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Benign paroxysmal positional vertigo



BPPV is a common disorder of the inner ear characterized by repeated episodes of positional vertigo and nystagmus.
BPPV has an unknown origin but is thought to result from degeneration of the macula. Secondary causes include otoconial dislodgement due to otologic and nonotologic surgery, head trauma, or any means by which mechanical force reaches the inner ear, inner ear disorders (vestibular neuritis, Meniere's disease, and sudden sensorineural hearing loss.
Disease course
The aberrant semicircular canal signaling (canalithiasis and cupulolithiasis) results in BPPV, which causes clinical manifestations of dizziness that lasts < 20 seconds accompanied by a lingering, nonspecific imbalance and characteristic nystagmus with Dix-Hallpike maneuver. Spontaneous resolution occurs in 25% of patients by 1 month and up to 50% at 3 months.
Prognosis and risk of recurrence
BPPV is not associated with an increase in mortality.


Key sources

The following summarized guidelines for the evaluation and management of benign paroxysmal positional vertigo are prepared by our editorial team based on guidelines from the Society for Academic Emergency Medicine (SAEM 2023), the American Physical Therapy Association (APTA 2022), the American Academy of Neurology (AAN 2017), and the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2017). ...
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Screening and diagnosis

Differential diagnosis
As per AAO-HNSF 2017 guidelines:
Differentiate BPPV from other causes of imbalance, dizziness, and vertigo.
Assess patients with BPPV for factors modifying management, including impaired mobility or balance, CNS disorders, a lack of home support, and/or increased risk for falling.
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Diagnostic investigations

Dix-Hallpike test: as per AAO-HNSF 2017 guidelines, perform the Dix-Hallpike maneuver (by bringing the patient from an upright to supine position with the head turned 45 degrees to one side and the neck extended 20 degrees with the affected ear down) to elicit provoked vertigo associated with torsional, upbeating nystagmus for the diagnosis of posterior semicircular canal BPPV. Repeat the maneuver with the opposite ear down if the initial maneuver is negative.

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  • Supine roll test

  • Diagnostic imaging

  • Vestibular function testing

Medical management

Watchful waiting: as per AAO-HNSF 2017 guidelines, consider offering observation with follow-up as an initial management strategy in patients with BPPV.

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  • Vestibular suppressants

Nonpharmacologic interventions

Vestibular rehabilitation: as per APTA 2022 guidelines, offer vestibular physical therapy in patients with acute, subacute, or chronic unilateral vestibular hypofunction.
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Therapeutic procedures

Canalith repositioning: as per SAEM 2023 guidelines, perform the Epley canalith repositioning maneuver at the time of diagnosis of posterior canal BPPV in adult patients diagnosed by a positive Dix-Hallpike test.

Patient education

General counseling: as per AAO-HNSF 2017 guidelines, educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up.

Follow-up and surveillance

Management of unresolved symptoms: as per AAO-HNSF 2017 guidelines, evaluate patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or CNS disorders.

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  • Serial clinical assessment