Vestibulum — Vertigo Teaching Atlas

Step 1 of 6 · HISTORY

History

A 52-year-old woman presents to the office with a 5-day history of brief episodes of spinning vertigo. Each is triggered by rolling over in bed, looking up at a high shelf, or bending forward. Episodes last 15-30 seconds and resolve completely. Between attacks she is at her baseline. No hearing loss, tinnitus, or aural fullness. No headache, no neurologic symptoms. Past history unremarkable; no medications.

Step 2 of 6 · QUESTION

Question

Which vestibular syndrome best fits the timing and triggers?

Brief (seconds), triggered by head position changes, with normal exam between = triggered EVS. The differential is BPPV vs. orthostatic vs. central positional vertigo.

Step 3 of 6 · EXAM

Bedside exam — Dix-Hallpike

Standard exam is normal. You proceed to a Dix-Hallpike maneuver to the right side. After a 3-second latency, the following nystagmus appears, builds to a peak, and decays over ~20 seconds. The patient reports vertigo that resolves with the nystagmus. On returning to sitting, a brief reverse nystagmus appears.

What you see

Fast-phase: ↑ upbeating vertical · ↻ right-torsional (CW) · fatigable · latency 2.5s

"Upbeating + right-torsional (top-poles beat toward the dependent right ear) nystagmus after latency 1–5 s. Crescendo–decrescendo over 10–30 s. Fatigable."

→ View full nystagmus profile

Step 4 of 6 · QUESTION

Question

How would you classify this nystagmus pattern?

Upbeating + torsional toward the lower (right) ear, with latency, crescendo-decrescendo, and fatigue — the classic posterior-canal canalithiasis pattern.

Step 5 of 6 · QUESTION

Question

What is the most appropriate next step?

Right Epley is the treatment of choice — ~80% efficacy on first attempt.

Step 6 of 6 · REVEAL

Diagnosis

Right posterior canal benign paroxysmal positional vertigo (canalithiasis)

Teaching points

1.BPPV affects ~2.4% of people in their lifetime; posterior canal accounts for ~85% of cases.
2.Diagnostic latency (1-5 s), crescendo-decrescendo course, duration <60 s, and fatigability are the four diagnostic features of canalithiasis.
3.Always test both sides with Dix-Hallpike, and do a supine roll test if Dix-Hallpike is negative but BPPV is suspected.
4.Persistent positional nystagmus without latency or fatigue should prompt consideration of central positional nystagmus (cerebellar pathology).

→ Read the full clinical profile of Benign paroxysmal positional vertigo (BPPV)