CASE REPORT
Management of Benign Paroxysmal Positional Vertigo
With the Canalith Repositioning Maneuver in the Emergency Department Setting
David B. Burmeister, DO
Regina Sacco, DPT, NCS
Valerie Rupp, RN, BSN
Vertigo is a common clinical manifestation in the emer-
gency department (ED). It is important for physicians to
determine if the peripheral cause of vertigo is benign parox-
ysmal positional vertigo (BPPV), a disorder accounting for
20% of all vertigo cases. However, the Dix-Hallpike test—the
standard for BPPV diagnosis—is not common in the ED
setting. If no central origin of the vertigo is determined,
patients in the ED are typically treated with benzodiazepine,
antihistamine, or anticholinergic agents. Studies have shown
that these pharmaceutical treatment options may not be the
best for patients with BPPV. The authors describe a case of
a 38-year-old woman who presented to the ED with com-
plaints of severe, sudden-onset vertigo. The patient’s BPPV
was diagnosed by means of a Dix-Hallpike test and the
patient was acutely treated in the ED with physical therapy
using the canalith repositioning maneuver.
J Am Osteopath Assoc. 2010;110(10):602-604
ertigo is a common complaint among patients who seek
V care in the emergency department (ED). Benign parox-
ysmal positional vertigo (BPPV) is the most common periph-
eral vestibular disorder, accounting for approximately 20%
of all vertigo cases.1 According to the Vestibular Disorders
Association, approximately 50% of elderly patients who pre-
sent with a chief complaint of dizziness have BPPV.1 The
ED standard of care for patients presenting with vertigo is to
rule out serious medical causes based on patient history,
physical examination, and diagnostic workup. Once the clin-
ician determines that there is no central etiology, patients
are typically treated with benzodiazepine, antihistamine, or
anticholinergic agents. However, several reviews1 on the
From the Department of Emergency Medicine (Dr Burmeister and Ms Rupp)
and Lehigh Valley Homecare and Hospice (Dr Sacco) in the Lehigh Valley
Health Network in Allentown, Pennsylvania.
Financial Disclosures: None reported.
Address correspondence to David B. Burmeister, DO, Lehigh Valley Health
Network, Department of Emergency Medicine, 1240 S Cedar Crest Blvd, Suite
214, Allentown, PA 18103-6218.
E-mail: david_b.burmeister@lvh.com
Submitted March 26, 2009; revision received January 5, 2010; accepted
February 25, 2010.
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management of vertigo have indicated that medications cur-
rently used for the treatment of vertigo do not have well-
established curative or prophylactic value and are not suitable
for long-term treatment.
Report of Case
A 38-year-old woman presented to our ED with acute onset of
vertigo, nausea, and vomiting, all exacerbated with head move-
ment. The patient’s past medical history was notable for ver-
tigo, for which she received vestibular rehabilitation. Phys-
ical examination revealed the patient to be alert and oriented
to person, place, and time. Resting nystagmus was not present,
and cranial nerves II through XII were intact. All other perti-
nent physical examination findings were normal. Dix-Hallpike
testing on the right side was normal and on the left side
revealed an upbeating, left torsional nystagmus lasting approx-
imately 15 seconds (Figure 1).
Acute vertigo secondary to BPPV was diagnosed based on
the examination findings. A physical therapist was contacted
to evaluate the patient. Examination revealed normal balance
and no gross gait deviations. The physical therapist repeated
the Dix-Hallpike test, the findings of which were consistent
with those of the first test conducted by the emergency physi-
cian. After the Dix-Hallpike test, the patient rated both her
dizziness and nausea as 10 out of 10 on a visual analog scale.
The physical therapist treated the patient with a canalith repo-
sitioning maneuver for the left, posterior, semicircular canal
(Figure 2). After completion of the treatment, the patient rated
her dizziness as 1 out of 10 and her nausea as 2 out of 10 on the
visual analog scale.
Visual analog ratings were repeated 15 and 30 minutes
after treatment. Fifteen minutes after treatment, the patient
rated her dizziness as 2 out of 10 and her nausea as 3 out of 10.
Thirty minutes after treatment, she rated her dizziness as 1 out
of 10; her nausea rating remained the same. Thirty minutes after
treatment, the patient felt well enough to go home. Before dis-
charge, the physician repeated the Dix-Hallpike test, the results
of which were normal for both right and left sides. No medi-
cations were given to the patient while she was in the ED. At
discharge, the patient received a prescription for meclizine
hydrochloride (25 mg [administered orally] every 8 hours)
for treatment of her breakthrough vertigo and received a
referral for outpatient vestibular rehabilitation.
Burmeister et al • Case Report
 CASE REPORT

