Benign Paroxysmal Positional Vertigo
Key Points
Key Points
- A primary complaint of dizziness accounts for 5.6 million clinic visits in the United States per year.
- Between 17% and 42% of patients with vertigo ultimately receive a diagnosis of benign paroxysmal positional vertigo (BPPV).
- BPPV can recover spontaneously in approximately 20% of patients by one month of follow-up and up to 50% at three months.
- Patients with BPPV are at increased risk for falls and impairment in the performance of daily activities and adverse effects on individual health-related quality of life and utility measures.
- BPPV is most commonly clinically encountered as one of two variants:
- Posterior canal BPPV is more common than horizontal canal BPPV, constituting approximately 85–95% of BPPV cases.
- Lateral (horizontal) canal BPPV accounts for between 5% and 15% of BPPV cases.
Table 1. Definitions of Words Used in the Guideline
| Vertigo | An illusory sensation of motion of either the self or the surroundings in the absence of true motion. |
| Nystagmus | A rapid, involuntary, oscillatory movement of the eyeball. |
| Vestibular system/apparatus | The sensory system within the inner ear that together with the vestibular nerve and its connections in the brain provides the fundamental input to the brain regarding balance and spatial orientation. |
| Positional vertigo | Vertigo produced by changes in the head position relative to gravity |
| Benign paroxysmal positional vertigo (BPPV) | A disorder of the inner ear characterized by repeated episodes of positional vertigo. |
| Posterior canal BPPV | A form of BPPV in which dislodged inner ear particles in the posterior semicircular canal abnormally influence the balance system producing the vertigo, most commonly diagnosed with the Dix-Hallpike test. |
| Lateral canal BPPV | A form of BPPV in which dislodged inner ear particles in the lateral semicircular canal abnormally influence the balance system producing the vertigo, most commonly diagnosed by the supine roll test. |
| Canalithiasis | A theory for the pathogenesis of BPPV that proposes that there are free-floating particles (otoconia) that have moved from the utricle and collect near the cupula of the affected canal, causing forces in the canal leading to abnormal stimulation of the vestibular apparatus. |
| Cupulolithiasis | A theory for the pathogenesis of BPPV that proposes that otoconial debris attached to the cupula of the affected semicircular canal cause abnormal stimulation of the vestibular apparatus. |
| Canalith repositioning procedures (CRP) | A group of procedures in which the patient moves through specific body positions designed to relocate dislodged particles within the inner ear for the purpose of relieving symptoms of BPPV. The specific CRP chosen relates to the type of BPPV diagnosed. These have also been termed canalith repositioning maneuvers or canalith repositioning techniques. |
Table 2. Summary of Key Action Statements (KAS)
.... Summary of Key Action Statements (KAS)...
...posterior canal BPPVClinicians should dia...
Diagnosis of lateral (horizontal) canal BPP...
...ifferential diagnosisClinicians should diff...
...ifying factorsClinicians should assess...
...testingClinicians should NOT obtain radiograph...
...r testingClinicians should NOT order...
Repositioning procedures as initial t...
...restrictionsClinicians should NOT recommend po...
...ion as initial therapyClinicians may o...
...abilitation therapyThe clinician may off...
...edical therapyClinicians should NOT r...
...smentClinicians should reassess patients w...
...uation of treatment failureClinici...
...cians should educate patients regar...
Management
Manageme...
...able 3. Basic Differential Diagnosis of BPPVHaving...
...able 4. Common Causes of Acute Dizz...
...gnostic Criteria for Posterior Canal BPPVHavin...
...ed Methods to Determine the Affected Ear in Latera...
Treatment
...reatme...
Figure 1. Diagrammatic representation...
...igure 2. Diagrammatic views of the supine...
...3. Depiction of the canalith repositioni...
...7. Stepwise Sequence for the Performance o...
...ont Liberatory maneuver for treatment of ri...
...epwise Description of the Performance of the Semon...
Figure 5. The Lempert 360° roll maneuver...
...able 9. Stepwise Description of the Performan...
...foni maneuver for treatment of right...
...e 7. Gufoni maneuver for treatment of right...
Table 10. Gufoni Maneuver for Treatment of Right...
...Maneuver for Treatment of Right-sided Lateral...
...8. Algorithm...
Patient Information
...t Information...
...d Questions What is BPPV? Be...