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BASICS

  • BPPV is a mechanical disorder of the inner ear characterized by brief vertigo with positional changes.
  • Results from dislodged otoconia (calcium carbonate crystals) moving within semicircular canals.
  • Posterior semicircular canal involvement is most common.
  • BPPV is the most common cause of vertigo.

EPIDEMIOLOGY

  • Typical onset: 5th to 7th decade of life.
  • Incidence increases with age.
  • More common in females.
  • 1-year incidence approximately 0.6%; lifetime prevalence about 2.4%.
  • Associated with falls, depression, and lower quality-of-life scores.

ETIOLOGY AND PATHOPHYSIOLOGY

  • Dislodgement of otoconia from utricle maculae into semicircular canals.
  • Otoconia movement disturbs endolymph flow causing abnormal cupula deflection.
  • Causes vertigo and nystagmus upon head reorientation relative to gravity.
  • Etiologies include idiopathic, posttraumatic, or viral neurolabyrinthitis.

RISK FACTORS

  • Female sex.
  • Vitamin D deficiency.

DIAGNOSIS

History

  • Episodic vertigo triggered by head movements: rolling in bed, getting up, looking up (“top-shelf syndrome”), bending forward.
  • Vertigo described as spinning sensation lasting seconds to a minute.
  • Associated nausea and vomiting may occur.

Physical Exam

  • Dix-Hallpike test (DHT) provokes characteristic nystagmus and vertigo.
  • Test performed by rapidly moving patient from sitting to head-hanging position, observing latency (<30 sec), duration (~40 sec), fatigability, and direction of nystagmus.
  • Differentiate peripheral BPPV from central causes using features:
  • Triggered paroxysmal nystagmus (peripheral) vs spontaneous or gaze-evoked (central).
  • Intense spinning vertigo, onset sudden.
  • Symptoms worsen with movement; nausea/dizziness common.
  • Hearing loss or tinnitus not typically present.
  • HINTS exam (Head-Impulse, Nystagmus, Test of Skew) for stroke exclusion in acute vestibular syndrome.

DIFFERENTIAL DIAGNOSIS

  • Orthostatic hypotension.
  • Central vertigo: brainstem/cerebellar stroke, tumor, hemorrhage.
  • Vestibular neuronitis.
  • Migraine-associated vertigo.
  • Traumatic brain injury.

DIAGNOSTIC TESTS & INTERPRETATION

  • Diagnosis is clinical using history and positional testing.
  • Use TiTrATE approach (Timing, Triggers, and Targeted Exams) to differentiate causes.
  • Imaging (CT/MRI) if central causes suspected.

TREATMENT

Canalith Repositioning Procedures (CRP)

  • Epley maneuver is first-line for posterior canal BPPV.
  • Sequence of head movements to relocate otoconia from semicircular canal back to utricle.
  • Other maneuvers: Semont, Lempert roll (barbecue), Gufoni for horizontal canal BPPV.
  • Post-maneuver restrictions are generally not necessary.
  • Self-administered CRP may be used for maintenance or recurrence.

Medication

  • Vestibular suppressants (benzodiazepines, antihistamines) are not recommended except for short-term nausea management.
  • Ondansetron may be used for severe nausea during maneuvers.

Additional Therapies

  • Vestibular rehabilitation therapy (VRT) may improve compensation and quality of life.
  • Address comorbidities like hypertension, diabetes, osteoporosis, and vitamin D deficiency to reduce recurrences.

ISSUES FOR REFERRAL

  • Atypical or refractory BPPV.
  • Non-posterior canal involvement.
  • Diagnostic uncertainty.
  • Referral to physical therapy, neurology, or otolaryngology as needed.

ONGOING CARE

  • Follow-up within 1 week post-treatment to confirm symptom resolution.
  • Educate on self-treatment techniques.

PATIENT EDUCATION

  • Instructional videos available for CRP maneuvers.
  • Encouraged to maintain mobility and avoid fear of movement.

PROGNOSIS

  • ~80% cure rate with CRP maneuvers.
  • Recurrence rates: 30% at 1 year, 44% at 2 years.

COMPLICATIONS

  • Canal conversion (dislodged debris moves to another canal) during maneuvers.

REFERENCES

  1. Chen J, Zhao W, Yue X, et al. Risk factors for benign paroxysmal positional vertigo: a systematic review and meta-analysis. Front Neurol. 2020;11:506.
  2. Newman-Toker DE, Kerber KA, Hsieh YH, et al. HINTS outperforms ABCD2 to screen for stroke in acute continuous vertigo and dizziness. Acad Emerg Med. 2013;20(10):986-996.
  3. Sharif S, Khoujah D, Greer A, et al. Vestibular suppressants for benign paroxysmal positional vertigo: a systematic review and meta-analysis of randomized controlled trials. Acad Emerg Med. 2023;30(5):541-551.

ICD10

  • H81.10 Benign paroxysmal vertigo, unspecified ear
  • H81.11 Benign paroxysmal vertigo, right ear
  • H81.12 Benign paroxysmal vertigo, left ear

Clinical Pearls

  • Diagnosis is clinical and based on history and Dix-Hallpike test.
  • Epley maneuver is effective first-line treatment.
  • Avoid vestibular suppressants except short-term for nausea.
  • Ambulate patient prior to discharge to assess gait and balance.