Dizziness and Vertigo Primary Care: Clinics in Office Practice

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Dizziness and Vertigo Primary Care: Clinics in Office Practice Jennifer Wipperman, MD, MPH Primary Care: Clinics in Office Practice Volume 41, Issue 1, Pages 115-131 (March 2014) DOI: 10.1016/j.pop.2013.10.004 Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 1 Treatment maneuver for benign paroxysmal positional vertigo affecting the right ear. To treat the left ear, the procedure is reversed. The drawing of the labyrinth in the center shows the position of the particle as it moves around the posterior semicircular canal (PSC) and into the utricle (UT). The patient is seated upright, with head facing the examiner, who is standing on the right. (A) The patient is rapidly moved to head-hanging right position (Dix-Hallpike test). This position is maintained until the nystagmus ceases. (B) The examiner moves to the head of the table, repositioning hands as shown. (C) The head is rotated quickly to the left with right ear upward. This position is maintained for 30 seconds. (D) The patient rolls onto the left side while the examiner rapidly rotates the head leftward until the nose is directed toward the floor. This position is then held for 30 seconds. (E) The patient is rapidly lifted into the sitting position, now facing left. The entire sequence should be repeated until no nystagmus can be elicited. After the maneuver, the patient is instructed to avoid head-hanging positions to prevent the particles from reentering the posterior canal. (From Rakel RE. Conn's current therapy 1995. Philadelphia: WB Saunders; 1995. p. 839; with permission.) Primary Care: Clinics in Office Practice 2014 41, 115-131DOI: (10.1016/j.pop.2013.10.004) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 2 Supine roll test. (1) Start supine with head in neutral position. (2) Turn the patient’s head quickly 90 degrees to the right and observe for nystagmus. Return the head to neutral position (1). (3) After any residual nystagmus or symptoms resolve, turn the patient’s head quickly 90 degrees to the left and observe for nystagmus. (From Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2008;70:2067–74; with permission.) Primary Care: Clinics in Office Practice 2014 41, 115-131DOI: (10.1016/j.pop.2013.10.004) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 3 Head-thrust test. Top panel shows a positive head-thrust test. The examiner moves the patient’s head quickly 10 degrees to the side, in this case to the patient’s left. A catch-up saccade is observed when the patient looks away and then refixes on the visual target, indicating a peripheral lesion on the left. Bottom panel shows a normal head-thrust test. The patient maintains visual fixation during head movement. (From Seemungal BM, Bronstein AM. A practical approach to acute vertigo. Pract Neurol 2008;8:211–21; with permission.) Primary Care: Clinics in Office Practice 2014 41, 115-131DOI: (10.1016/j.pop.2013.10.004) Copyright © 2014 Elsevier Inc. Terms and Conditions

Fig. 4 Audiogram of low-frequency hearing loss in Meniere's disease. SDS, speech discrimination score. (From Bope ET, Kellerman RD. Conn's Current Therapy 2013. Philadelphia: Saunders; 2012. p. 301; with permission.) Primary Care: Clinics in Office Practice 2014 41, 115-131DOI: (10.1016/j.pop.2013.10.004) Copyright © 2014 Elsevier Inc. Terms and Conditions