The dizzy patient: BPPV, vestibular neuritis, Ménière disease or a stroke?

"The room is spinning" can come from loose debris in the inner ear or from a stroke in the cerebellum. On the exam, as at the bedside, a few questions sort most cases. Is it vertigo or presyncope? How long does it last, and what sets it off? Has the hearing changed? Are there other neurological signs?

Peripheral or central?

Once you know it's vertigo, decide whether the problem is in the inner ear and eighth nerve (peripheral) or in the brainstem and cerebellum (central).

Finding	Peripheral	Central
Tinnitus or hearing loss	Often present	Usually absent
Double vision, slurred speech, numbness, weakness, ataxia	Absent	Usually present
Head impulse test in constant vertigo	Abnormal: the eyes slip and need a catch-up saccade	Normal

Palpitations or shortness of breath with the dizziness point somewhere else: the heart.

The peripheral look-alikes

Diagnosis	The story	Hearing	Next step
BPPV	Episodes of spinning lasting under a minute, set off by rolling over, getting out of bed or looking up; more common with age	Normal	Dix-Hallpike maneuver to confirm; canalith repositioning (Epley maneuver) to treat
Vestibular neuritis	Sudden, constant vertigo for days, often after a viral illness	Normal	Supportive care; a short course of steroids may be used
Labyrinthitis	Sudden, constant vertigo for days	Hearing loss and tinnitus in one ear	Supportive care; a short course of steroids may be used
Ménière disease	Recurrent attacks lasting minutes to hours, with ear fullness	Fluctuating hearing loss in one ear that worsens over time; tinnitus	Rule out syphilis (RPR or VDRL), then salt restriction and diuretics; surgical decompression if those fail
Perilymphatic fistula	Brief vertigo set off by sneezing, straining, lifting or Valsalva; after ear trauma or scuba diving	Can fluctuate	Supportive care
Acoustic neuroma	Slowly progressive imbalance rather than attacks of spinning	Progressive, one-sided hearing loss and tinnitus	Audiogram and MRI
Aminoglycoside ototoxicity	Imbalance and hearing loss during treatment with gentamicin	Hearing loss	Stop the drug

Two memory hooks help. Vestibular neuritis is to the eighth nerve what Bell's palsy is to the seventh: a viral or post-viral inflammation of one nerve. And Ménière disease is a volume overload of the inner ear, which is why its treatment is salt restriction and a diuretic.

The distinctions that decide the question

BPPV or vestibular neuritis?

What separates these cases: timing. BPPV lasts seconds and comes only with head movement; ask the patient to move the head, and the dizziness returns and settles within a minute after stopping. Vestibular neuritis is constant for days, even when the head is still.

Vestibular neuritis or labyrinthitis?

What separates these cases: hearing. Vestibular neuritis spares hearing; labyrinthitis takes it.

Ménière disease, labyrinthitis or acoustic neuroma?

All three can bring the triad of vertigo, tinnitus and hearing loss. The time course separates them.

What separates these cases: labyrinthitis is one acute episode lasting a few days. Ménière disease relapses and remits, with hearing that gets worse over the years. Acoustic neuroma is chronic and steadily progressive, with imbalance more than spinning.

When it's a stroke

A patient with sudden, constant vertigo who also has ataxia, dysmetria on finger-to-nose testing, double vision or slurred speech has a posterior circulation stroke until proven otherwise. A negative CT doesn't rule it out, because CT misses most strokes in the posterior fossa; MRI with diffusion is the test. If the patient is within the treatment window and the CT shows no bleeding, the next step is thrombolysis.

For constant vertigo with nystagmus and no other signs, three bedside tests (HINTS) separate vestibular neuritis from a stroke:

Test	Points to the inner ear	Points to stroke
Head impulse	Abnormal: a catch-up saccade	Normal
Nystagmus	One direction only, beating away from the affected ear	Changes direction with gaze, or is purely vertical
Test of skew	No vertical correction	The uncovered eye moves vertically to refixate (skew deviation)

What separates these cases: in acute, constant vertigo, an abnormal head impulse test is the reassuring finding. A normal head impulse test in a patient who is spinning and has nystagmus suggests a stroke.

One more trap: brief, discrete episodes of vertigo in an older patient with vascular risk factors, together with double vision or facial numbness, are vertebrobasilar ischemia, not BPPV. BPPV never causes double vision.

Try these cases from the Pradis question bank

Each case below is adapted from a row in the Pradis Neurology chapter. Decide before you read the answer.

1. A 60-year-old man has had several brief episodes of vertigo, sometimes with nausea, brought on by turning his head, rolling over or getting out of bed.
Answer: BPPV, from loose debris in the inner ear, which becomes more common with age. Confirm with the Dix-Hallpike maneuver and treat with a repositioning maneuver such as the Epley.

2. A 40-year-old man has had sudden, constant vertigo for a few days, with no tinnitus and no hearing loss. When his head is turned quickly toward one side, he can't keep his eyes on the target.
Answer: vestibular neuritis. Supportive care, and a short course of steroids may be used.

3. The same story in a 45-year-old man, except that he also has hearing loss and tinnitus in his left ear.
Answer: labyrinthitis. The same inflammation has reached the cochlear branch of the eighth nerve.

4. A 50-year-old man has had months of intermittent vertigo, tinnitus and slowly worsening hearing loss in his right ear. An MRI of the brain is negative.
Answer: Ménière disease. Rule out syphilis with an RPR or VDRL first, then treat with salt restriction and a diuretic.

5. A 40-year-old man has brief spells of vertigo, each lasting about a minute, set off by lifting heavy weights or sneezing, with some intermittent hearing loss. A Valsalva maneuver brings on nystagmus and his symptoms.
Answer: perilymphatic fistula. Supportive care. Exam stems sometimes leave out the giveaway history of ear trauma or scuba diving.

6. A 55-year-old woman has slowly progressive imbalance, tinnitus and hearing loss in one ear.
Answer: acoustic neuroma (vestibular schwannoma). Get an audiogram to document the sensorineural loss, and an MRI rather than a CT.

7. A 55-year-old woman has had constant spinning for 2 hours, worse with any head movement. Finger-to-nose and heel-to-shin testing are abnormal on the left, and her gait is ataxic. A CT of the head is negative.
Answer: a posterior circulation stroke. She is within the window and the CT shows no bleeding, so the next step is thrombolysis.

How to study these

Ask the questions in order: how long it lasts, what triggers it, what happened to the hearing, and whether there are other neurological signs. Most stems give you all four answers in the first two sentences.

In Pradis, each row of a look-alike table is its own question with its own stars, so the pair you confuse comes back until you don't. The Biostatistics chapter is free once you log in.

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Written for USMLE Step 2 CK and shelf exam preparation. In patient care, follow current guidelines and your institution's protocols.