Spinning world: Benign Paroxysmal Positional Vertigo

Dizziness, a common cause of referral to otolaryngology clinic, includes a broad range of sensations from severe vertigo to momentary light-headedness , and Vertigo most common of dizziness  is an illusion of movement of the body or environment.

Vertigo may be because of otologic, neurologic, or systemic reasons.

Causes of Otologic dizziness

  • Benign paroxysmal positional vertigo) – about 50% of otologic, 20% all
  • Meniere’s disease – about 20%
  • Vestibular neuritis and related conditions (15%)
  • Bilateral vestibular loss (about 1%)
  • SCD and Fistula (rare)

What is Benign Paroxysmal Positional Vertigo?

Benign paroxysmal positional vertigo (BPPV) is the most common underlying cause of vertigo accounting for about 20% of all dizziness and 50% of otologic dizziness.

Benign paroxysmal positional vertigo is defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo.

Positional vertigo means a spinning sensation produced by changes in head position relative to gravity.
Benign means not due to any serious brain or CNS (Central Nervous System)disorder  and the overall prognosis for recovery is favorable. (However, undiagnosed and untreated BPPV may have health, and quality-of-life impacts).
Paroxysmal—  means Rapid and sudden onset of the vertigo

Symptoms of BPPV-

Dizziness, Imbalance, Nausea, light-headedness

That is

  • Brief and strong
  • Provoked by change of head position
  • Definitively diagnosed by Hallpike test
  • Many patients wake up with the condition, noticing the vertigo while trying to sit up suddenly.
  • People do not usually feel dizzy all the time. Dizziness attacks triggered by head movements (classically with lying down or rolling over in bed) and between episodes patients usually have few or no symptoms.
  • Classic BPPV is usually triggered by the sudden action of moving from the erect position to the supine position while angling the head 45° toward the side of the affected ear.

The pathophysiology of BPPV –

Normal Ear Anatomy

The labyrinth of the inner ear is composed of the vestibule (utricle and saccule) and the 3 semicircular canals. These are filled with fluid called endolymph and have receptors to inform the brain about the head’s position in space.

Inner Ear

Utricle contains small calcium oxalate crystals called otoliths or otoconia for gravity and position receptors for linear acceleration.

Similarly, angular acceleration receptors are located in the cupula of the semicircular canals. When head turns, these receptors inform the brain via vestibular nerve that the head is turning. Once the head stops turning, the endolymph stops moving, the receptors stop firing, and the brain now knows that the head has stopped turning.

Inner ear semicircular canals-BPPV

In BPPV, the otoliths become dislodged from normal position and accumulate in wrong place in one of the semicircular canals (most commonly in the posterior semicircular canal since it is at the most dependent position)

When the patient turns his head, otoliths move, and trigger faulty signals even after head stops moving. The eyes, however, inform the brain that the head has stopped moving. Brain Receives conflicting information causing brief but intense sense of spinning.

Diagnosis of BPPV—

Comprehensive History is most important aspect. Patient describes his complaints in his own words and a specific set of leading questions specially onset of symptoms, duration, associated eye,  ear and neurologic systems, history of any ear/head trauma, medical disease or medication  are asked by health care provider. While talking to patient usually a diagnosis is established.

Basic ENT and Ear examination is done for concomitant ear problem.

Neurological examination to rule out any CNS lesion is carried out.

Neurotologic examination Evaluation of static disturbances (with head still) and dynamic disturbances (with head motion)

Dix-Hallpike maneuver– Standard clinical test for BPPV


This test is performed by rapidly moving the patient from a sitting position to the supine position with the head turned 45° to the right. After waiting approximately 20-30 seconds, the patient is returned to the sitting position. If no nystagmus is observed, the procedure is then repeated on the left side.

The finding of classic rotatory nystagmus with latency and limited duration is considered pathognomonic. A negative test result is meaningless.

Classic BPPV is the most common variety of BPPV. It involves the posterior Semi Circular Canals.

Diagnostic criteria for posterior canal BPPV
  • History – Patient reports repeated episodes of vertigo with changes in head position.
  • Physical examination each of the following criteria are fulfilled:–
  • Vertigo associated with nystagmus is provoked by the Dix-Hallpike test. There is a latency period between the completion of the Dix-Hallpike test and the onset of vertigo and Nystagmus, Geotropic (means towards earth-refer to upper half of the eyes nystagmus with the problem ear down
  • The provoked vertigo and nystagmus increase and then resolve within a time period of 60 seconds from onset of nystagmus.
  • Reversal upon return to upright position
  • Response decline upon repetitive provocation
Nystagmus is involuntary eye movements (usually triggered by inner ear stimulation) named by the direction of the fast phase. Thus, nystagmus may be horizontal (right beating, left beating, up-beating), vertical (down-beating), or rotational (geotropic-towards earth and ageotropic).


Workup for BPPV

Laboratory Studies

  • Laboratory tests are not needed to make the diagnosis of benign paroxysmal positional vertigo (BPPV).
  • Tests may be advised for other associated inner ear pathology.
  • Blood sugar and routine complete blood count may be done to rule out hypoglycemia and anemia.
  • Electrolyte level may be done if patient had severe episodes of vomiting

Imaging Studies

Imaging studies (CT scan and MRI) are not routinely required for patient with BPPV. In cases of doubt it may be advised.

Other tests

  • Audiogram – simple test which may be done for concomitant ear pathology
  • Caloric test
  • Electronystagmography (ENG)
  • Posturography

Differential diagnoses for benign paroxysmal positional vertigo (BPPV)

  • Ménière disease
  • Inner ear concussion
  • Alcohol intoxication
  • Vestibular labyrinthitis
  • Vascular loop syndrome
  • Lesion of the nodulus from stroke, multiple sclerosis, Arnold-Chiari malformation, ischemia, cerebellar degeneration, and intoxication.
  • Posterior fossa lesion such as acoustic neuroma or meningioma.
  • Vertebral artery insufficiency
  • Cervical vertigo, or head extension vertigo,
  • Orthostatic hypotension,
  • Medication side effects
  • Anxiety or panic disorder
  • Migraine related vertigo
  • Management of BPPV

    Epley Maneuver— Initial and most important management strategy is Canalith repositioning maneuver or CRP or Epley maneuver. ( for details read previous post Canalith repositioning maneuver for BPPV)

    Vestibular Rehabilitation Exercises Vestibular rehabilitation is an exercise program to help compensate for a loss or imbalance within the vestibular system either self-administered or with a clinician.

    Cawthrone cooksey exercises and Brand  Daroff exercises for BPPV are beneficial for hastening of restoration of normal balance.

    Observation – wait and watch with reassurance and follow-up visits as symptoms resolve in 1-2 month time.

    Medical TherapyVestibular suppressant medications can be used but many times not effective and masks the problem.. Adverse effects of grogginess and sleepiness ca occur.

    Health Education – Patients are counseled regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up.

    Surgical Care

    Surgery is reserved for those in whom CRP fails. There is possibility of complications such as hearing loss and facial nerve damage.

    The most viable surgical option is posterior canal occlusion. The aim is to stop the benign positional vertigo by collapsing the posterior canal, immobilizing the movement of particles through the canal.

    Benign Paroxysmal positional vertigo usually is not due to any serious neurological disorder and the overall prognosis for recovery is favorable; however, undiagnosed and untreated BPPV may have safety concerns and quality-of-life impacts.

    Proper Diagnosis and treatment of patients with BPPV may lead to significant health care quality improvements thus it is very important to implement a well-constructed clinical practice guidelines.

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