What is Benign Paroxysmal Positional Vertigo (BPPV), its symptoms, examination findings, and treatment options?

Benign Paroxysmal Positional Vertigo (BPPV): Definition, Symptoms, Examination Findings, and Treatment

BPPV is the most common cause of vertigo, characterized by brief episodes of spinning sensation triggered by specific head position changes relative to gravity, and is effectively treated with canalith repositioning procedures that have high success rates (around 80%) with only 1-3 treatments. 1

What is BPPV?

BPPV is a disorder of the inner ear characterized by repeated episodes of positional vertigo. The name describes its key features:

• Benign: not life-threatening
• Paroxysmal: comes in sudden, short spells
• Positional: triggered by certain head positions or movements
• Vertigo: false sensation of spinning 1

Pathophysiology

BPPV occurs when calcium carbonate crystals (otoconia) normally found in the utricle of the inner ear become dislodged and migrate into one of the semicircular canals. This causes abnormal stimulation of the vestibular system when the head changes position relative to gravity. There are two mechanisms:

1. Canalithiasis: Free-floating particles in the canal
2. Cupulolithiasis: Particles attached to the cupula 1

BPPV most commonly affects the posterior semicircular canal (85-95% of cases), followed by the lateral (horizontal) canal (5-15%). Anterior canal involvement is rare. 1

Symptoms of BPPV

Key symptoms include:

• Brief episodes of vertigo (spinning sensation) lasting seconds to minutes
• Positional triggering - symptoms occur with:
  • Lying down
  • Rolling over in bed
  • Looking up or bending over
  • Getting in or out of bed
• Nausea (sometimes vomiting)
• Disorientation and sense of imbalance
• No hearing loss or other ear symptoms 1

The first attack often occurs in bed or upon getting up, and can be quite alarming 2. The natural course of BPPV is that episodes tend to become less severe over time, with the first episode typically being the worst 1.

Examination Findings

The diagnosis of BPPV is based on characteristic findings during specific positioning tests:

1. Posterior Canal BPPV (most common)

• Dix-Hallpike test: The examiner moves the patient from sitting to lying with the head turned 45° to one side and extended 20° below horizontal
• Positive findings: Torsional upbeating nystagmus after a brief latency (1-5 seconds)
• Duration: Nystagmus typically lasts less than 1 minute
• Associated vertigo during the nystagmus 1, 3, 4

2. Lateral Canal BPPV

• Supine roll test: With the patient lying flat, the head is quickly turned 90° to one side, then the other
• Positive findings: Horizontal nystagmus that can be either:
  • Geotropic (beating toward the ground) in canalithiasis
  • Apogeotropic (beating away from the ground) in cupulolithiasis 3, 4

Important Examination Characteristics

• Latency: Brief delay (1-5 seconds) between position change and onset of symptoms
• BPPV fatigue: Repeated testing causes diminished response
• Limited duration: Symptoms resolve within 1 minute (typically 10-20 seconds) 4

Treatment of BPPV

1. Canalith Repositioning Procedures (CRPs)

These are the primary treatment for BPPV, with high success rates around 80% with only 1-3 treatments 1.

For Posterior Canal BPPV:

• Epley maneuver: Series of head position changes that move the particles from the canal back to the utricle
• Semont maneuver: Alternative repositioning technique 1, 4, 5

For Lateral Canal BPPV:

• Gufoni maneuver or Vannucchi maneuver: Specific repositioning techniques for lateral canal BPPV 4, 5

2. Self-Administered Exercises

• Patients can be taught to perform modified repositioning maneuvers at home under supervision
• Particularly useful for recurrent cases 1

3. Observation

• BPPV may resolve spontaneously in about 20% of patients within 1 month and up to 50% at 3 months
• Observation with follow-up is a reasonable option for some patients 1

4. Medications

• Not recommended as primary treatment
• Vestibular suppressants (antihistamines, benzodiazepines) should not be routinely used
• May be used briefly for severe nausea only 1

Common Pitfalls and Caveats

1. Misdiagnosis: BPPV is often misdiagnosed as other conditions, leading to unnecessary testing and treatments
2. Inappropriate medication use: Vestibular suppressants mask symptoms but don't treat the underlying cause
3. Unnecessary imaging: Routine imaging is not recommended for typical BPPV
4. Failure to recognize canal type: Different canals require different repositioning maneuvers
5. Overlooking comorbidities: BPPV can coexist with other vestibular disorders
6. Inadequate follow-up: Recurrence rates can be high (30-50% within 5 years) 1

Special Considerations

• Seniors: More prone to BPPV and at higher risk for falls; should seek treatment promptly
• Multiple canal involvement: May require sequential or combined treatment approaches
• Recurrent BPPV: May benefit from self-administered repositioning exercises
• Persistent symptoms: Consider referral to vestibular specialist if symptoms persist after proper repositioning 1

BPPV, while distressing, is generally a benign condition with excellent treatment outcomes when properly diagnosed and managed with appropriate repositioning techniques.