BPPV, vestibular neuritis, Ménière's disease, HINTS examination for stroke, fall prevention, and GCC-specific vestibular risks
BPPV & EpleyHINTS ExamMénière'sGCC Context
BPPV — Benign Paroxysmal Positional Vertigo
Key Features
Most common cause of vertigo
Brief episodes <1 minute
Triggered by head position changes
Posterior semicircular canal most common
Caused by displaced otoliths (calcium carbonate crystals)
No hearing loss or tinnitus
Diagnosis & Treatment
Dix-Hallpike test: positive if upbeat-torsional nystagmus on bringing patient to the affected side. Treatment: Epley manoeuvre — repositions otoliths back into utricle. 80% success rate. May need repeat sessions.
Vestibular Neuritis
Acute severe sustained vertigo lasting days
No hearing loss (distinguishes from labyrinthitis)
Often follows URTI (viral origin — often herpes simplex)
Assess fall risk on admission. Bed rails up. Non-slip footwear. Call bell within reach. Supervise ambulation. Falls risk wristband. Environmental hazard removal.
Safe Mobilisation
Head movement restriction initially (BPPV). Teach safe position changes: sit at edge of bed before standing. Use walking aids. Two-person assist if very unsteady.
Psychological Reassurance
Vertigo is distressing and disabling. Reassure BPPV is benign and treatable. Explain Epley manoeuvre process. Anxiety worsens vestibular symptoms.
Symptom Relief
Prochlorperazine or cyclizine for acute nausea/vomiting. Maximum 3 days — then vestibular rehab. Ondansetron for severe vomiting. IV fluids if dehydrated from vomiting.
Falls & Fractures
Acute vertigo significantly increases fall risk. Elderly patients with vertigo + osteoporosis are at very high risk of hip fracture. Falls in the bathroom or during nighttime ambulation are particularly dangerous. Implement full falls prevention protocol for all admitted vertigo patients.
Ménière's — Sudden Drop Attacks (Tumarkin Otolithic Crises)
10–15% of Ménière's patients experience sudden falls without warning (no dizziness preceding fall). Caused by sudden otolith stimulation. Extremely dangerous — can cause severe injury. Patients require supervision and helmet protection if severe. Medical alert bracelet advised.
GCC Context
Dehydration Precipitates Vertigo
In GCC's extreme heat, dehydration is common and can precipitate or worsen Ménière's disease (dehydration increases endolymph concentration) and POTS. Outdoor workers, elderly patients, and those fasting during Ramadan are particularly vulnerable. Adequate hydration is a key prevention and management strategy.
Construction at Height — Fall Risk
Millions of construction workers work at height across GCC. A worker with undiagnosed BPPV or Ménière's disease faces catastrophic fall risk. Occupational health screening for vestibular disorders is essential for workers at height. Nurses in occupational health settings should be competent in vestibular assessment.
Hajj Falls in Elderly Pilgrims
During Hajj, 2+ million pilgrims (many elderly) undergo physically demanding rituals in extreme heat. Vertigo, dehydration-related POTS, and BPPV can cause falls. Saudi MOH deploys emergency teams to manage falls during Tawaf (circumambulation of the Kaaba) and Sa'i. Nurses working in Hajj medical teams need vestibular emergency skills.
Ménière's patients who fast during Ramadan may experience increased frequency of vertigo attacks due to dehydration and electrolyte shifts. Advise patients to maximise fluid intake at Iftar and Suhoor. Salt-loading strategies may need adjustment during fasting months. Consult with ENT specialist regarding safety of fasting in severe Ménière's disease.
ENT and otoneurology services are available across major GCC hospitals. Epley manoeuvre can be performed by trained nurses and physiotherapists, reducing wait times for specialist review. Vestibular rehabilitation therapy is available in larger centres. Betahistine is widely available in GCC pharmacies.
Key Exam Points
BPPV = most common vertigo; brief <1 min; positional; posterior canal; displaced otoliths
HINTS — central (stroke): normal head impulse + direction-changing nystagmus + skew deviation
Fall risk assessment mandatory for all vertigo patients
Practice MCQs
1. A 65-year-old has brief dizzy spells when rolling over in bed, lasting less than 30 seconds. Dix-Hallpike is positive. The most appropriate treatment is:
2. Why should prochlorperazine be used for a maximum of 3 days in vestibular neuritis?
3. On HINTS examination, which finding suggests a central (stroke) cause of acute vestibular syndrome?
4. The classic triad of Ménière's disease includes episodic vertigo lasting 20 min–12 hours, tinnitus, and: