Benign Paroxysmal Positional Vertigo (BPPV)
Right Posterior Canalithiasis
A 34 year-old male with no significant past medical history presented to our clinic with a chief complaint of episodic vertigo occurring over the past 2 weeks. The patient stated that he had initial episode of vertigo while lying down in bed and rolling over from his right to left side. He stated that the vertigo “woke me up” and was described as a “room spinning” sensation. The episode lasted for seconds and resolved with keeping his head completely still. He had mild nausea, however no vomiting. The vertigo returned when he attempted to get out of bed to go the bathroom and worsened when he went to lie back down in bed. He would continue to have episodes of vertigo also noted with looking up to reach for something in a cupboard in his kitchen or while pitching his head down to put on his shoes. While sitting, he has no symptoms. The patient denied any other focal, motor, sensory, or cranial nerve complaints associated with his vertigo.
The patient denied any drug allergies and was not taking any medication.
He denied tobacco, alcohol, or recreational drug use.
His exam was unremarkable and without any focal findings.
Infrared video oculography was performed and identified a robust torsional nystagmus while having the patient lying supine with head extended over the exam table 30 degrees and head rotated to the right 45 degrees (Dix-Hallpike test). The patient reported worsening vertigo and nausea associated with the observed nystagmus. This indicated that the patient had BPPV involving the right posterior semicircular canal or as it is commonly referred to in our practice, “loose crystals” in the right posterior canal. This eye movement was recorded and shown to the patient.
Treatment was performed using canalith repositioning maneuvers, specifically the Epley maneuver. Following treatment, infrared video oculography was performed again and the patient’s head was placed in the same position that had exacerbated his symptoms and produced the nystagmus pattern. The nystagmus had resolved and the patient reported marked improvement of his symptoms. The post-treatment recording was reviewed with the patient.
The patient was given the BPPV education sheet, scheduled a follow-up in 2 weeks, and instructed to return to clinic ASAP with worsening symptoms. Of note, audiometric testing and an MRI of the brain were obtained in order to assess for what is referred to as “retrocochlear pathology” as a benign tumor called an acoustic neuroma could have caused the otoconia or crystals to break loose from the utricle in the first place. Both studies were normal and were reviewed and discussed with the patient at follow-up. At the patient’s follow-up he reported complete resolution of symptoms and was able to lie flat in bed, roll over, and pitch his head up and down without causing vertigo.