NeurologyTier 1Disease (DEADMAN)

Benign paroxysmal positional vertigo

Description

Otoconia (calcium carbonate crystals) displaced from the utricle into a semicircular canal -> abnormal endolymph movement with head position change -> brief vertigo
Commonest cause of vertigo overall
Posterior canal involved in ~85-90% of cases

Canalithiasis (free-floating otoconia in canal, commonest mechanism) vs cupulolithiasis (otoconia adherent to the cupula - causes longer-lasting nystagmus)
Idiopathic in most (degenerative otoconial detachment with age)
Secondary: head trauma, vestibular neuritis, Meniere disease, prolonged bed rest, post-otological surgery

Clinical - Dix-Hallpike test confirms posterior/anterior canal BPPV

Brief (<1 minute) vertigo triggered by specific head position change (rolling in bed, looking up, bending over)
Latency of a few seconds before nystagmus onset, nystagmus fatigues with repetition
Torsional/upbeating nystagmus (posterior canal) - torsional geotropic
Supine roll test for horizontal (lateral) canal BPPV - horizontal nystagmus, direction-changing with head turn

Central vs peripheral vertigo - the key discriminator

	BPPV (peripheral)	Central
Onset	Positional, brief	May be positional but often continuous
Nystagmus	Torsional/upbeating, fatigues, latency	Any direction, non-fatiguing, no latency, may be purely vertical/direction-changing
Associated signs	None	Diplopia, dysarthria, limb ataxia, other brainstem signs
HINTS (if spontaneous nystagmus present)	Normal head impulse, no skew	Abnormal ("benign") pattern suggests peripheral; normal head impulse + skew deviation suggests central

*No hearing loss, tinnitus, or neurological deficit in BPPV* - any of these should prompt work-up for an alternative cause

A. Canalith repositioning - first-line and diagnostic-therapeutic

Epley manoeuvre for posterior canal BPPV - highly effective, often single-session resolution
Gufoni/Barbecue roll manoeuvre for horizontal canal BPPV
Can be taught to patients for self-administration (e.g. modified Epley/Semont) if recurrent

B. Medication - adjunct only, not primary treatment

Vestibular suppressants (e.g. prochlorperazine, betahistine) for symptomatic relief only, short-term - do not treat the mechanical problem and may delay central compensation if overused

C. Persistent/recurrent disease

Refer for vestibular physiotherapy/further ENT assessment if repositioning fails or atypical features emerge
Reconsider central cause if repositioning manoeuvres do not resolve symptoms as expected

Head trauma
Vestibular neuritis, Meniere disease (secondary BPPV)
Prolonged bed rest, post-otological surgery
Osteoporosis (shared otoconial degeneration mechanism, epidemiological association)

Excellent response to repositioning - often resolves in one to a few sessions
Recurrence common (~50% at 5 years) - patients should be taught the manoeuvre or know to re-present
Falls risk during acute episodes, particularly in older adults
Self-limiting even untreated over weeks-months as central compensation occurs, but repositioning accelerates resolution

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