Benign Paroxysmal Positional Vertigo (BPPV)

What is BPPV?

BPPV is the most common inner ear disorder causing vertigo, a sensation of spinning or dizziness. It occurs due to displaced otoconia (tiny calcium carbonate crystals) within the inner ear canals, triggering abnormal signals sent to the brain regarding head position.

Clinical presentation

Brief episodes of vertigo (seconds to minutes) triggered by specific head movements (e.g., lying down, rolling over)
Possible nausea and vomiting, imbalance or light-headedness, and nystagmus during vertigo episodes
Hearing is NOT affected and tinnitus is not a feature

BBPV differentials

Please also refer to the balance differentials document for more information.

These are some of the main differentials to consider when evaluating a patient with symptoms suggestive of BPPV. It's essential to conduct a thorough history, physical examination, and possibly diagnostic tests to accurately diagnose the underlying cause of vertigo. Differentials of BBPV include: meniere’s disease, vestibular neuritis, labyrinthitis, central vertigo, vestibular migraine to name a few.

Assessment

Detailed history focusing on vertigo characteristics and triggers.

Examination is likely to be normal at rest in a sitting position.

Physical examination (full ENT, cardiovascular, neurological examinations) to exclude other causes.

Imaging is not required to diagnose BPPV, it is to rule out other causes.

Dix-Hallpike manoeuvre

(Be cautious if considering the Dix-Hallpike manoeuvre if the person has a neck or back problem, or cardiovascular problems such as carotid sinus syncope, as it involves turning the head and extending the neck)

To carry out the manoeuvre:

Advise the person that they may experience transient vertigo during the procedure.
Ask the person to keep their eyes open throughout the manoeuvre and to look straight ahead.
Ask the person to sit upright on the couch with their head turned 45 degrees to one side.
From this position, lie the person down rapidly (over 2 seconds), supporting their head and neck, until their head is extended 20-30 degrees over the end of the couch with the chin pointing slightly upwards and the test ear downwards. Support the head to maintain this position for at least 30 seconds.
Observe their eyes closely for up to 30 seconds for the development of nystagmus. If nystagmus is present, maintain the position for its duration (maximum 2 minutes if persistent) and note its duration, type, direction, and latency.
Record duration, severity, and latency of any vertigo.
Support the head in position and slowly sit the person up.
Repeat with the head rotated 45 degrees to the other side.

Referral for GPs (red flags) to ENT

Admit the person to hospital if they have severe nausea and vomiting and are unable to tolerate oral fluids.
Physical limitations affect the safety or practicality of carrying out canalith repositioning procedures in primary care.
A canalith repositioning procedure (for example the Epley manoeuvre) has been performed and repeated, and symptoms are still present.
Symptoms or signs are atypical.
Symptoms and signs have not resolved in 4 weeks
Uncontrolled vertigo despite appropriate CRM attempts.
Suspected central nervous system involvement (e.g. stroke, tumour).

Management

Discuss the option of watchful waiting to see whether symptoms settle without treatment over a few weeks.
Consider suggesting Brandt-Daroff exercises which the person can do at home, particularly if the Epley manoeuvre cannot be performed immediately or is inappropriate. These exercises can improve balance and reduce dizziness after successful canalith repositioning manoeuvres (CRMs):

Sit on the edge of a bed or couch with the eyes closed.
Quickly lie down sideways on one side with their eyes closed so that they are lying on their side with the lateral aspect of their occiput resting on the bed, with the head positioned as if they are looking towards the ceiling (rotated 45 degrees upwards)
Rest in this position for at least 30 seconds, until any vertigo subsides.
Keeping the eyes closed, sit upright again, and remain in this position for 30 seconds.
Repeat on the other side.
Repeat the sequence 3–4 times until they are symptom free.
Repeat 3–4 times a day until there have been 2 consecutive days without symptoms.

CRMs are highly effective exercises performed by a healthcare professional to reposition the displaced otoconia. Common CRMs include Epley maneuver and Semont maneuver.

(Be cautious performing the Epley manoeuvre if the person has neck or back problems, unstable cardiac disease, suspected vertebrobasilar disease, carotid stenosis, or morbid obesity)

Video of Epley maoeuvre

Advise the person that they will experience transient vertigo during the manoeuvre.
Stand at the side or behind the person to guide head movements. Maintain each head position for at least 30 seconds. If vertigo continues, wait until it has subsided.
Ideally, movements should be rapid, within 1 second, but this is often not possible, particularly in older people. Expert opinion suggests that the procedure can be effective if movements are carried out slowly.
Start with the person sitting upright with their head turned 45 degrees to the affected side, then lie them back (with their head still turned 45 degrees) until the head is dependent 30 degrees over the edge of the couch (as if performing the Dix-Hallpike manoeuvre). Wait for at least 30 seconds. Then:
With the face upwards, but still tilted backwards by 30 degrees, rotate the head through 90 degrees to the opposite side.
Hold the head in this position for about 20 seconds and ask the person to roll onto the same side as they are facing.
Rotate the person's head so that they are facing obliquely downward with their nose 45 degrees below the horizontal
Sit the person up sideways while the head remains rotated and tilted to the side.
Rotate the head to the central position and move the chin downwards by 45 degrees.
There is usually no need to advise the person of any positional restrictions after the procedure has been performed.

Medications: Not typically curative, but short-term use of antiemetics or vestibulosuppressants (suppress inner ear activity) may be considered for symptom relief e.g. prochlorperazine, cinnarizine.

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