What is the likely cause of dizziness in a 4-year-old female patient, presenting with symptoms of the house moving, without fever, current illness, or ear pain, and a recent history of swimming 2 days ago?

Likely Diagnosis: Benign Paroxysmal Positional Vertigo (BPPV)

This 4-year-old most likely has Benign Paroxysmal Positional Vertigo (BPPV) triggered by water exposure during swimming, which can cause debris to shift within the inner ear canals. 1

Clinical Reasoning

The presentation strongly suggests BPPV based on several key features:

• The description "the house is moving" represents true vertigo (sensation of environmental motion), which is specific for inner ear dysfunction and distinguishes this from non-vestibular causes like presyncope or lightheadedness 2

• Recent swimming history is a relevant trigger, as water exposure can cause debris (canaliths) to shift within the vestibular labyrinth, precipitating BPPV episodes 2

• Absence of fever, current illness, and ear pain effectively rules out infectious causes such as acute otitis media, labyrinthitis, or vestibular neuritis, which would typically present with systemic symptoms or otalgia 1, 3

• BPPV is the most common cause of peripheral vertigo, accounting for 42% of cases in general practice settings, and can occur in children following swimming or head position changes 1, 2

Immediate Diagnostic Approach

Perform the Dix-Hallpike maneuver bilaterally as the gold standard diagnostic test 1, 3. Look for these characteristic findings that confirm BPPV:

• Latency period of 5-20 seconds before symptoms begin 1
• Torsional, upbeating nystagmus toward the affected ear 1, 2
• Vertigo and nystagmus that increase then resolve within 60 seconds 1
• Symptoms that fatigue with repeat testing 2

Red Flags to Exclude (None Present in This Case)

The American Academy of Otolaryngology-Head and Neck Surgery identifies these concerning features that would require urgent neuroimaging, none of which are present in this patient 1, 2:

• Focal neurological deficits
• Inability to stand or walk
• Severe postural instability with falling
• Downbeating nystagmus without torsional component
• New severe headache accompanying dizziness
• Sudden unilateral hearing loss

Treatment Plan

If the Dix-Hallpike test is positive, perform the Epley maneuver (canalith repositioning procedure) immediately 1, 3. This is first-line treatment with:

• 80% success rate after 1-3 treatments 1, 4
• 90-98% success rate with additional maneuvers if initial treatment fails 1, 2

Do NOT order imaging or vestibular testing for typical BPPV with positive Dix-Hallpike and no red flags, as this unnecessarily delays treatment and has no diagnostic value 1, 2

Do NOT prescribe vestibular suppressant medications (such as meclizine), as they prevent central compensation and are unnecessary for typical BPPV 2

Follow-Up

• Reassess within one month to document resolution or persistence of symptoms 1
• Counsel parents about recurrence risk and the importance of returning promptly if symptoms recur for repeat repositioning procedures 1
• Monitor for fall risk, particularly if symptoms persist 1

Common Pitfalls to Avoid

• Skipping the Dix-Hallpike maneuver is the most common error—this is the gold standard diagnostic test and should never be omitted 3
• Ordering unnecessary imaging for straightforward BPPV delays treatment and provides no diagnostic benefit 1, 2
• Assuming a central cause without performing proper vestibular testing—approximately 10% of cerebellar strokes can mimic peripheral vestibular disorders, but this patient lacks any red flags 2
• Prescribing vestibular suppressants routinely, which interferes with the natural compensation process 2