What is the best course of treatment for a 27-year-old male with dizziness, nasal congestion, and a history of similar episodes, suspected to have Benign Paroxysmal Positional Vertigo (BPPV) or Eustachian tube disorder?

Assessment of Clinical Documentation and Management Plan

Your clinical note demonstrates appropriate diagnostic reasoning and treatment for suspected BPPV, but the negative Dix-Hallpike test argues against a definitive BPPV diagnosis, and prescribing decongestants without performing in-office canalith repositioning represents a missed opportunity for immediate therapeutic intervention. 1

Strengths of Your Clinical Approach

History Documentation

• You correctly identified the cardinal features of BPPV: positional vertigo triggered by head movements (standing up, turning head, sitting up quickly) with brief duration 1, 2
• The associated nausea and single episode of emesis align with typical BPPV presentations 1, 2
• Your documentation appropriately ruled out red flags including no focal neurological deficits, no hearing loss, no chest pain, and no recent trauma 1, 3

Physical Examination

• Comprehensive HEENT examination was appropriate and well-documented 1
• Vital signs within normal limits help exclude cardiovascular causes 3
• Unremarkable neurological examination is crucial for ruling out central causes of vertigo 1, 3

Critical Issues with Your Management

Diagnostic Testing Problem

The most significant issue is that your Dix-Hallpike test was negative (no nystagmus observed), which means this patient does NOT meet diagnostic criteria for posterior canal BPPV. 1

• The American Academy of Otolaryngology-Head and Neck Surgery requires torsional, upbeating nystagmus provoked by the Dix-Hallpike maneuver to diagnose posterior canal BPPV 1
• A negative Dix-Hallpike with a history of positional symptoms suggests either: (1) horizontal canal BPPV requiring supine roll testing, (2) symptoms resolved spontaneously before examination, (3) orthostatic hypotension, or (4) another vestibular disorder 1, 3
• You should have performed the supine roll test to evaluate for horizontal canal BPPV when the Dix-Hallpike was negative 1, 4

Treatment Approach Issues

Prescribing decongestants and home Epley maneuvers without a positive Dix-Hallpike test is not evidence-based management. 1

• The American Academy of Otolaryngology-Head and Neck Surgery states that medications (other than for immediate nausea relief) are not indicated for BPPV treatment 1
• Canalith repositioning procedures should be performed IN THE CLINIC when BPPV is diagnosed, not taught for home use as initial therapy 1, 5
• The Epley maneuver has 80% success rates after 1-3 in-office treatments, and teaching home maneuvers is reserved for recurrent cases or treatment failures 1, 3
• Decongestants may be reasonable for the chronic nasal congestion and postnasal drip you observed, but they do not treat BPPV 1

What You Should Have Done

Immediate Management Algorithm

1. Since Dix-Hallpike was negative, perform supine roll test to evaluate for horizontal canal BPPV (the second most common variant) 1, 4, 5

2. If supine roll test is also negative:

   • Consider orthostatic vital signs given the symptom of dizziness upon standing 3
   • Reassess whether symptoms truly represent positional vertigo versus orthostatic lightheadedness 3
   • Consider that BPPV may have resolved spontaneously (symptoms started yesterday, natural resolution can occur) 1

3. If either test is positive:

   • Perform the appropriate repositioning maneuver IMMEDIATELY in the clinic (Epley for posterior canal, barbecue roll for horizontal canal) 1, 5
   • Repeat the diagnostic test after treatment to confirm resolution 5
   • Success rates are 70-90% with immediate in-office treatment 4, 5

4. For the chronic nasal congestion:

   • Decongestants are reasonable for the observed postnasal drip and turbinate inflammation [@evidence from physical exam findings]
   • This addresses potential Eustachian tube dysfunction as a contributing factor [@clinical reasoning]

Follow-Up Instructions

• Your 2-week follow-up is appropriate, but should be contingent on persistent symptoms 1
• Patients should be counseled about BPPV recurrence risk (can recur in 15-50% of cases) and instructed to return promptly for repeat repositioning if symptoms recur 3
• Fall precautions are appropriate, especially given the single episode of vomiting suggesting significant symptom severity 1, 2

Common Pitfalls You Avoided

• You correctly avoided ordering brain imaging, which has <1% diagnostic yield for isolated positional dizziness with normal neurological exam 3
• You appropriately consulted with a supervising provider [@clinical practice standard]
• You documented red flag symptoms that were absent (no hearing loss, no focal deficits, no severe headache) [1, @7@]

Recommendations for Documentation Improvement

Revise your assessment to reflect the negative Dix-Hallpike finding:

• "Positional dizziness with negative Dix-Hallpike test. Differential includes resolving BPPV, horizontal canal BPPV (not yet tested), orthostatic hypotension, or vestibular neuritis with positional component." 1, 3

Modify your treatment plan:

• Perform supine roll test at follow-up if symptoms persist [@9@, 5]
• Reserve home Epley maneuvers for confirmed BPPV cases that recur after successful in-office treatment [@3@, @7