Benign paroxysmal positional vertigo

Abstract

Objectives: Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular end-organ disease. This article aims to summarize research findings and key discoveries of BPPV. The pathophysiology, diagnosis, nonsurgical, and surgical management are discussed.

Methods: A comprehensive review of the literature regarding BPPV up through June 2018 was performed.

Results: BPPV is typified by sudden, brief episodes of vertigo precipitated by specific head movements. While often self-limited, BPPV can have a considerable impact on quality of life. The diagnosis can be established with a Dix-Hallpike maneuver for the posterior and anterior canals, or supine roll test for the horizontal canal, and typically does not require additional ancillary testing. Understanding the pathophysiology of both canalithiasis and cupulolithiasis has allowed for the development of various repositioning techniques. Of these, the particle repositioning maneuver is an effective way to treat posterior canal BPPV, the most common variant. Options for operative intervention are available for intractable cases or patients with severe and frequent recurrences.

Conclusions: A diagnosis of BPPV can be made through clinical history along with diagnostic maneuvers. BPPV is generally amenable to in-office repositioning techniques. For a small subset of patients with intractable BPPV, canal occlusion can be considered.

Level of evidence: N/A.

Keywords: Benign paroxysmal positional vertigo; Dix‐Hallpike; canalith; particle repositioning maneuver; semicircular canal occlusion.

Figure 1

Left inner ear. Demonstration of canalithiasis of the posterior canal and cupulolithiasis of the horizontal canal. Reprinted from Parnes, Agrawal and Atlas. Diagnosis and management of benign paroxysmal positional vertigo (BPPV) Canadian Medical Association Journal September 30, 2003 169 (7) 681–693. © Canadian Medical Association 2003. This work is protected by copyright and the making of this copy was with the permission of the Canadian Medical Association Journal (www.cmaj.ca) and Access Copyright. Any alteration of its content or further copying in any form whatsoever is strictly prohibited unless otherwise permitted by law.

Figure 2

Scanning electron micrograph image of otoconia within the posterior canal endolymphatic duct removed from a patient with intractable BPPV. Image shown at 20k magnification. Scale bar 20 micrometres. Reproduced with permission from Kao, Parnes, and Chole. Otoconia and otolithic membrane fragments within the posterior semicircular canal in benign paroxysmal positional vertigo. Laryngoscope 90:709–714 (2016)

Figure 3

Dix‐Hallpike maneuver (right ear). A, the patient is seated with the head rotated at 45 degrees. B, the patient is quickly lowered into supine position with neck extended below the level of the table. With head extended, examiner observes the patient for nystagmus. Reprinted from Parnes, Agrawal and Atlas. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). Canadian Medical Association Journal September 30, 2003 169 (7) 681‐693. © Canadian Medical Association 2003. This work is protected by copyright and the making of this copy was with the permission of the Canadian Medical Association Journal (www.cmaj.ca) and Access Copyright. Any alteration of its content or further copying in any form whatsoever is strictly prohibited unless otherwise permitted by law.

Figure 4

Particle repositioning maneuver (right ear). Sequential movements and the corresponding position of the utricle and semicircular canals. A, the patient is seated as viewed from the right side. B, first step of particle repositioning maneuver and the same position assumed during normal Dix‐Hallpike. This position is maintained for 1‐2 minutes. C, the patient's head is rotated toward the opposite side while neck remains extended. D, in a steady motion, the patient is rolled onto the opposite side. Position D is maintained for another 1‐2 minutes before the patient sits up to position A. D = DIRECTION OF VIEW OF LABYRINTH, DARK CIRCLE = POSITION OF PARTICLE CONGLOMERATE, OPEN CIRCLE = PREVIOUS POSITION. Reprinted from Parnes, Agrawal and Atlas. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). Canadian Medical Association Journal September 30, 2003 169 (7) 681‐693. © Canadian Medical Association 2003. This work is protected by copyright and the making of this copy was with the permission of the Canadian Medical Association Journal (www.cmaj.ca) and Access Copyright. Any alteration of its content or further copying in any form whatsoever is strictly prohibited unless otherwise permitted by law.