What is the diagnosis and treatment for a patient with symptoms of peripheral vestibular dysfunction, such as vertigo, dizziness, and imbalance?

Diagnosis and Treatment of Peripheral Vestibular Dysfunction

Diagnostic Approach

The diagnosis of peripheral vestibular dysfunction begins with identifying the specific pattern of symptoms and performing targeted bedside maneuvers, not with imaging or laboratory tests. 1

Clinical Presentation Patterns

The symptom pattern determines the diagnostic pathway:

• Episodic vertigo triggered by head position changes (lasting seconds to minutes) indicates benign paroxysmal positional vertigo (BPPV), the most common peripheral vestibular disorder accounting for 80-90% of cases 1
• Acute persistent vertigo (continuous for hours to days) with nausea, vomiting, and gait instability defines acute vestibular syndrome (AVS), most commonly caused by vestibular neuritis or labyrinthitis 2, 1
• Recurrent episodic vertigo with auditory symptoms (hearing loss, tinnitus, aural fullness) suggests Ménière's disease 3

Essential Bedside Examination

For suspected BPPV, perform the Dix-Hallpike maneuver immediately - this is both diagnostic and identifies which canal is affected 2, 1:

• Position the patient seated with head turned 45° toward the suspected side
• Rapidly move the patient to supine with head hanging 20° below horizontal
• Observe for characteristic upbeating, torsional nystagmus with 5-20 second latency that resolves within 60 seconds 2
• A positive test confirms posterior canal BPPV (85-95% of BPPV cases) 1

If Dix-Hallpike is negative but BPPV suspected, perform the supine roll test for horizontal canal BPPV (10-15% of cases) 4:

• With patient supine, rapidly turn head 90° to each side
• Observe for horizontal nystagmus (geotropic or apogeotropic patterns) 4

For acute persistent vertigo, perform the HINTS examination (Head-Impulse, Nystagmus, Test of Skew) to distinguish peripheral from central causes 1:

• This examination has 100% sensitivity for detecting stroke when performed by trained practitioners 1
• Peripheral vestibular dysfunction shows: abnormal head impulse test, unidirectional horizontal nystagmus, and no vertical skew deviation 5

When Imaging is NOT Indicated

Do not obtain radiographic imaging or vestibular function testing in patients with typical BPPV confirmed by positive Dix-Hallpike testing 2, 1. The costs are not justified, diagnostic accuracy is not improved, and management is not altered in the vast majority of cases 2.

When Imaging IS Indicated

Consider MRI (not CT) only when 2:

• Diagnosis remains uncertain after bedside testing
• Additional neurological symptoms are present (abnormal cranial nerve findings, visual disturbances, severe headache) 2
• HINTS examination suggests central etiology 1
• Atypical nystagmus patterns that don't fit peripheral vestibular dysfunction 2
• Patient remains symptomatic following appropriate treatment 2

The detection rate of contributory CNS pathology on imaging in patients with normal neurologic examination is less than 1% 2.

Treatment Approach

For BPPV (Most Common Peripheral Vestibular Disorder)

Perform canalith repositioning procedures (CRP) immediately - this is the definitive first-line treatment, not medication 1, 4:

Posterior Canal BPPV (85-95% of cases):

The Epley maneuver achieves 80% success with 1-3 treatments and 90-98% with repeat maneuvers 1, 4:

1. Patient seated, head turned 45° toward affected ear
2. Rapidly lay patient back to supine head-hanging 20° position for 20-30 seconds
3. Turn head 90° to opposite side, hold 20-30 seconds
4. Roll patient onto side (nose pointing down), hold 20-30 seconds
5. Return to upright sitting position 4

Alternative: Semont (Liberatory) maneuver has 94.2% resolution at 6 months and 71% at 1 week 4

Horizontal Canal BPPV (10-15% of cases):

• Geotropic variant: Barbecue Roll (Lempert) maneuver (50-100% success) or Gufoni maneuver (93% success) 4
• Apogeotropic variant: Modified Gufoni maneuver (patient lies on affected side) 4

Critical Post-Treatment Instructions

Do NOT impose postprocedural restrictions - patients can resume normal activities immediately 1, 4. Strong evidence shows restrictions provide no benefit and may cause complications 4.

Medication Management: What NOT to Do

Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment for BPPV 1, 4. Despite FDA approval of meclizine for "vertigo associated with diseases affecting the vestibular system" 6, guidelines are clear that:

• No evidence supports effectiveness as definitive primary treatment for BPPV 4
• These medications cause drowsiness, cognitive deficits, and increased fall risk (especially in elderly) 4
• They interfere with central compensation mechanisms 4
• They decrease diagnostic sensitivity during Dix-Hallpike testing 4

Limited exception: Consider short-term use only for severe autonomic symptoms (nausea, vomiting) in severely symptomatic patients 4

For Vestibular Neuritis/Labyrinthitis (Acute Vestibular Syndrome)

Vestibular rehabilitation therapy (VRT) is the primary treatment, not long-term medication 5, 7, 8:

• VRT includes habituation exercises, adaptation exercises for gaze stabilization, and compensation training 4
• Moderate to strong evidence shows VRT is safe and effective for unilateral peripheral vestibular dysfunction 8
• VRT reduces dizziness (OR 2.67,95% CI 1.85-3.86) and improves function (SMD -0.83,95% CI -1.02 to -0.64) 8
• VRT plus manual therapy speeds recovery compared to VRT alone 9

Treatment Failures: Reassessment Protocol

If symptoms persist after initial CRP, repeat the diagnostic test 4:

• Persistent positive test: Perform additional repositioning maneuvers (success rates reach 90-98%) 1, 4
• Check for canal conversion (occurs in 6-7% of cases) 4
• Evaluate for multiple canal involvement or bilateral BPPV 4
• Consider coexisting vestibular pathology if symptoms occur with general head movements or spontaneously 4
• Rule out central causes if atypical features present 4

Self-Treatment Options

Teach motivated patients self-administered Epley maneuver after at least one properly performed in-office treatment 1, 4:

• Self-administered CRP: 64% improvement 1, 4
• Self-administered Brandt-Daroff exercises: Only 23% improvement 1
• Single CRP is >10 times more effective than a week of Brandt-Daroff exercises (OR 12.38,95% CI 4.32-35.47) 4

Special Populations and Risk Factors

Assess all patients for fall risk before treatment 4:

• Elderly patients with BPPV have 9% prevalence in geriatric clinics, with three-quarters having fallen within 3 months 4
• Evaluate for impaired mobility, CNS disorders, lack of home support 4
• Patients with severe cervical stenosis, rheumatoid arthritis, or spinal issues may need modified approaches or referral to specialized vestibular physical therapy 4

Follow-Up and Recurrence

Reassess patients within one month after initial treatment to confirm symptom resolution 1:

• BPPV recurrence rates: 5-13.5% at 6 months, 10-18% at 1 year, up to 36% long-term 1
• Educate about increased fall risk and recurrence potential 1

Common Pitfalls to Avoid

• Ordering imaging for typical BPPV with positive Dix-Hallpike - this delays treatment and adds unnecessary cost without improving outcomes 2, 1
• Prescribing meclizine or other vestibular suppressants as primary BPPV treatment - despite FDA approval, guidelines show no evidence of effectiveness and potential harm 4, 6
• Imposing postprocedural restrictions after CRP - strong evidence shows no benefit 1, 4
• Not performing repositioning maneuvers quickly enough - reduces effectiveness 4
• Failing to identify the specific affected canal before treatment - leads to ineffective treatment 4
• Not reassessing treatment failures - repeat maneuvers achieve 90-98% success 1, 4