ENT

Benign paroxysmal positional vertigo

Brief, position-triggered vertigo caused by displaced otoconia in a semicircular canal; diagnose with positional testing and treat posterior-canal disease with a canalith-repositioning manoeuvre.

In a nutshell

BPPV causes brief, position-triggered spinning because displaced otoconia move within a semicircular canal. Confirm the side with Hallpike/Dix–Hallpike, treat posterior-canal disease with Epley, and investigate red flags rather than masking persistent or atypical vertigo with vestibular suppressants.

Classic presentation

Brief intense spinning when rolling in bed, lying back, looking up or bending, with nausea but normal hearing and no persistent neurological deficit.

Key points

Posterior-canal BPPV is suggested by transient torsional upbeating nystagmus after Hallpike/Dix–Hallpike.
The Epley manoeuvre is the first-line mechanical treatment for confirmed posterior-canal BPPV; the side and contraindications matter.
Brandt–Daroff or vestibular rehabilitation can be used when Epley is unsuitable, unavailable or incomplete, but they do not replace red-flag assessment.
Hearing loss, persistent spontaneous vertigo, focal neurology, severe gait ataxia or central eye signs are not typical BPPV.
Vestibular suppressants are not curative and should not be used routinely or long term; they can increase sedation and falls.
Avoid unsupervised home manoeuvres until the diagnosis, affected side and positional safety have been established.
Persistent, recurrent or diagnostically uncertain symptoms need vestibular physiotherapy, audiovestibular or ENT review.

First-line investigation

Focused vertigo history and Hallpike/Dix–Hallpike manoeuvre in a safe setting; consider the roll test or specialist assessment if the pattern is not posterior canal.

Management

Exclude central and auditory red flags

Escalate persistent spontaneous vertigo, focal neurological signs, severe ataxia, new hearing loss, severe headache or central nystagmus urgently.^1,2

Confirm canal and side

Perform Hallpike/Dix–Hallpike for posterior-canal disease; use roll testing or specialist vestibular assessment when the pattern is atypical or Hallpike is negative.^3,1

Reposition the otoconia

Perform Epley or an appropriate canalith-repositioning manoeuvre for confirmed posterior-canal BPPV, with attention to neck and spinal safety.^1,4

Rehabilitate and prevent falls

Use Brandt–Daroff or vestibular rehabilitation selectively; give falls, driving and safe-mobility advice and avoid routine vestibular suppressants.^1,2,5

Review persistence and recurrence

Refer persistent, recurrent, atypical or uncertain cases to vestibular physiotherapy, audiovestibular medicine or ENT rather than repeating empirical treatment indefinitely.^1,4

Exam traps

BPPV attacks are brief and positional; hours of spontaneous vertigo suggests another diagnosis.
Hearing loss or persistent tinnitus should not be attributed to uncomplicated BPPV.
A positive positional symptom without the expected nystagmus still needs a safe, skilled assessment and may require specialist review.
Epley is a treatment for the affected canal and side, not a generic exercise to prescribe without diagnosis.
Prochlorperazine may reduce nausea but does not reposition otoconia.

Illustrations

Otoconia in the semicircular canalDiagram showing displaced otoconia moving within a semicircular canal during head movement and generating an abnormal vestibular signal.PassFinals · original

Dix–Hallpike manoeuvreStepwise clinical diagram of the Dix–Hallpike positional test with the examiner supporting the patient's head and observing for torsional upbeating nystagmus.PassFinals · original

Epley canalith-repositioning manoeuvreSequence showing the head and body positions used to move posterior-canal otoconia back into the utricle on the affected side.PassFinals · original

Key sources

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.