Key Facts

BPPV is a mechanical disorder of the inner ear causing brief episodes of vertigo triggered by specific head movements. It is the most common vestibular disorder and is diagnosed and treated at the bedside with specific positional manoeuvres.

Epidemiology

• Most common cause of vertigo (20-30% of all vertigo)
• Lifetime prevalence: 2.4%
• Annual incidence: 64 per 100,000
• Peak age: 50-70 years
• Female:male ratio 2:1
• Incidence increases with age

Aetiology

• Idiopathic in >50% of cases (especially elderly)
• Head trauma (15-20%)
• Vestibular neuritis (preceding viral illness)
• Ménière disease (associated)
• Prolonged bed rest or immobility
• Inner ear surgery (post-stapedectomy, post-cochlear implant)
• Osteoporosis and vitamin D deficiency (associated with recurrence)

Pathophysiology

• Otoconia (calcium carbonate crystals) normally embedded in the utricular macula become dislodged
• Free-floating otoconia enter a semicircular canal (posterior canal in 90%, horizontal in 8%, anterior in 2%)
• Canalithiasis: otoconia float freely in canal endolymph (most common mechanism)
• Cupulolithiasis: otoconia adhere to cupula (less common, causes persistent positional nystagmus)
• Head movement in the plane of the affected canal causes gravity-dependent movement of otoconia
• This creates abnormal endolymph flow, deflecting the cupula and stimulating vestibular nerve
• Results in brief intense vertigo with characteristic nystagmus pattern

Typical Presentation

• Brief episodes of intense rotational vertigo lasting <1 minute (typically 10-30 seconds)
• Triggered by specific head movements: rolling over in bed, looking up, bending forward, getting out of bed
• Often worse in the morning
• Associated nausea (vomiting less common)
• No hearing loss, no tinnitus, no neurological symptoms
• Between episodes: may have mild unsteadiness

Dix-Hallpike Test Findings (Posterior Canal BPPV)

• Latency: 2-5 seconds before nystagmus onset
• Torsional upbeat nystagmus (geotropic, towards the ground, with torsional component towards the affected ear)
• Duration: <1 minute (typically 10-30 seconds)
• Crescendo-decrescendo pattern
• Fatigable: reduces on repeated testing
• Associated with vertigo

Red Flags

• Vertigo lasting >1 minute continuously (not BPPV)
• Hearing loss or tinnitus (consider Ménière, labyrinthitis)
• Neurological symptoms (diplopia, dysarthria, dysphagia, limb weakness) — posterior stroke
• Non-fatigable, no latency nystagmus (central cause)
• Persistent vertigo not related to position
• Downbeat nystagmus (posterior fossa lesion)

Bedside

• Dix-Hallpike test: gold standard for posterior canal BPPV (positive on affected side)
• Supine roll test: for horizontal canal BPPV (geotropic or apogeotropic nystagmus)
• HINTS exam (Head Impulse, Nystagmus, Test of Skew): to differentiate peripheral from central vertigo in acute vestibular syndrome
• Romberg test, gait assessment
• Cranial nerve examination
• Otoscopy (should be normal)

Bloods

• Not routinely required
• Vitamin D levels if recurrent BPPV

Imaging

• Not routinely required for typical BPPV with positive Dix-Hallpike
• MRI brain: if atypical features, central signs, or failed treatment after multiple repositioning manoeuvres

Special Tests

• Audiometry: not routinely needed; if performed, should be normal
• Videonystagmography (VNG): may be used to confirm and characterise nystagmus

Non-pharmacological

• Epley manoeuvre (canalith repositioning procedure): first-line treatment for posterior canal BPPV
  • Single treatment effective in 80%
  • Can be repeated; >95% effective with repeated treatments
  • Can be taught as home exercise (modified Epley)
• Semont manoeuvre: alternative to Epley for posterior canal BPPV
• BBQ roll manoeuvre (Lempert/Gufoni): for horizontal canal BPPV
• Brandt-Daroff exercises: home vestibular habituation exercises for persistent symptoms
• Post-Epley: no evidence that post-manoeuvre restrictions (sleeping upright, avoiding head movement) improve outcomes

Pharmacological

• Vestibular sedatives are NOT recommended (prochlorperazine, betahistine, cinnarizine) — they delay vestibular compensation and are ineffective for BPPV
• Short-term antiemetics (cyclizine) may be used for acute severe nausea
• Vitamin D supplementation: evidence suggests reduces recurrence if deficient (serum 25-OH vitamin D <20ng/ml)

Surgical

• Posterior semicircular canal occlusion: very rarely, for intractable BPPV unresponsive to repeated repositioning manoeuvres; highly effective (>95%) but risk of SNHL
• Singular neurectomy: historical; rarely performed

Referral Criteria

• Most BPPV can be diagnosed and treated in primary care or emergency departments
• ENT/vestibular physiotherapy referral: if failed Epley after 3 attempts, atypical features, horizontal/anterior canal BPPV
• Urgent referral: if central features, neurological symptoms, diagnostic uncertainty

• Epley manoeuvre success rate: 80% after single treatment, >95% after repeated treatments
• Spontaneous resolution: 20-30% within 1 month even without treatment
• Recurrence: 30-50% within 5 years; higher in elderly, post-traumatic, and vitamin D deficient patients
• No risk of permanent hearing loss or vestibular damage
• Functional impact: risk of falls in elderly; driving and work may be temporarily affected
• Quality of life returns to normal between episodes with successful treatment
• Chronic or treatment-resistant BPPV (<5%): consider cupulolithiasis, bilateral BPPV, or central mimic

Epley Manoeuvre Steps (Right Posterior Canal)

Types of BPPV by Canal Affected

BPPV vs Central Positional Vertigo