Belign Paraxysmal Postonal vertigo (BPPV)

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.

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.


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.

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).

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)

• Meacute niegravere  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

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 Therapy – Vestibular 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.

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.