# Benign Paroxysmal Positional Vertigo > BPPV for FMGE ENT: posterior canal canalithiasis, Dix-Hallpike diagnosis, Epley and Semont manoeuvres, Brandt-Daroff exercises and recurrences. - Canonical URL: https://prepelephant.com/topics/fmge/ent/bppv-fmge - Exam / course: FMGE · Subject: ENT - Publisher: PrepElephant (https://prepelephant.com) — Prepared and reviewed by the PrepElephant Academic Review Team - First published: 2026-10-02 - Last updated: 2026-10-02 - How to cite: "Benign Paroxysmal Positional Vertigo", PrepElephant, https://prepelephant.com/topics/fmge/ent/bppv-fmge ## Direct answer Benign paroxysmal positional vertigo is the dislodgement of otoconia from the utricular macula into a semicircular canal — the posterior canal in the large majority — where floating debris turns head-position changes into false endolymph currents and brief, violent spinning. The history alone nearly makes the diagnosis: vertigo lasting well under a minute, provoked by turning in bed, looking up or bending, with a few seconds of latency, marked fatigability on repetition and no hearing loss or focal neurology. Dix-Hallpike provokes the geotropic torsional nystagmus that confirms it, and the Epley repositioning manoeuvre cures most patients at the bedside without any drug; recurrence over the following years, however, is common enough that patients must be taught to recognise it. ## What you must remember - **Canal order:** posterior canal in roughly 80-90 per cent of cases, horizontal canal next, anterior canal rare; antecedents include head trauma and prolonged bed rest, but most cases are idiopathic. - **Mechanism split:** canalithiasis — free-floating debris causing paroxysmal nystagmus that fatigues (the usual picture); cupulolithiasis — debris adherent to the cupula causing persistent nystagmus as long as the position is held. - **Dix-Hallpike (Nylen-Barany) test:** with the head turned 45 degrees toward the examined ear, the patient is laid supine with the head extended 20 degrees over the couch edge; latency of a few seconds, geotropic torsional-plus-upbeating nystagmus lasting under a minute, and fatigability on repetition constitute a positive test. - **Horizontal canal BPPV:** diagnosed with the supine roll test; geotropic nystagmus that is stronger on one side localises the affected ear — the stronger side — while apogeotropic nystagmus suggests cupulolithiasis. - **Treatment by canal:** posterior canal — Epley or Semont manoeuvre; horizontal canal — Lempert barbecue roll; Brandt-Daroff as the home programme. - **Drugs have no role** in established BPPV: vestibular suppressants only dampen compensation and add sedation; they may be used briefly if nausea prevents manoeuvres. - **Red flags that overturn the diagnosis:** vertical or downbeating nystagmus, absence of latency and fatigability, continuous vertigo, hearing loss, headache or ataxia — think central positional vertigo or posterior fossa lesion and image. - **Natural history:** many resolve spontaneously over weeks, but recurrence over subsequent years is common enough that patients deserve advance counselling. ## A typical exam case worked through A 58-year-old woman reports that rolling onto her right side in bed triggers a 20-second spin with nausea for three weeks; she is normal between episodes and hears normally. With her head turned 45 degrees to the right, laying her supine with the head extended provokes, after a few seconds, torsional nystagmus beating toward the undermost right ear with an upbeating component, fatiguing within half a minute — posterior canal canalithiasis, right ear, the commonest vertigo diagnosis in any clinic. Treat in the same visit with the Epley manoeuvre: sequential head positions walking the debris from the posterior canal to the common crus and utricle, each held about 30 seconds. Most patients clear in one or two sessions; teach Brandt-Daroff exercises for residual symptoms or recurrence, and review in a week. If manoeuvres instead provoke downbeating or unfatigable nystagmus, or she cannot stand or has dysarthria, stop and order magnetic resonance imaging — a posterior fossa lesion can imitate positional vertigo, and age with vascular risk demands respect. ## Where students slip Duration anchoring fails most: BPPV lasts seconds, Meniere disease tens of minutes, vestibular neuritis days — an all-day spin is not BPPV regardless of positional flavour. The second slip is ordering drugs or imaging first: the answer to classic positional vertigo is Dix-Hallpike then repositioning. Candidates also localise horizontal canal BPPV by the weaker side on the roll test — it is the stronger geotropic response that identifies the affected ear. Finally, avoid blaming cervical spondylosis for every positional symptom in an older patient before reproducing it with testing. ## Frequently asked questions ### Which semicircular canal is most often affected in BPPV? The posterior canal, in roughly 80-90 per cent of cases, because gravity and its orientation make it the easiest resting place for dislodged otoconia. ### How is the Dix-Hallpike test performed and what is a positive result? With the head turned 45 degrees toward the tested ear, the patient is laid supine with head extended; latency of a few seconds followed by geotropic torsional, fatigable nystagmus with vertigo confirms posterior canal BPPV on that side. ### What is the first-line treatment of posterior canal BPPV? The Epley canalith repositioning manoeuvre, performed at the bedside, moving the head through sequential positions so the debris exits the canal into the utricle; the Semont manoeuvre is an alternative. ### What are Brandt-Daroff exercises and when are they used? A home exercise programme of repeated sitting-to-side-lying positions performed in sets several times daily, used for residual symptoms, recurrences, or when clinic manoeuvres are not tolerated. ### When should BPPV-like vertigo raise suspicion of a central cause? Downbeating or purely vertical nystagmus, absent latency and fatigability, continuous vertigo, or accompanying neurological signs indicate central positional vertigo and warrant MRI rather than manoeuvres.