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ent.bppv.core.v1

Benign paroxysmal positional vertigo (with acute-vertigo triage)

general_internal_medicineacutesubacuteadultgeriatricacuteoutpatientinpatient
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NEUROTOLOGY/EMERGENCY-NEURO-OTOLOGY-framed engine — two inseparable jobs: positively diagnose + definitively repositioning-treat BPPV (the commonest peripheral vertigo) AND robustly triage the dangerous central look-alikes. The peripheral-vs-central decision is framed explicitly via TiTrATE (timing/triggers) + HINTS (for AVS). Definitive management of posterior-circulation stroke, vestibular neuritis, Ménière, vestibular migraine, SSNHL, and the geriatric falls programme is recognised then routed OUT by engine_id (neuro.posterior-circulation-stroke.core.v1, ent.vestibular-neuritis.core.v1, ent.meniere-disease.core.v1, neuro.vestibular-migraine.core.v1, ent.sudden-sensorineural-hearing-loss.core.v1, geriatrics.falls.core.v1) — not re-authored here. RxCUI status: meclizine 6750, dimenhydrinate 3409, prochlorperazine 8704, diazepam 3322 are well-established RxNorm CUIs for the strictly-short-term symptomatic-bridge axis (AAO-HNS 2017 recommends AGAINST routine/chronic vestibular-suppressant use — they are rescue-only, not BPPV therapy). Betahistine is intentionally NOT given an rxcui (not US-FDA approved, region-dependent, NOT a BPPV treatment) — non_pharm per the omit-rather-than-fabricate rule. Canalith repositioning maneuvers (Epley/Semont/BBQ-roll/Gufoni) + vestibular rehabilitation + vitamin-D repletion are non_pharm — the DEFINITIVE treatment is a procedure, not a drug. Bayesian linkage (TiTrATE pre-test priors BPPV-vs-neuritis-vs-Ménière-vs-VM-vs-central by timing/triggers/exam; per-component HINTS likelihood ratios — normal head-impulse + direction-changing nystagmus + skew = central; Dix-Hallpike operating characteristics; ABCD2-vs-HINTS LR contrast; imaging decision thresholds when HINTS cannot be applied / red flags present; bidirectional cross-engine routing edges by engine_id) is documented in the co-located _design-brief.md + _research-bundle.md; first-class TS LR fields remain schema-blocked (same constraint as derm.cellulitis.core.v1). Effect sizes (≥5): HINTS for stroke in AVS 100% sens / 96% spec, > early MRI-DWI (Kattah Stroke 2009, PMID 19762709); HINTS sens 96.5% / spec 84.4% / LR+ 6.19 / LR− 0.04 vs ABCD2 sens 61% / spec 62% / LR+ 1.62 / LR− 0.62 (Newman-Toker AEM 2013, PMID 24127701); early MRI-DWI false-negative ~12-15% (<48 h) and ~53% for small strokes (Kattah 2009; Saber Tehrani Neurology 2014, PMID 24920847); Epley vertigo-resolution OR 4.42 (95% CI 2.62-7.44; 21%→56%) and Dix-Hallpike conversion OR 9.62 (95% CI 6.0-15.42), recurrence ~36% (Hilton Cochrane 2014, PMID 25485940); BPPV lifetime prevalence 2.4%, 1-yr 1.6%, ~8% of all moderate/severe dizziness (von Brevern JNNP 2006, PMID 17135456); methylprednisolone caloric-recovery 62.4 vs placebo 39.6 percentage points in vestibular neuritis (Strupp NEJM 2004, PMID 15269315); Epley+betahistine DHI SMD −0.61 (95% CI −0.96 to −0.26) with NO cure/recurrence change (Li Medicine 2023, PMID 37000080). Clinical-uncertainty notes: (1) ICD-10 H81.1x BPPV codes, R42 dizziness, H81.4 central vertigo, G45.0 vertebrobasilar TIA, I63.9 cerebral infarction are standard ICD-10-CM; per memory the terminology pipeline is ⚠ partial — codes are canonical but flagged for scripts/terminology/ revalidation. (2) HINTS operating characteristics derive from high-risk AVS cohorts examined by neuro-otology specialists; real-world ED non-specialist performance is lower — encoded as the "cannot reliably apply HINTS → image/consult" guardrail rather than over-claimed. (3) HINTS applies ONLY to continuous spontaneous AVS, NOT to triggered-episodic BPPV (where Dix-Hallpike governs) — mis-applying HINTS to BPPV is itself a documented pitfall and is gated by the TiTrATE timing pivot.

