A 54-year-old Caucasian chef presents to clinic complaining about "a new problem with really bad dizziness." She says that when she first sat up in bed this morning, she suddenly felt very unstable and as if her body was spinning in space. She was overcome by nausea but did not vomit, and then the episode passed after approximately one minute. She had similar episode when she was working in the restaurant kitchen. She has not been ill recently or in contact with any ill people to her knowledge. Her past medical history is significant for mild chronic obstructive pulmonary disease and ulcerative colitis. Current medications include albuterol, prednisone, mesalamine, and ibuprofen. She has a remote thirty pack-year history of cigarette smoking and drinks alcohol only on social occasions. Her temperature is 36.8C (98F), blood pressure is 124/72 mm Hg (sitting) and 120/68 mm Hg (standing), pulse is 75/min, and respirations are 14/min. Positional nystagmus is noted on physical examination. Which of the following measures is the most appropriate course of action?

Question

A 54-year-old Caucasian chef presents to clinic complaining about "a new problem with really bad dizziness."  She says that when she first sat up in bed this morning, she suddenly felt very unstable and as if her body was spinning in space.  She was overcome by nausea but did not vomit, and then the episode passed after approximately one minute.  She had similar episode when she was working in the restaurant kitchen.  She has not been ill recently or in contact with any ill people to her knowledge.  Her past medical history is significant for mild chronic obstructive pulmonary disease and ulcerative colitis.  Current medications include albuterol, prednisone, mesalamine, and ibuprofen.  She has a remote thirty pack-year history of cigarette smoking and drinks alcohol only on social occasions.  Her temperature is 36.8C (98F), blood pressure is 124/72 mm Hg (sitting) and 120/68 mm Hg (standing), pulse is 75/min, and respirations are 14/min.  Positional nystagmus is noted on physical examination.  Which of the following measures is the most appropriate course of action?

Quizplus · Accepted Answer

Explanation: Benign paroxysmal positional vertigo (BPPV) is defined as an abnormal feeling of motion triggered by certain provocative positions. The condition is most often attributed to canalithiasis, or the presence of calcium "rocks" within the posterior semicircular canal. If there is substantial debris in the canal, then linear accelerations (eg, gravity) may cause the endolymph to move inappropriately. This results in the inaccurate sensation of spinning subsequent to movement of the head. Although the condition is often idiopathic, it can also be associated with head trauma or vestibular pathologies. BPPV should first be treated with the canalith repositioning procedure (Choice C), which is a series of maneuvers that move particles out of the posterior semicircular canal and into the utricle. BPPV is a clinical diagnosis. Further testing is not indicated with typical posterior canal BPPV presentation. Imaging of the head (Choices A and B) is indicated if a mass lesion, hemorrhage, stroke, or Meniere's disease is thought responsible for the patient's vertigo. Promethazine (Choice D) is a nonselective antihistamine used in the treatment of nausea or vomiting. It may be of help in patients with vertigo but addresses only this particular symptom and not the cause. Plugging of the posterior canal (Choice E) is a surgical procedure used in patients with intractable symptoms of BPPV. In most cases, the procedure reduces the functionality of the posterior canal without affecting hearing. Educational Objective: Benign paroxysmal positional vertigo should first be treated with the canalith repositioning procedure, which is a series of maneuvers that moves particles out of the posterior semicircular canal and into the utricle. References: Management of benign paroxysmal positional vertigo with the canalith repositioning maneuver in the emergency department setting. (http://www.ncbi.nlm.nih.gov/pubmed/21068225) Benign paroxysmal positional vertigo. (http://www.ncbi.nlm.nih.gov/pubmed/20607044)

A 54-Year-Old Caucasian Chef Presents to Clinic Complaining About "A