NR 603: Week 1 Discussion: Compare and Contrast: Benign Positional Vertigo and Meniere's Disease

Dr. Starks & Class,

The purpose of this discussion is to compare and contrast benign positional vertigo (BPV) also

known as benign paroxysmal positional vertigo (BPPV) and Meniere’s disease (MD) as well as to

disseminate how the provider can recognize and further evaluate similarities and differences in these

two similar diseases in order to determine the correct diagnosis and management.

BPV and MD are two neurological disorders that may be challenging for a provider to identify the

correct diagnosis because they have similar signs and symptoms, with the chief complaints being

dizziness. The complaint of dizziness encompasses numerous sensations including presyncope,

lightheadedness, vertigo, and disequilibrium (Yetiser, 2017). The complaint of dizziness is encountered

frequently in the primary care setting and the complaint can be vague and imprecise. It is imperative that

the primary care provider is able to distinguish benign causes from more serious etiologies (Muncie et

al., 2017). It is estimated that the chief complaint of dizziness, including vertigo is reported by 15% to

20% of adults annually. A common form of vertigo is identified as BPV and nearly 2.9 % of the population

will experience BPV in their lifetime. Due to the age -related changes in the otolithic membrane the

incidence of BPV increases with age. Although, BPV can occur at any age, the prevalence is significantly

higher is in persons 50 to 70 years of age. Interestingly, this disease process is two to three times more

common in females than males (Palmeri et al., 2019). On the other hand, MD can also occur at any time

across the lifespan. However, the onset most commonly presents between 20 to 60 years of age (Muncie

et al., 2017). Studies suggest that the incidence between men are women are proportionately equal.

Approximately, 0.2% of the American population has a diagnosis of MD, making it a more rare disorder

[ CITATION Ame2013 \l 1033 ].

Presentation:

Patient with BPV often report episodes of dizziness that last for one minute or less. These

episodes are often brought on by head movements, particularly looking up, position changes such as

getting out of bed or rolling over in bed (Muncie et al., 2017). Some patients may also report nausea and

vomiting associated with the episodes of vertigo (Argaet et al., 2019). Unlike BPV, MD is associated with

a triad of symptoms which include aural fullness, tinnitus, and hearing loss in addition to episodes of

vertigo. Additionally, these episodes are not triggered or related to changes in the position of the head.

The natural progression of MD is progressive and unpredictable, some patients may experience a

significant number of attacks in the early phase and have a reduction of episodes periodically and

temporarily. However, some patient’s symptoms increase with frequency and severity overtime (Basura

et al., 2020). The episodes associated with MD typically last 20 minutes to 24 hours (Koenen et al.,

2019). The episodes associated with MD are often severe and may necessitate bed rest and severely

impairing the patient’s functional ability, therefore, requiring assistance in some instances. These

episodes are unpredictable in nature and have a negative impact on the patient’s quality of life by

restricting participation in work, homelife, and social activities (Basura et al., 2020).

 Risk factors for the development of BPV include age and gender, however, there are other

associated risk factors such as, chronic alcoholism, hypertension, hyperlipidemia, central nervous system

disorders, and history of head injury or trauma (Zhu et al., 2019). MD risk factors include a family history

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of the disease, a preexisting autoimmune disorder, head trauma, ear trauma, allergies, and occasionally

syphilis (Cureoglu et al., 2016).

Pathophysiology:

The pathophysiology of BPV involves dislodgement of the otoconia, otherwise known as otoliths

or canaliths, which are calcium -carbonate crystals. Once dislodged these settles within the endolymph

or fluid filled areas within the semicircular canals of the inner ear. When the head remains motionless,

there is no stimuli to signal the hair cells within the inner ear to fire. However, with movement of the

head, the displaced otoconia move within the fluid, signaling to the brain that the individual is in motion,

when in fact they are not in motion. Therefore, there is stimulus to one ear that leads to imbalance of

the opposite ear, thus causing the symptoms of spinning, swaying, or dizziness that is known as vertigo

(McCance et al., 2019). Movement with BPV elicits significant symptoms, however, symptoms diminish

with rest due to the fact that there is no stimulus of the tiny hair cells within the canal of the inner ear

(Muncie et al., 2017). MD is an idiopathic episodic vestibular disorder and in contrast has nothing to do

with movement of the head (Basura et al., 2020). The pathogenesis of MD is an overabundance of

endolymphatic fluid within the labyrinth of the inner ear that causes increased pressure, and results in

inner ear dysfunction (Koenen et al., 2019). The true etiology of MD is unknown, however, the

overabundance of fluid, increased pressure , and distortion and distention of the internal structures of

the labyrinth leads to damage of the cochlear hair cells; resulting in sudden onset hearing loss, vertigo,

tinnitus, and aural fullness(Cureoglu et al., 2016).

Assessment:

When a patient presents to the clinic with a neurologic complaint it is imperative for the

provider to obtain a detailed and precise history, as well as a thorough physical examination. This is in

order determine whether the causative factor is vestibular versus central and differentiating between

benign and emergent and life-threatening processes, which is of the utmost importance (Palmeri et al.,

2019). A detailed history must be obtained through using open-ended questions. Open-ended questions

in order to obtain the most accurate description of symptoms, as well as timing of symptoms, and

alleviating or exacerbating factors (Palmeri et al., 2019). According to Muncie et al., (2017), when the

patient reports symptoms when getting out of bed or changing positions and it is associated with loss of

balance, nausea, vomiting, and last for a short time and subsequently resolves with rest there is

likelihood of BPV and the further assessments should be implored. Physical assessment of patients with

the complaint of dizziness must include orthostatic blood pressures, nystagmus assessment, and the DixHallpike maneuver for triggered vertigo, as well as the HINTS (head-impulse, nystagmus, test of skew)

exam (Walther, 2017). However, if the patient reports decrease or loss of hearing in one ear or the

feeling of “fullness” in one ear with the accompaniment of symptoms of vertigo that last greater than 20

minutes and or tinnitus the diagnosis of MD should be at the top of the differential (Basura et al., 2020).

When MD is suspected, a full otologic examination should follow, such as Rinne and Weber, facial nerve

testing, assessment of nystagmus with Frenzel goggles, as well as the head impulse test (HIT).

Audiometric evaluation is also necessary in patients with unilateral hearing deficits, as fluctuating low

frequency unilateral sensorial hearing loss is a characteristic of MD (Koenen et al., 2019).

Diagnosis:

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