Entry points (5)

  • symptom
    Recurrent brief (<1 min) vertigo spells triggered by rolling over in bed / lying down / looking up — classic positional BPPV history (Bárány Society criteria, von Brevern 2017; AAO-HNS BPPV CPG 2017)
    brief_positional_vertigo_seconds
  • symptom
    Acute continuous spontaneous vertigo with nystagmus + nausea + head-motion intolerance + gait unsteadiness lasting hours-days (acute vestibular syndrome — apply HINTS, NOT positional testing first) (Kattah Stroke 2009; Newman-Toker Neurol Clin 2015 TiTrATE)
    acute_continuous_spontaneous_vertigo_avs
  • symptom
    Positional or continuous vertigo PLUS any of the 4 D's (diplopia, dysarthria, dysphagia, dysmetria), severe gait/truncal ataxia, or other focal neuro signs — central-vertigo / posterior-circulation-stroke entry (Kattah Stroke 2009; AAO-HNS BPPV CPG 2017)
    positional_vertigo_with_neuro_red_flags
  • history
    Recurrent or repositioning-refractory positional vertigo (≥2 prior BPPV episodes, or persistent after ≥1 canalith repositioning maneuver) — recurrent/secondary-BPPV entry (Hilton Cochrane 2014 — ~36% recurrence; AAO-HNS BPPV CPG 2017)
    recurrent_or_refractory_bppv
  • problem_list
    Older adult with positional dizziness on a falls / unexplained-falls problem list — BPPV is a treatable, frequently-missed fall contributor (AAO-HNS BPPV CPG 2017 — assess mobility/fall-risk modifiers)
    elderly_falls_with_positional_dizziness

Required inputs (16)

  • symptom_timing_continuous_vs_episodicrequired
    symptom • used at ENTRY
    TiTrATE pivot 1 — episodic (seconds, recurrent, triggered) → BPPV channel; continuous (hours-days, spontaneous) → AVS channel where HINTS, not Dix-Hallpike, governs (Newman-Toker Neurol Clin 2015 TiTrATE)
  • positional_trigger_obligaterequired
    symptom • used at CONTEXT
    TiTrATE pivot 2 — vertigo OBLIGATELY provoked by head-position change (not merely worse with movement) defines triggered-episodic vestibular syndrome and is the BPPV gateway (Bárány Society criteria, von Brevern 2017)
  • spell_duration_seconds_vs_longerrequired
    symptom • used at CONTEXT
    BPPV paroxysms last <1 min (typically 10-30 s) and fatigue; spells of minutes-hours-days argue Ménière / vestibular migraine / AVS (Bárány Society criteria; von Brevern JNNP 2006 — median episode 2 wk of recurrent brief spells)
  • dix_hallpike_nystagmus_patternrequired
    symptom • used at INITIAL_WORKUP
    Up-beating + torsional (geotropic, top-pole toward affected/down ear) nystagmus with latency, crescendo-decrescendo, <1 min, fatigability = posterior-canal BPPV; persistent / pure-vertical / pure-torsional / direction-fixed downbeat raises central mimic (AAO-HNS BPPV CPG 2017; Bárány 2017)
  • supine_roll_horizontal_nystagmus
    symptom • used at BRANCHING_WORKUP
    If Dix-Hallpike negative/non-diagnostic but history compatible: supine roll (Pagnini-McClure) — geotropic horizontal nystagmus = canalolithiasis, apogeotropic = cupulolithiasis; identifies horizontal-canal BPPV (~5-15%) (AAO-HNS BPPV CPG 2017 Recommendation; Bárány 2017)
  • hints_head_impulserequired
    symptom • used at RED_FLAGS
    In AVS: a NORMAL (no corrective saccade) horizontal head-impulse is the single most ominous HINTS element — points central/stroke (an abnormal/positive HIT supports peripheral vestibular neuritis) (Kattah Stroke 2009 — HINTS 100% sens / 96% spec for stroke)
  • hints_nystagmus_directionrequired
    symptom • used at RED_FLAGS
    Direction-CHANGING gaze-evoked or pure-vertical/torsional nystagmus = central; unidirectional horizontal-torsional fixation-suppressible nystagmus = peripheral (Kattah Stroke 2009; Newman-Toker AEM 2013)
