTS plus testing	All 4 findings: Undirectional nystagmus No vertical skew Abnormal HIT No hearing loss HINTS plus = peripheral	Any of: Bidirectional nystagmus Vertical skew present Normal HIT New hearing loss HINTS plus = central
Imaging indicated	No	No	Yes
Primary treatment	Epley maneuver	Supportive treatment	Treatment for stroke

Note: BPPV = benign paroxysmal positional vertigo, HINTS = head impulse, nystagmus and test of skew, with plus refering to a test of recent hearing loss, HIT = head impulse test. With permission from Tintinalli JE, Ma OJ, Yealy DM, et al. Tintinalli’s emergency medicine: a comprehensive study guide, 9th edition. New York: McGraw Hill; 2020.