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)
...able 2. Summary of Key Action Statements (KAS...
...posterior canal BPPVClinicians sh...
...nosis of lateral (horizontal) canal BPPV...
...iagnosisClinicians should differen...
...factorsClinicians should assess patie...
...hic testingClinicians should NOT ob...
...testingClinicians should NOT order ves...
...itioning procedures as initial therapyClini...
...restrictionsClinicians should NOT recommend postp...
...ervation as initial therapyClinicians may offer o...
...lar rehabilitation therapyThe clinician may of...
...cal therapyClinicians should NOT routinely tre...
...mentClinicians should reassess pat...
...eatment failureClinicians should evaluate, o...
...ucationClinicians should educate pati...
Management
...agement...
...3. Basic Differential Diagnosis of BPP...
...Causes of Acute Dizziness: Differential Diagn...
...stic Criteria for Posterior Canal BPPVHaving troub...
...ted Methods to Determine the Affected Ear...
Treatment
...reatment...
...grammatic representation of performance of...
...igure 2. Diagrammatic views of the supine roll tes...
...igure 3. Depiction of the canalith repositioning...
Table 7. Stepwise Sequence for the Performance o...
...e 4. Semont Liberatory maneuver for treatment of...
...8. Stepwise Description of the Performance of the...
...5. The Lempert 360° roll maneuver (...
Table 9. Stepwise Description of the Performa...
...igure 6. Gufoni maneuver for treatment...
...7. Gufoni maneuver for treatment of right-si...
...i Maneuver for Treatment of Right-s...
...Gufoni Maneuver for Treatment of Right-side...
Figure 8. Algorithm
Patient Information
...atient Information...
...d Questions What is BPPV? Benig...