  • hints_test_of_skewrequired
    symptom • used at RED_FLAGS
    Vertical ocular misalignment on alternate cover (skew deviation) = brainstem/central; present in ~17% and rescues the false-localising abnormal head-impulse (Kattah Stroke 2009 — skew predicts brainstem)
  • central_neuro_4Ds_gaitrequired
    symptom • used at RED_FLAGS
    The 4 D's (diplopia, dysarthria, dysphagia, dysmetria), severe truncal/gait ataxia (cannot stand/walk unaided), limb ataxia, new severe headache/neck pain → posterior-circulation stroke until excluded; route OUT (AAO-HNS BPPV CPG 2017; Kattah Stroke 2009)
  • vascular_risk_factorsrequired
    history • used at CONTEXT
    Age, HTN, DM, AF, smoking, prior stroke/TIA, recent neck trauma/manipulation (vertebral dissection) raise the pre-test posterior-circulation-stroke prior in AVS and lower the imaging threshold (von Brevern JNNP 2006 — HTN/stroke independently associated; Kattah 2009)
  • auditory_symptoms_hearing_tinnitus_aural_fullness
    symptom • used at CONTEXT
    New unilateral hearing loss / tinnitus / aural fullness → Ménière or AICA-territory stroke or SSNHL (HINTS "plus" — any new hearing loss in AVS raises central/AICA risk) — route to ENT/SSNHL engine (Newman-Toker AEM 2013 HINTS-plus; Bárány)
  • migraine_history
    history • used at CONTEXT
    Migraine history + episodic spontaneous vertigo (± photophobia/aura) suggests vestibular migraine — the commonest central episodic mimic and frequently comorbid with BPPV (Eggers J Vestib Res 2014 — BPPV/Ménière/motion-sickness over-represented in migraineurs)
  • agerequired
    demographic • used at CONTEXT
    BPPV incidence rises steeply with age; elderly BPPV drives falls/fracture risk and modifies maneuver choice (cervical/vascular limits) and disposition (AAO-HNS BPPV CPG 2017 — fall-risk modifier; von Brevern JNNP 2006)
  • cervical_spine_or_vascular_limitation
    history • used at TREATMENT
    Severe cervical spondylosis/RA/instability, carotid disease or vertebral compromise limit Dix-Hallpike/Epley neck extension-rotation → use side-lying (Semont) or modified maneuvers (Hilton Cochrane 2014 — cervical-spine intolerance noted; AAO-HNS BPPV CPG 2017)
  • pregnancy
    history • used at TREATMENT
    Pregnancy: prefer repositioning maneuvers (definitive, drug-free) and minimise vestibular suppressants/antiemetics — antiemetic safety gating (AAO-HNS BPPV CPG 2017 — limit suppressants; safety)
  • intractable_vomiting_dehydration
    symptom • used at DISPOSITION
    Severe persistent vomiting/inability to tolerate oral intake → short-term parenteral antiemetic + rehydration and admission threshold; also a marker of a more severe vestibular insult or central cause (AAO-HNS BPPV CPG 2017; clinical)

12-phase flow (12)

  1. 1FRAME
    Frame the encounter as a TWO-CHANNEL problem: positively diagnose + definitively repositioning-treat BPPV (the commonest peripheral vertigo) AND robustly exclude the dangerous central look-alikes. The explicit peripheral-vs-central decision is the spine of this engine. Definitive stroke/neuritis/Ménière/migraine/falls management is routed OUT by engine_id, not re-authored.
    advance: two-channel scope confirmed; out-of-scope definitive management flagged for engine_id routing
  2. 2ENTRY
    Apply TiTrATE timing pivot at the door: episodic-triggered (seconds, recurrent, position-provoked) → BPPV channel; continuous-spontaneous (hours-days) → acute vestibular syndrome channel where HINTS — not Dix-Hallpike — governs. Capture timing up front because it reroutes the entire work-up (Newman-Toker Neurol Clin 2015).
