Clinical Assessment: 54-Year-Old Male with Throat Pain + Positional Vertigo

Step 1: Red Flags - Exclude Dangerous Causes First

Throat Pain Red Flags (Rosen's Emergency Medicine)

Critical: A 54-year-old male with throat pain and dizziness should have an ECG done early. ACS can present with referred throat pain; cranial nerves IX and X innervate both the pharynx and carry cardiac afferents. - Rosen's Emergency Medicine, p.232

Positional Vertigo Red Flags

• Diplopia, dysarthria, dysphagia, ataxia, crossed neurological deficits
• Sudden onset without typical BPPV triggers
• Vertigo lasting >1 minute or persistent (not truly paroxysmal)
• No fatigability with repeated testing (central pattern)

Step 2: Unifying Diagnoses to Consider

A. Vertebrobasilar Insufficiency (VBI) / Posterior Circulation TIA

B. Eagle Syndrome (Styloid Process Syndrome)

C. Cervical Spine Pathology (Cervicogenic)

Step 3: If No Dangerous Etiology Found - Evaluate Each Symptom Separately

Throat Pain: Differential Diagnosis

• Viral pharyngitis (rhinovirus, adenovirus, EBV) - typically mild, associated URI symptoms
• Group A Streptococcal pharyngitis (GABHS) - rapid onset severe throat pain, fever 39-40.5°C, malaise, headache, tonsillar exudates
• Peritonsillar abscess - unilateral swelling, uvular deviation, trismus

• Thyroiditis (subacute/De Quervain's): anterior neck/throat pain, tender thyroid, may have systemic symptoms
• GERD/LPR: chronic throat discomfort, more morning symptoms, hoarseness
• Neoplasm: smoking/alcohol history, >6 weeks duration, lymphadenopathy

Positional Vertigo: BPPV Assessment

• Brief episodes (<1 minute) triggered by specific head movements (lying down, rolling over in bed, looking up)
• Nausea common; vomiting less so
• Fatigability with repeated maneuvers
• No hearing loss, no neurological deficits
• Age 54 male: idiopathic BPPV increases with age due to otolith degeneration

• Seat patient, turn head 45° toward the side being tested
• Briskly lower to 30° below horizontal (head hanging)
• Observe for upbeat-torsional nystagmus with 5-20 sec latency, lasting <60 seconds, fatigable
• Positive test = posterior canal BPPV confirmed - Scott-Brown's Otorhinolaryngology, p.876

If nystagmus is atypical (direction-changing, non-fatigable, no latency, lasts >1 min), a central cause must be considered and MRI obtained. - Roberts and Hedges' Clinical Procedures

Step 4: Management Algorithm

54M Throat Pain + Positional Vertigo
           |
    ─────────────────
    |               |
  Airway OK?    Red flags?
  (assess first) (ACS, stroke, abscess)
    |               |
   YES         → Urgent workup:
    |             ECG, troponin, CT/MRI,
    |             laryngoscopy, blood cultures
    |
  Stable → Separate workup:
    |
    ├─ THROAT PAIN
    │   • McIsaac score
    │   • Rapid Strep test / throat swab
    │   • Consider mono test (EBV) if young adults, generalized LAD
    │   • Neck CT if abscess suspected
    │   • Thyroid exam + TFTs if tender
    │
    └─ POSITIONAL VERTIGO
        • Dix-Hallpike test
        • If positive (posterior canal BPPV):
          → Epley maneuver (canalith repositioning)
          → 80-90% success rate
          → Brandt-Daroff exercises for home
          → Avoid vestibular suppressants as routine
        • If negative / atypical nystagmus:
          → HINTS exam (Head Impulse, Nystagmus direction, Test of Skew)
          → MRI brain/posterior fossa with DWI

Step 5: Treatment - BPPV Epley Maneuver

1. Start seated, head turned 45° to affected side
2. Rapidly lie back to head-hanging position (30° below horizontal) - hold 30 sec
3. Rotate head 90° to opposite side - hold 30 sec
4. Roll body and head a further 90° (face-down) - hold 30 sec
5. Sit up slowly

• Rosen's Emergency Medicine, p.192 - the maneuver involves 4-5 sequential rotations of the head, holding each position until nystagmus/vertigo resolves.

Summary / Key Points

1. First exclude ACS - a 54-year-old male with throat pain and dizziness needs an ECG early; ACS presents with referred throat pain via cranial nerves IX/X
2. Exclude posterior circulation TIA/stroke - especially if vertigo is not truly positional, lasts >1 min, or comes with other brainstem symptoms
3. Assess airway - epiglottitis and retropharyngeal abscess can be rapidly fatal
4. If these are excluded, the most likely explanations are GABHS or viral pharyngitis + BPPV as independent concurrent conditions
5. Dix-Hallpike test diagnoses BPPV; Epley maneuver treats it
6. Use McIsaac score to guide antibiotic decision for throat pain