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Practice

Clinical diagnosis of benign paroxysmal positional vertigo and vestibular neuritis

Peter Johns and James Quinn
CMAJ February 24, 2020 192 (8) E182-E186; DOI: https://doi.org/10.1503/cmaj.190334
Peter Johns
Department of Emergency Medicine (Johns), University of Ottawa, Ottawa, Ont.; Department of Emergency Medicine (Quinn), Stanford University, Stanford, Calif.
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James Quinn
Department of Emergency Medicine (Johns), University of Ottawa, Ottawa, Ont.; Department of Emergency Medicine (Quinn), Stanford University, Stanford, Calif.
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    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.

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    Box 1: Clinical presentation and guide to bedside testing for benign paroxysmal positional vertigo, vestibular neuritis and cerebellar stroke
    SymptomBPPVVestibular neuritisCerebellar stroke
    Vertigo when patient is stillNoYesYes
    Patient is able to stand unaidedYesYesMay not be able to
    Spontaneous and/or gaze-evoked nystagmusNoYesYes
    Typical spontaneous or gaze-evoked nystagmus observedNot presentUndirectional horizontal/rotatory
    Not purely vertical
    Various, including bidirectional horizonal/rotatory; sometimes vertical
    Worse when patient moves their headYesYesYes
    Other neurologic symptoms or findingsNoNoOften but not always present
    New hearing lossNoNoCan occur
    Appropriate to perform Dix–Hallpike testYesNoNo
    Nystagmus produced during Dix–Hallpike testVertical upward and rotatoryDo not perform Dix–Hallpike testDo not perform Dix–Hallpike test
    Appropriate to perform HINTS plus examinationNoYesYes
    Results from HINTS plus examinationDo not perform HINTS plus testingAll 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 indicatedNoNoYes
    Primary treatmentEpley maneuverSupportive treatmentTreatment 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.

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Canadian Medical Association Journal: 192 (8)
CMAJ
Vol. 192, Issue 8
24 Feb 2020
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Clinical diagnosis of benign paroxysmal positional vertigo and vestibular neuritis
Peter Johns, James Quinn
CMAJ Feb 2020, 192 (8) E182-E186; DOI: 10.1503/cmaj.190334

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Clinical diagnosis of benign paroxysmal positional vertigo and vestibular neuritis
Peter Johns, James Quinn
CMAJ Feb 2020, 192 (8) E182-E186; DOI: 10.1503/cmaj.190334
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