What is the workup for vertigo that worsens with walking towards the right side, differing from baseline vertigo?

Diagnostic Workup for Vertigo with Directional Worsening

For vertigo that worsens with walking toward the right side, a focused vestibular evaluation is essential, starting with the Dix-Hallpike maneuver and supine roll test to differentiate between peripheral and central causes.

Initial Assessment

• The directional component of vertigo (worsening when walking toward the right) suggests a possible lateral semicircular canal involvement or asymmetric vestibular function 1
• Differentiation between peripheral and central causes is the first critical step in evaluation 2, 3

Diagnostic Testing Algorithm

Step 1: Positional Testing

• Dix-Hallpike Maneuver: Essential for diagnosing posterior canal BPPV

  • Patient is moved from seated to supine position with head turned 45° to one side and extended 20° 1
  • Observe for characteristic torsional, upbeating nystagmus with latency period (5-20 seconds) 1
  • Test must be performed bilaterally to determine affected ear 1

• Supine Roll Test: Critical for diagnosing lateral canal BPPV

  • Position patient supine with head neutral, then quickly rotate head 90° to each side 1
  • Observe for horizontal nystagmus patterns:
    • Geotropic type: More intense nystagmus beating toward the undermost (affected) ear 1
    • Apogeotropic type: Nystagmus beating toward the uppermost ear 1

Step 2: Vestibular Function Testing

• Comprehensive vestibular testing if positional tests are negative or inconclusive 4
• Evaluate for vestibulo-ocular reflex abnormalities 4

Step 3: Neuroimaging

• MRI Brain: Indicated if:

  • Central signs present (direction-changing nystagmus without positional trigger, downbeat nystagmus without torsional component) 4
  • Neurological symptoms accompany vertigo 1, 4
  • Positional testing suggests central pathology 4

• CT Temporal Bone: Consider if conductive hearing loss is present or superior canal dehiscence is suspected 1

Key Diagnostic Findings to Watch For

• Peripheral Vertigo Signs:

  • Nystagmus that lessens with visual fixation 2
  • Positive response to repositioning maneuvers 1
  • No associated neurological deficits 5

• Central Vertigo Red Flags:

  • Nystagmus that does not lessen with visual fixation 2
  • Downbeating nystagmus without a torsional component 4
  • Associated neurological symptoms (headache, dysarthria, ataxia) 4, 6
  • Direction-changing nystagmus without positional trigger 4

Management Based on Diagnosis

• If Posterior Canal BPPV: Canalith Repositioning Procedure (Epley maneuver) 1
• If Lateral Canal BPPV - Geotropic: Barbecue roll maneuver or Gufoni maneuver 1
• If Lateral Canal BPPV - Apogeotropic: Gufoni maneuver for apogeotropic type 1
• If Vestibular Neuritis: Vestibular suppressants and rehabilitation exercises 7, 5
• If Meniere's Disease: Low-salt diet and diuretics 7, 5
• If Central Cause: Urgent referral for further neurological evaluation 4, 3

Symptomatic Relief During Workup

• Meclizine may be used for symptomatic relief of vertigo during diagnostic workup 8
• Avoid prolonged use of vestibular suppressants as they may delay central compensation 7

Common Pitfalls to Avoid

• Failing to perform both Dix-Hallpike and supine roll tests, potentially missing lateral canal BPPV 1
• Misinterpreting downbeat nystagmus as BPPV when it may indicate a central cause 4
• Neglecting to consider directional components of vertigo which may provide diagnostic clues 6
• Relying solely on imaging without proper clinical vestibular testing 1, 2