Abstract
BACKGROUND:
Head trauma can cause secondary benign paroxysmal positional vertigo (BPPV). BPPV is a common peripheral condition which can lead to significant morbidity, psychosocial impact and increased medical costs [1].
CASE DESCRIPTION:
A patient post fall with an associated head trauma presented to the emergency department with severe vertigo, nausea, and decreased mobility. The patient was assessed and treated by a vestibular trained physiotherapist. The patient was treated with one Epley repositioning manoeuvre and had complete resolution of symptoms and was discharged home the same day.
CONCLUSION:
BPPV can be successfully identified and treated by vestibular trained physiotherapists in the emergency department. Early access to vestibular trained physiotherapy in the emergency department resulted in diagnosis and evidence-based treatment of BPPV which prevented hospital admission and improved this patient’s outcome. The patient had complete resolution of symptoms post the repositioning manoeuvre and was discharged to home.
Background
Benign paroxysmal positional vertigo (BPPV) is a peripheral disorder and is characterised by brief episodes of rotary vertigo associated with head movements and a positionally induced vertigo [1]. BPPV is believed to be caused when free floating octonia gravitates into one of the three semicircular canals of the inner ear [2]. In the majority of cases BPPV is idiopathic however in about 30% of patients it can be attributed to a specific cause and is called secondary BPPV [3]. The purpose of this case report is to describe the assessment and treatment of a patient who developed vertigo, nausea, vomiting and an unsteady gait three days after a fall that resulted in a head trauma.
Patient presentation
The patient was an 80-year-old male who had presented to his local model two hospital which was the closest hospital to the patient’s home. He presented with a 12-hour history of vomiting, vertigo and decreased balance and periorbital bruising and swelling. He had a fall 3 days previous in which he hit his head but reported no loss of consciousness. The patients fall occurred outside his home where he reported he tripped on gravel and the patient had no previous falls history. The patient was transferred by ambulance to the nearest model 4 hospital due to a suspected head injury for diagnostic imaging specifically Computed Tomography (CT) of the brain and treatment as per local protocol. The patient was assessed by the emergency medicine doctor and nurses. The assessment and investigation findings as documented in the patient’s medical chart are shown in Table 1 below.
Medical and nursing assessment findings
Medical and nursing assessment findings
The emergency doctor referred the patient to the emergency department physiotherapist for further assessment. The physiotherapist was trained in vestibular assessment and rehabilitation. The physiotherapist assessment included a thorough subjective, vestibular and oculomotor assessment including observing eye movements during positional tests. Subjectively the patient was describing vertigo on head movement with associated nausea. Table 2 shows the objective findings of the assessment.
Physiotherapy objective assessment findings
Physiotherapy objective assessment findings
The Dix Hallpike is considered the gold standard for diagnosing BPPV [2], this patient had a positive left side Dix Hallpike test. The test was considered positive as vertigo was provoked, nystagmus present and the typical characteristic of latency. The patient was diagnosed with left sided BPPV post head trauma. The patient was treated with a single Epley’s manoeuvre in the emergency department. The Epley manoeuvre is the most widely used manoeuvre to treat BPPV and research has demonstrated its effectiveness in an emergency department setting [4]. The patient was re-examined 30 minutes post Epley manoeuvre and the patient reported that the nausea and vertigo was resolved with no further episodes. The patients gait and balance was examined, and the patient was found to have decreased balance which was treated with prescription of a walking stick, balance programme, community physiotherapy follow up and geriatric outpatient review. The patient was discharged home that day with a phone call follow up three days later by the physiotherapist. The patient reported no further symptoms at telephone follow up as well as at outpatient appointment four weeks post treatment.
Discussion
This patient was diagnosed with BPPV following head trauma after a fall. It has been reported that head trauma is the most common cause of secondary BPPV representing 8.5 –20% of all BPPV cases [5]. Other causes of secondary BPPV are ear surgery, prolonged bed rest, migraines, viral labyrinthitis and Ménière’s disease [5]. The pathophysiological mechanism for idiopathic and secondary BPPV are the same and include theories of canalithiasis (otoconia debris that collects in the semicircular canals) and cupulolithiasis (when otoconia adhere to the cupula) [1]. Considering the patient in this case study a possible cause of the BPPV was the impact and force of the patient’s head hitting the ground which could have caused octonia to be loosened or become free and migrate into the semicircular canal which manifested as secondary BPPV.
Studies have shown that patients who develop BPPV post head trauma develop symptoms within two weeks [2], the patient is this case study presented with symptoms after 3 days which was similar to other studies. In this case study BPPV was diagnosed using the Dix Hallpike manoeuvre and the patient was treated with one Epley Manoeuvre for left sided BPPV. Research indicates that patients with secondary BPPV due to head trauma had lower treatment success and more therapeutic treatments are required [3]. However, is the case study the patient’s symptoms resolved after one treatment manoeuvre with no return of symptoms at both 3 days and four weeks post treatment.
The patient’s presentation to hospital resulted from a fall. Falls are common in older adults and are the main cause of injury, injury related disability and death in older adult [5]. The patient had decreased balance identified in his assessment which is a modifiable risk factor for falls. This patient was treated for BPPV but also provided with treatment and community physiotherapy and geriatric outpatient follow up to assess and reduce his risk of falls [6]. This has the potential to reduce further falls for this patient and reduce demand on health care services as a result from further falls.
Vestibular trained physiotherapists in Ireland are typically in an outpatient setting. At the time of this report a pilot of a vestibular physiotherapist service in the emergency department in Ireland was in the early stages however most emergency departments do not have vestibular physiotherapy in the emergency department. This report provides support for early assessment of vestibular conditions in the emergency department by vestibular trained physiotherapists. It provides insight into the positive impact of vestibular physiotherapy for the patient in terms of early assessment and treatment and same day discharge as well as for the hospital systems in decreasing costs of unnecessary admissions and improving patient flow.
Conclusion
Head trauma may lead to disturbances in the normal anatomy of the semicircular canals of the inner ear. Vestibular physiotherapy for patients in the emergency department offers early diagnosis and treatment of BPPV and prevented admission for an older adult in this case study. BPPV post head trauma should be considered as a differential diagnosis for patients presenting with vertigo to an emergency department. This case study provides insight into the benefits of having a vestibular physiotherapy service in the emergency department as it provided early access to assessment, diagnosis and treatment for this patient which enabled safe discharge home. This case study supports previous literature of the effectiveness of positional manoeuvres for treatment of BPPV but also highlights the role and impact of vestibular physiotherapy in the acute setting.
Conflict of interest
The authors have no conflict of interest to report.