What is the difference between Vestibular Neuritis and Benign Paroxysmal Positional Vertigo (BPPV)?

Vestibular Neuritis vs BPPV: Key Differences and Management

Vestibular neuritis and benign paroxysmal positional vertigo (BPPV) are distinct vestibular disorders with different pathophysiology, clinical presentations, diagnostic approaches, and treatment strategies.

Pathophysiology

BPPV

• Caused by dislodged otoconia (calcium carbonate crystals) that have moved from the utricle into the semicircular canals 1
• Most commonly affects the posterior semicircular canal (85-95% of cases) 1
• Can also affect the lateral/horizontal canal (5-15% of cases) 1
• Rare variants include anterior canal BPPV and multicanal BPPV 1

Vestibular Neuritis

• Inflammatory disorder affecting the vestibular nerve 2
• Often follows viral infections 3
• Results in acute unilateral peripheral vestibulopathy 3
• Preserves hearing function (unlike labyrinthitis which affects both vestibular and cochlear function) 2

Clinical Presentation

BPPV

• Triggered episodic vestibular syndrome - brief episodes of vertigo triggered by specific head movements 1, 2
• Vertigo lasts seconds (typically <1 minute) 1, 4
• Symptoms provoked by position changes like:
  • Rolling over in bed
  • Looking up or bending down
  • Tilting head 1, 4
• No associated hearing loss or other neurological symptoms 2
• May have spontaneous resolution within 1-3 months in up to 50% of cases 1

Vestibular Neuritis

• Acute vestibular syndrome - sudden onset of persistent vertigo 2
• Vertigo lasts days to weeks 2, 5
• Constant vertigo not dependent on position changes 2
• Associated with:
  • Nausea and vomiting
  • Gait instability
  • Head motion intolerance 2
• No hearing loss (distinguishing it from labyrinthitis) 2

Diagnostic Approach

BPPV

• Diagnosed with positional testing:
  • Posterior canal BPPV: Dix-Hallpike maneuver produces characteristic torsional upbeating nystagmus after brief latency 1, 4
  • Lateral canal BPPV: Supine roll test produces horizontal direction-changing nystagmus 1
• No imaging needed for typical presentations 1, 5
• No vestibular function testing needed for typical presentations 1

Vestibular Neuritis

• Clinical diagnosis based on history and examination 2
• HINTS examination (Head-Impulse, Nystagmus, Test of Skew) helps differentiate from central causes 2
• MRI brain may be indicated in atypical presentations to rule out stroke 2, 5
• Caloric testing may show reduced vestibular response on affected side 3

Treatment

BPPV

• Canalith repositioning procedures (CRPs) are the definitive treatment for BPPV 1, 4
• Specific maneuvers based on canal involvement:
  • Posterior canal: Epley maneuver or Semont maneuver 1, 6
  • Lateral canal: Roll maneuvers or Gufoni maneuver 1
• Medications (vestibular suppressants) are NOT recommended for routine BPPV treatment 1, 5
• Home-based exercises may be offered as an option 1

Vestibular Neuritis

• Symptomatic treatment with:
  • Short-term vestibular suppressants for acute symptoms 2
  • Corticosteroids (may improve recovery) 5
• Vestibular rehabilitation for chronic symptoms 2
• Treatment of any underlying cause 2

Prognosis

BPPV

• Excellent with proper treatment - immediate resolution in many cases 4
• Recurrence rate of approximately 15% per year (up to 50% at 5 years) 2
• Can resolve spontaneously in 20% of patients within 1 month 1

Vestibular Neuritis

• Gradual improvement over weeks to months 2
• Some patients may have residual symptoms requiring vestibular rehabilitation 2
• Can lead to secondary BPPV in some cases (24 out of 2847 BPPV patients in one study) 3

Common Pitfalls

1. Misdiagnosis: BPPV and vestibular neuritis are often misdiagnosed in emergency settings, leading to inappropriate management 5

2. Overuse of imaging: CT scans are frequently overused in BPPV diagnosis, while MRI may be underused in cases where vestibular neuritis needs to be distinguished from stroke 5

3. Inappropriate medication use: Vestibular suppressants like meclizine are often inappropriately prescribed for BPPV when repositioning maneuvers are the definitive treatment 5

4. Failure to recognize secondary BPPV: About 3% of BPPV cases are secondary to other inner ear disorders, including vestibular neuritis 3

5. Missed central causes: Failure to perform appropriate testing (like HINTS) can lead to missing central causes of vertigo that may mimic peripheral disorders 2

By understanding these key differences, clinicians can accurately diagnose and appropriately manage these common vestibular disorders, improving patient outcomes and quality of life.