ENTPending review
Benign paroxysmal positional vertigo
Brief, intense vertigo triggered by head movement, caused by displaced otoconia moving freely within a semicircular canal and inappropriately signalling rotation that is not actually happening.
In a nutshell
Otoconia dislodged from the utricle fall into a semicircular canal and move under gravity with head position, generating a false rotational signal. Vertigo is brief because the particles quickly settle, and the Epley manoeuvre cures the problem by physically repositioning them.
Classic presentation
Brief, intense spinning vertigo lasting under a minute, triggered by rolling over in bed or looking up, with normal hearing.
Key points
- The posterior semicircular canal is affected most often because of its dependent position relative to the utricle.
- Vertigo is brief because otoconia settle within seconds of a new head position, stopping the false rotational signal.
- Dix-Hallpike reproduces the characteristic torsional, upbeating, fatiguing nystagmus and confirms the diagnosis.
- The Epley manoeuvre is a mechanical treatment that repositions the otoconia and is often curative after a single session.
- Hearing loss or tinnitus should not occur in BPPV: their presence points to an alternative diagnosis.
First-line investigation
Dix-Hallpike manoeuvre to confirm the diagnosis and identify the affected side.
First-line management
The Epley manoeuvre, performed on the affected side identified by a positive Dix-Hallpike test.
Exam traps
- Vestibular sedatives such as prochlorperazine do not treat BPPV; they only mask symptoms and should not be used long-term.
- Vertigo lasting hours or days, or occurring without positional trigger, is not typical BPPV and should prompt consideration of vestibular neuritis or a central cause.
- Associated hearing loss or tinnitus should not be attributed to BPPV and needs further assessment.
Educational content pending clinical review. Not medical advice.