Patient: GC

Age: 55

First seen as a patient at NSU’s clinic 3/10/08.  Shortly before that date, I received a call from an alum (whose work is exclusively in pediatrics) indicating a good friend of hers was having dizziness problems that sounded to her like BPPV.  She reported that her friend had received extensive testing for her dizziness without resolution, and she asked if NSU could see her to do a bedside evaluation for BPPV and treat as needed.  While this type of appointment (without first doing a full audio) is unusual, we have been known to honor such requests and I facilitated this with the receptionist, having her scheduled with our balance guru, Dr Patricia Gaffney.  Dr Gaffney called me during the patient’s first visit to ask why she wasn’t seen in a regular slot. I explained, and Dr Gaffney reported that no, this was not a simple case of BPPV.

The patient’s intake report describes her dizziness as follows.

-Provoked by head or eye movement

-Symptoms last minutes to hours

- Nausea accompanies the vertiginous episodes

• Which symptoms are and are not consistent with BPPV?

She reports gradual onset hearing loss  in both ears, and tinnitus in the left ear. She describes it as occurring occasionally, being mildly bothersome, and she circled “ringing” and “pulsatile” on the history form but wrote in “ticking.”  Both ears feel full.  She takes Depakote 500 mg, Prozac 10 mg, Aciphex 20 mg, Singulair 10 mg and Nasoacort.

• What are those medications for?

The patient had been seen for MRI which she indicated was normal.  She had a carotid artery study, also normal.

Because of time constraints, testing was limited. Tympanometry was normal, and the pure tone audiogram showed an asymmetrical loss.

It appears that saccadic, smooth pursuit and OPK testing were not conducted, likely due to insufficient time.  The positioning tests and then the caloric tests are shown below.  You’ll need to click on them to expand them to see them clearly.  (Click again and the image will be even larger.)  The last image is of just the caloric summary data with sufficient resolution so you can read the values.  Hallpike results are not shown, but are said to have minimal (1-3 degree/sec) left beating nystagmus, not significant for BPPV.

• Analyze the findings and interpret them.
• Discuss referral/case management.

Many people have seen this patient over the years. Case credits mostly go to NSU doctor of audiology student, soon to be alum, Sandra Yampolsky, who presented this case at Grand Rounds.