Benign Paroxysmal Positional Vertigo

Overview

Benign paroxysmal positional vertigo (BPPV) is a disorder of the inner ear characterised by repeated episodes of positional vertigo i.e. symptoms are triggered by changes in head position. It is the most common cause of vertigo.

BPPV is thought to be due to small calcified crystals moving around loosely in the inner ear. 

Epidemiology

• BPPV is the most common cause of vertigo
• Peak age of onset is >40 years
• Prevalence is up to 140 per 100,000
• Women are affected more than men

Risk Factors

• Older age
• Female sex
• Head trauma
• Labyrinthitis
• Vestibular neuronitis
• Inner ear surgery/trauma
• Meniere’s disease

Presentation

Patients classically have short episodes of vertigo triggered by changes in head position. Features are:

• Short episodes of vertigo triggered by changes of head position – usually 10-20s
• Hearing is unaffected
• There is no tinnitus

Differential Diagnoses

Meniere’s disease

• Recurrent episodes of hearing loss, tinnitus, vertigo, and a sensation of aural fullness
• There is usually no preceding viral infection

Vestibular neuronitis

• There is vertigo but no hearing loss
• Usually follows a viral infection

Labyrinthitis

• There is vertigo but hearing loss is present
• Usually follows a recent viral infection

Benign paroxysmal positional vertigo

• Episodes of vertigo are triggered by changes in head position
• There is usually no preceding viral infection
• Vestibular schwannoma
• Sensorineural hearing loss, vertigo, and tinnitus present with potential cranial nerve involvement e.g. absent corneal reflex is CN V is involved

Posterior stroke

• Ataxia
• Romberg’s test negative
• Facial paralysis/dysphagia
• Contralateral lower extremity weakness

Diagnosis

Overview

• Dix-Hallpike manoeuvre – diagnoses posterior canal BPPV
  • The patient experiences vertigo and rotatory (torsional) nystagmus
• Supine lateral head turns – diagnoses horizontal canal BPPV
  • The patient experiences vertigo and nystagmus without a rotatory component
• If the diagnosis is uncertain, consider CT or MRI

Provided the clinical picture is clear, BPPV can be diagnosed using the Dix-Hallpike manoeuvre or supine lateral head turns.

Management

• 1st-line: Epley manoeuvre – gives symptomatic relief
• Admit to the hospital if patients have severe nausea and vomiting and cannot tolerate oral fluids

Monitoring

• Patients are generally followed up in 4 weeks if symptoms have not resolved.

Patient Advice

• Patients should be reassured that the prognosis is good and most patients recover over several weeks
• Patients should get out of bed slowly and try to avoid activities that involve looking upwards
• Patients should notify the DVLA regarding driving
• Patients should try to reduce the risks of falling at home and discuss managing occupational risks with employers

Complications

• Falls
• Difficulties carrying out activities of daily living
• Psychosocial problems e.g. depression

Prognosis

• BPPV usually has a relapsing and remitting course
• There is usually a high chance of remission, but it usually remits spontaneously