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Clinical Crossroads |

A 69-Year-Old Man With Chronic Dizziness

David A. Drachman, MD
JAMA. 1998;280(24):2111-2118. doi:10.1001/jama.280.24.2111.
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DR PARKER:Mr D is a 69-year-old man troubled by dizziness. He is retired from his job as building superintendent for a public school. He is married, lives in the Boston, Mass, suburbs, and has managed Medicare insurance.

Mr D dates the onset of his dizziness to 1994, when the symptoms were predominantly vertiginous. He described the sensation as "everything is moving" and "like I had too much to drink." These episodes lasted 1 to 2 hours, occurred several times per week, and often came on suddenly, such as when arising in the middle of the night. At that time, use of meclizine hydrochloride seemed to decrease the symptoms. Results of a magnetic resonance imaging (MRI) scan of the brain at that time were normal.

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"Epley canalith repositioning maneuver for benign paroxysmal positional vertigo. . ." Treatment maneuver for benign paroxysmal positional vertigo affecting the right ear. The procedure can be reversed for treating the left ear. 1, The patient is seated upright, with the head facing the operator, who is standing on the right. For stability, the patient should grasp the forearm of the operator with both hands. 2, The patient is rapidly moved into the supine position, allowing the head to extend just beyond the end of the examining table, with the right ear downward. 3, The operator moves to the head of the table, repositioning the hands as shown. 4, The head is quickly rotated toward the left, stopping with the right ear upward. Position is maintained for 30 seconds. 5, The patient rolls to the left side, while the examiner rapidly rotates the head leftward until the nose is directed toward the floor. This position is held for 30 seconds. 6, The patient is rapidly lifted into the sitting position, now facing left. The entire sequence should be repeated until no nystagmus can be elicited. The patient must keep the head elevated above 45° for 48 hours following the procedure. PSC indicates posterior semicircular canal; UT, utricle. Reprinted with permission from Office Practice of Neurology. Copyright 1996, Churchill Livingstone Inc.

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