Figure 1. Illustration of the Dix-Hallpike test being performed on a patient suspected of having benign paroxysmal positional vertigo. (A)
The patient’s head is turned toward her ear while she is in a sitting position. (B) The patient is quickly moved into a supine position with
her head extended and rotated 45 degrees toward her ear. Source: Reprinted with the permission from: Furman JM, Cass SP. Benign parox-
ysmal positional vertigo. N Engl J Med. 1999;341(21):1590-1596.

A follow-up phone call was placed to the patient 30 days
after discharge. The patient had sought follow-up treatment
with an ear, nose, and throat physician but had received no
additional treatment because her symptoms resolved. The
patient rated her satisfaction of care in the ED 10 out of 10 on
a Likert scale, with 1 meaning not satisfied and 10 meaning
very satisfied. This patient’s overall length of stay in the ED was
180 minutes. The time from the examination by the physician
to the patient’s discharge was 133 minutes. Average length of
stay for patients treated in our ED with a diagnosis of BPPV
is 260 minutes.
Comment
The theory of BPPV centers around canalithiasis, in which

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 CASE REPORT
otoconia break free into the semicircular canals of the inner ear.
Approximately 89% to 95% of BPPV cases involve the poste-
rior canal because of its orientation to gravity.2
The Dix-Hallpike test is the standard for the diagnosis of
BPPV; it is nearly 100% specific to BPPV and has a sensitivity
of 88%.3 However, the Dix-Hallpike test is not frequently used
in the ED setting, where vertigo is a common clinical presen-
tation. In our experience, patients with BPPV who present to
the ED are often treated with medication only. If the patient’s
symptoms improve enough with medication in the ED, the
patient is usually sent home and the etiology of the vertigo is
rarely determined prior to discharge. If this type of treatment
does not resolve the patient’s symptoms, the patient may need
to be admitted to the hospital. Patients are sometimes evalu-
ated by a physical therapist 1 to 2 days after hospital admission,
at which point the Dix-Hallpike test is performed.
Roughly 90% of patients in whom BPPV is diagnosed
can be appropriately treated with the canalith repositioning
maneuver (Figure 2). The canalith repositioning maneuver is
similar to the Epley maneuver but without the use of a mas-
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Figure 2. The canalith repositioning maneuver
being performed on a patient with benign parox-
ysmal positional vertigo. Source: Reprinted with
permission from: Mitka M. Practice parameter:
simple maneuver is best therapy for common
form of vertigo. JAMA. 2008;300(2):157-158.
toid oscillator. It is a safe and effective
treatment for patients that can be per-
formed by a clinician or a physical thera-
pist in the ED setting.4,5
Conclusion
In the present case, we were able to
decrease time from presentation to
symptom resolution, as well as eliminate
the root cause of the vertigo, by using the
Dix-Hallpike test to diagnose BPPV and
the canalith repositioning maneuver to
treat BPPV in the ED setting. The high
level of diagnostic accuracy of the Dix-
Hallpike test provides emergency physi-
cians with a simple tool to diagnose
BPPV. The canalith repositioning
maneuver provides a conservative alter-
native to medication therapy. For patients
with BPPV, early diagnosis and treatment
could result in decreased levels of anx-
iety, decreased number of panic disor-
ders, and less severe depression—all of
which have been associated with ver-
tigo6—as well as decreased length of stay,
number of admissions into the hospital, and costs associated
with medical testing and loss of wages.7
References
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1999;107(5):468-478.
4. Chang AK, Schoeman G, Hill M. A randomized clinical trial to assess the effi-
cacy of the Epley maneuver in the treatment of acute benign positional ver-
tigo. Acad Emerg Med. 2004;11(9):918-924.
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456.
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ness in a general practice community sample of working age people. Br J Gen
Pract. 1998;48(429):1131-1135.
Burmeister et al • Case Report