Diagnosis of benign paroxysmal positional vertigo in Emergency Department: Our experience

Abstract

The Benign Paroxysmal Positional Vertigo (BPPV) represents the first cause of peripheral vertigo in populations and it is determined by a displacement of otoconial fragments within the semicircular canals. Following the patient's head movements, these fragments, moving by inertia, incorrectly stimulate the canals generating vertigo. The BPPV is diagnosable by observing the nystagmus that is generated in the patient following the Dix-Hallpike maneuver used for BPPV diagnosis of vertical semi-circular canal, and, following the supine head yaw test used for lateral semi-circular canal. Correctly identifying the origin of this specific peripheral vertigo, would mean to obtain a faster diagnosis and an immediate resolution of the problem for the patient. In this context, this study aims to identify precise training activities, aimed at the application of specific diagnostic maneuverers for algorithm decisions in support of medical personnel. The evaluations reported in this study refer to the data collected in the Emergency Department of the Cardarelli Hospital of Naples. The results obtained, over a six-month observation period, highlighted the advantages of the proposed procedures in terms of costs, time and number of BPPV diagnoses.

Keywords: benign paroxysmal positional vertigo; diagnostic algorithm; emergency department.

Figure 1.

The BPPV-Algorithm (BPPV-A). The exam begins with a seated patient. In the presence of a pseudo-spontaneous Nystagmus (Ny), the patient is subjected to supine Head Yaw Test (HYT). If the HYT is positive (bidirectional, bipositional, paroxysmal Ny on side), the vestibular examination is performed; if the HYT is negative (monodirectional, not paroxysmal Ny on side) further investigations are carried out. If spontaneous nystagmus is absent, the HYT and Dix-Hallpike maneuver are performed. If the Dix-Hallpike maneuver is positive, the vestibular examination is performed; if the maneuver is negative, further investigations are carried out. Vertical or torsional spontaneous nystagmus are not included.

Figure 2.

Emergency Room Access for Acute Vertigo. Out of a total of 363 patients, 188 (52%) had BPPV, 83 (23%) patients had a peripheral acute vestibular deficit, 19 patients (5%) with other peripheral pathologies, and 73 (20%) with central vertigo.

Figure 3.

BPPV: semicircular canals involved. Out of 37 BPPV from lithiasis of LSC: the right non-ampullary arm (geotropic form) was involved in 41% and the left non-ampullary arm (geotropic form) was involved in 16%; the right ampullary arm (apogeotropic form) was involved in 27% and the left ampullary arm (apogeotropic form) was involved in 16%.