Benign Paroxysmal Positional Vertigo

BPPV Basics - Dizzy When I Do This!

• Benign Paroxysmal Positional Vertigo (BPPV): Characterized by sudden, brief episodes of vertigo.
• Etiology: Dislodged otoconia (calcium carbonate crystals, "canaliths") from utricle migrate into Semicircular Canals (SCCs).
  • Most common: Posterior SCC (PSC) involvement, termed canalithiasis.
  • Rarer: Cupulolithiasis (otoconia adhere to cupula).
• Triggers: Specific head movements (e.g., rolling in bed, looking up).
• Clinical: Vertigo lasts < 1 minute, often with nausea. Nystagmus present. No hearing loss or tinnitus.

⭐ BPPV is the most common cause of recurrent vertigo, especially in the elderly.

Pathophysiology - Loose Rocks Rolling

• Otoconia (calcium carbonate crystals) from the utricular macula become dislodged.
• These dense particles ("ear rocks") inappropriately enter the semicircular canals (SCCs).

  ⭐ The posterior semicircular canal is involved in 80-90% of BPPV cases due to its dependent position.

• Mechanism of vertigo:
  • Canalithiasis (common, ~90%): Otoconia are free-floating in the SCC endolymph. Head movements cause them to move, creating endolymphatic flow that deflects the cupula, inducing vertigo and nystagmus.
  • Cupulolithiasis (rarer, ~10%): Otoconia adhere to the cupula, making it gravity-sensitive. This results in more persistent vertigo and nystagmus when the head is in provoking positions.

Clinical Picture & Diagnosis - Spin Doctor's Clues

• Symptoms:
  • Sudden, brief vertigo (< 1 min), triggered by head movements (e.g., rolling in bed, looking up).
  • Nausea/vomiting common.
  • NO hearing loss, tinnitus, or focal neurological signs.
• Diagnosis:
  • Dix-Hallpike Maneuver (Posterior Canal - most common):
    • Head turned 45°, then rapid supine movement with head extended 20-30°.
    • Positive: Latency, then torsional upbeating nystagmus (to affected ear) + vertigo; fatigable.
  • Supine Roll Test (Horizontal Canal):
    • Head rotation in supine position.
    • Nystagmus: Geotropic or apogeotropic.

⭐ The Dix-Hallpike maneuver elicits a characteristic nystagmus (e.g., torsional, upbeating, latency, fatigability) in posterior canal BPPV.

Management - Getting Stones Settled

• Primary Goal: Reposition displaced otoconia from canals to utricle via Canalith Repositioning Procedures (CRPs). High success rates.

• Key Maneuvers:
  • Epley Maneuver (Posterior Canal): (📌 "EPLEY = POSTERIOR PLEASES")

    ⭐ The Epley maneuver is highly effective (80-95% success rate) for treating posterior canal BPPV.

  • Semont Maneuver (Posterior Canal): Alternative for cupulolithiasis.
  • Barbecue Roll (Lempert) (Horizontal Canal): For geotropic type.
  • Gufoni Maneuver (Horizontal Canal): For apogeotropic type.
• Post-CRP Care:
  • Avoid quick head movements (24-48 hrs).
  • Sleep head-elevated (45°, 1-2 nights).
• Adjuncts:
  • Vestibular suppressants (e.g., dimenhydrinate) for severe nausea pre/post-CRP. Short-term. Awaiting image generation for: Diagram illustrating Epley Maneuver steps

DDx & Prognosis - Not Always BPPV

• DDx (Atypical? Consider):
  • Vestibular neuritis/labyrinthitis
  • Meniere's disease
  • Vertebrobasilar insufficiency (VBI)
  • Migrainous vertigo
  • Central causes (e.g., cerebellar)
• Prognosis:
  • Excellent with Canalith Repositioning Maneuvers (CRMs).
  • High CRM success (e.g., Epley 80-95%).

  ⭐ While BPPV has a good prognosis with treatment, recurrence is common, affecting up to 50% of patients within 5 years.

  • Residual dizziness post-CRM possible.

High‑Yield Points - ⚡ Biggest Takeaways

• BPPV is the most common cause of peripheral vertigo.
• Caused by free-floating otoconia (canaliths) in semicircular canals, typically the posterior canal.
• Characterized by sudden, brief episodes of vertigo (<1 minute) triggered by head position changes.
• Dix-Hallpike maneuver is diagnostic, eliciting rotatory nystagmus with latency and fatigability.
• Treatment involves Canalith Repositioning Maneuvers (CRMs) like the Epley maneuver.
• Importantly, there is no associated hearing loss, tinnitus, or focal neurological deficits (distinguishing from other causes).