Benign Paroxysmal Positional Vertigo (BPPV)
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Direct answer
Benign paroxysmal positional vertigo is the commonest cause of peripheral vertigo, produced when otoconia displaced from the utricle settle in a semicircular canal — most often the posterior canal — so that head movement in the plane of that canal provokes brief, fatigable attacks of rotatory vertigo. Each episode lasts seconds to under a minute, hearing is unaffected, and the diagnosis is confirmed by the Dix-Hallpike test. The Epley repositioning manoeuvre cures most patients without any medication.
What you must remember
- Mechanism: canalithiasis — free-floating otoconia in the endolymph move with head position and cupular stimulation; cupulolithiasis, where debris adheres to the cupula, is the alternative explanation.
- Canal involved: the posterior semicircular canal in most patients, the horizontal canal in a minority; the anterior canal is rarely affected.
- Symptoms: brief rotational vertigo on turning in bed, looking up or bending, with nausea but no hearing loss, tinnitus or neurological deficit — the diagnostic negative points.
- Dix-Hallpike test: with the head turned 45 degrees, the patient is moved quickly from sitting to supine with the head hanging; a brief latent period is followed by upbeating torsional nystagmus toward the undermost ear, fatiguing within a minute, and fatiguing further on repetition.
- Treatment: the Epley manoeuvre repositions the debris from the posterior canal into the utricle; the Semont liberatory manoeuvre and Brandt-Daroff habituation exercises are alternatives.
- Role of drugs: vestibular suppressants help nausea but do not cure and are not needed once repositioning succeeds; no medication dissolves otoconia.
- Follow-up and recurrence: symptoms can recur, and repeated manoeuvre treatment is safe; persistent or atypical nystagmus (downbeating, non-fatigable) or neurological signs call for imaging.
Common confusion
BPPV is confused with Meniere disease and orthostatic giddiness. BPPV attacks are seconds long, position-triggered and free of auditory symptoms; Meniere attacks last hours with fluctuating deafness and tinnitus; and orthostatic or cardiovascular giddiness is lightheadedness rather than true rotatory vertigo. Students also forget the latent period and fatigability of the nystagmus — those two features, plus its direction toward the undermost ear, define a positive Dix-Hallpike.
Exam-focused takeaway
For theory, write the definition, the canalithiasis mechanism, the Dix-Hallpike findings and the Epley manoeuvre steps in sequence, closing with one line on differentials. In viva and practicals, examiners ask which canal is involved, what the nystagmus direction means and how the Epley manoeuvre works — many ask you to demonstrate the sequence on a volunteer. In the posting, perform the Dix-Hallpike test yourself on every complaint of positional giddiness; the treatment you can offer in minutes is one of ENT's most satisfying cures.
Frequently asked questions
Which canal is most often affected in BPPV?
The posterior semicircular canal; horizontal canal involvement produces horizontal nystagmus on turning the head supine.
What are the features of a positive Dix-Hallpike test?
After a brief latency, geotropic torsional nystagmus beating toward the undermost ear, lasting under a minute and fatiguing on repetition, with reproduced vertigo.
What is the Epley manoeuvre?
A graded sequence of head and body positions that moves displaced otoconia out of the posterior canal back into the utricle, curing most patients.
Is hearing affected in BPPV?
No. Normal hearing is the rule; vertigo with deafness or tinnitus points to Meniere disease or labyrinthine pathology instead.
Are drugs needed to treat BPPV?
Medicines only ease nausea; the definitive treatment is repositioning manoeuvres, and habituation exercises suffice when manoeuvres fail.
When should BPPV be suspected of being something else?
When nystagmus is persistent, non-fatigable or direction-changing without latency, or when headache, diplopia, dysarthria or limb weakness accompany the dizziness.