    inputs: symptom_timing_continuous_vs_episodic
    actions: workup.vertigo
    advance: TiTrATE syndrome category (t-EVS vs AVS vs spontaneous-EVS) assigned
  3. 3CONTEXT
    Build the pre-test differential: obligate positional trigger + spell duration (seconds favour BPPV); vascular risk factors (raise stroke prior in AVS); auditory symptoms (Ménière / AICA / SSNHL); migraine history (vestibular migraine, often comorbid with BPPV); age (BPPV rises with age; fall risk). This phase sets the Bayesian prior before any maneuver.
    inputs: positional_trigger_obligate, spell_duration_seconds_vs_longer, vascular_risk_factors, auditory_symptoms_hearing_tinnitus_aural_fullness, migraine_history, age
    actions: workup.vertigo
    advance: TiTrATE triggers/timing + vascular/auditory/migraine prior assigned
  4. 4RED_FLAGS
    In ANY continuous/spontaneous AVS or any positional vertigo with neuro features: perform HINTS (Head-Impulse–Nystagmus–Test-of-Skew) + screen the 4 D's / gait / focal signs. Dangerous (central) pattern = NORMAL head-impulse, direction-CHANGING nystagmus, or skew deviation (any one) → posterior-circulation stroke until excluded → route OUT to neuro.posterior-circulation-stroke.core.v1. HINTS out-performs early MRI-DWI and ABCD2 (Kattah Stroke 2009; Newman-Toker AEM 2013).
    inputs: hints_head_impulse, hints_nystagmus_direction, hints_test_of_skew, central_neuro_4Ds_gait
    actions: calc.abcd2, calc.nihss, protocol.stroke, workup.acute_stroke, workup.acute_headache
    advance: HINTS interpreted (central pattern routed OUT by engine_id) AND 4 D's/gait/focal screen complete
  5. 5INITIAL_WORKUP
    For the BPPV channel (episodic-triggered, no central red flag): perform the Dix-Hallpike maneuver — upbeating + torsional (geotropic) nystagmus with latency, crescendo-decrescendo, <1 min, fatigability on the affected (down) side = posterior-canal BPPV (the ~85-90% subtype). Imaging and vestibular testing are NOT indicated when criteria are met (AAO-HNS BPPV CPG 2017 strong recommendation against routine imaging).
    inputs: dix_hallpike_nystagmus_pattern
    actions: workup.vertigo
    advance: Dix-Hallpike performed + canal/side determined OR non-diagnostic (→ branching)
  6. 6BRANCHING_WORKUP
    If Dix-Hallpike negative/non-diagnostic but history compatible: supine roll (Pagnini-McClure) test for horizontal-canal BPPV — geotropic = canalolithiasis (treat to less-intense side), apogeotropic = cupulolithiasis. Atypical nystagmus (pure vertical, pure torsional, direction-fixed downbeat, non-fatiguing, no latency) or persistent symptoms despite correct maneuvers → suspect central positional vertigo / posterior-fossa lesion → imaging + route OUT. Recurrent/secondary BPPV → seek post-trauma / post-vestibular-neuritis / osteoporosis-low-vitamin-D substrate.
    inputs: supine_roll_horizontal_nystagmus
    actions: workup.vertigo, workup.acute_stroke
    advance: canal + side localised, OR atypical/central-positional pattern routed OUT for imaging, OR recurrent-BPPV substrate sought
  7. 7DIFFERENTIAL
    Terminal vestibular differential with named pivots: BPPV (triggered, <1 min, fatiguing canal-specific nystagmus, normal between spells) vs vestibular neuritis (continuous AVS, unidirectional nystagmus, ABNORMAL head-impulse, NO central signs — route to ent.vestibular-neuritis.core.v1) vs posterior-circulation stroke (AVS with NORMAL head-impulse OR direction-changing nystagmus OR skew OR 4 D's — route to neuro.posterior-circulation-stroke.core.v1) vs Ménière (recurrent spontaneous spells minutes-hours + fluctuating low-frequency SNHL/tinnitus/fullness — route to ent.meniere-disease.core.v1) vs vestibular migraine (episodic spontaneous + migraine features, often comorbid with BPPV — route to neuro.vestibular-migraine.core.v1). The BPPV-vs-central pivot = HINTS / triggered-episodic vs continuous-spontaneous.
