The patient reports that physical therapy and home BPPV treatment have not improved his vertigo, and he still has cervical pain.  Dizziness is reported on getting in and out of bed, and rolling over in bed.

The following information comes from a therapy discharge note from physical therapy – since the patient is not improving, further therapy is not indicated.

Stepping Fakuda test lead to fall

Sensory Organization Tests results:

Standing eyes open – slight sway

Standing eyes closed – sway

Step forward eyes open – slight sway

Step forward eyes closed – sway

Standing on foam eyes open – sway

Standing on foam eyes closed – fall

Vertebral artery screen – negative right, onset of symptoms left.  Cervical vertigo tests: negative.

• Differentiate between vertebral artery testing and cervical vertigo testing.

Portions of a VNG was conducted at that facility as well, and these results are reported.  Caloric testing was not conducted.

Saccadic testing – poor performance

Smooth pursuit – slight nystagmus noticed, and the patient has increased symptoms

Gaze testing – normal. With head turned, poor range of motion, slight symptoms

OPK – not reported

Positional testing – negative side lying and supine.  Hallpike testing negative right, left produces symptoms but no nystagmus. Symptoms fatigue in 10 seconds.

• The PT discharge questions whether “perilymphatic fistula or something similar” may be involved.  Do you concur? If you were on the team seeing this patient on referral to Johns Hopkins, what testing would you want to conduct?