    actions: workup.vertigo
    advance: single best vestibular diagnosis selected; comorbid BPPV-on-migraine flagged; out-of-scope diagnoses routed by engine_id
  8. 8RISK_STRATIFICATION
    For confirmed BPPV: stratify fall/injury risk (age, gait/balance impairment, CNS comorbidity, lack of home support, anticoagulation, osteoporosis) — these are the AAO-HNS "factors that modify management." For the AVS channel: NIHSS / stroke severity if central, NEWS2 / qSOFA if systemically unwell, Clinical Frailty Scale + ABCD2 caveat (ABCD2 underperforms HINTS — do NOT use ABCD2 to rule out stroke in AVS).
    inputs: age, vascular_risk_factors
    actions: calc.clinical_frailty_scale, calc.abcd2, calc.nihss, calc.news2, calc.qsofa
    advance: fall-risk modifiers (BPPV channel) or stroke-severity/frailty (AVS channel) assigned
  9. 9TREATMENT
    DEFINITIVE BPPV treatment = canalith repositioning maneuver, NOT drugs. Posterior canal: Epley (or Semont) — single-treatment success high; no post-procedure postural restriction needed (AAO-HNS 2017 strong recommendation against restrictions). Horizontal canal: BBQ-roll / Gufoni / Lempert. Vestibular suppressants/antiemetics are explicitly LIMITED to short-term symptomatic use ONLY (severe nausea/vomiting at presentation or to enable a maneuver) — routine/chronic use is recommended AGAINST (delays compensation, masks signs, fall risk in elderly). Modify maneuver for cervical-spine/vascular limits (side-lying Semont); pregnancy → repositioning first, minimise suppressants.
    inputs: dix_hallpike_nystagmus_pattern, cervical_spine_or_vascular_limitation, pregnancy
    actions: workup.vertigo
    advance: canal-appropriate repositioning maneuver performed; short-term suppressant (if any) time-limited; immediate post-maneuver re-test planned
  10. 10DISPOSITION
    Successful repositioning + no central red flag + safe gait → discharge with vestibular safety advice + 1-month reassessment. Central pattern / HINTS-central / 4 D's / atypical positional nystagmus → admit / emergent neuro pathway, route OUT to neuro.posterior-circulation-stroke.core.v1. Intractable vomiting/dehydration or unsafe gait/high fall risk (frail elderly, no home support) → short-stay/admit for rehydration + supervised repositioning + PT. Refractory after ≥2 maneuvers → ENT/neurotology referral.
    inputs: central_neuro_4Ds_gait, intractable_vomiting_dehydration, age
    actions: protocol.stroke
    advance: disposition documented; central cases routed OUT by engine_id; fall-risk/hydration disposition set
  11. 11MONITORING
    Immediate post-maneuver re-test (repeat Dix-Hallpike/supine roll same visit) to confirm resolution; if persistent, repeat the maneuver (often 2-3 cycles). Counsel transient residual unsteadiness/light-headedness is common for days and is NOT treatment failure. Re-evaluate any new neuro/auditory feature emerging post-treatment as a central red flag (small posterior-fossa strokes can be missed on early MRI-DWI — Saber Tehrani Neurology 2014).
    inputs: dix_hallpike_nystagmus_pattern
    actions: workup.vertigo
    advance: post-maneuver re-test negative OR maneuver repeated OR new feature re-triaged as central
  12. 12FOLLOWUP
    AAO-HNS recommendation: reassess within ~1 month to document resolution vs persistence. Persistent/recurrent BPPV → evaluate (or refer) for unresolved BPPV vs underlying peripheral/central disorder; pursue secondary-BPPV substrate (head trauma, post-vestibular-neuritis, osteoporosis / low vitamin D — supplementation reduces recurrence). Educate on recurrence (~36% over time — Hilton Cochrane 2014), safety/fall impact, and self-administered home maneuvers (self-Epley) for recurrence. Elderly recurrent BPPV with falls → route to geriatrics.falls.core.v1 for the multifactorial programme.
    inputs: recurrent_or_refractory_bppv, age
    actions: workup.falls
    advance: 1-month reassessment booked; recurrence/secondary-substrate plan + education documented; falls/ENT referral made if criteria met