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Benign paroxysmal positional vertigo
Background
Overview
Definition
BPPV is a common disorder of the inner ear characterized by repeated episodes of positional vertigo and nystagmus.
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Pathophysiology
BPPV has an unknown origin but is thought to result from degeneration of the macula. Secondary causes include otoconial dislodgement due to otologic and nonotologic surgery, head trauma, or any means by which mechanical force reaches the inner ear, inner ear disorders (vestibular neuritis, Meniere's disease, and sudden sensorineural hearing loss.
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Disease course
The aberrant semicircular canal signaling (canalithiasis and cupulolithiasis) results in BPPV, which causes clinical manifestations of dizziness that lasts < 20 seconds accompanied by a lingering, nonspecific imbalance and characteristic nystagmus with Dix-Hallpike maneuver. Spontaneous resolution occurs in 25% of patients by 1 month and up to 50% at 3 months.
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Prognosis and risk of recurrence
BPPV is not associated with an increase in mortality.
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Guidelines
Key sources
The following summarized guidelines for the evaluation and management of benign paroxysmal positional vertigo are prepared by our editorial team based on guidelines from the Society for Academic Emergency Medicine (SAEM 2023), the American Physical Therapy Association (APTA 2022), the American Academy of Neurology (AAN 2017), and the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF 2017).
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Screening and diagnosis
Differential diagnosis
As per AAO-HNSF 2017 guidelines:
Differentiate BPPV from other causes of imbalance, dizziness, and vertigo.
B
Assess patients with BPPV for factors modifying management, including impaired mobility or balance, CNS disorders, a lack of home support, and/or increased risk for falling.
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Diagnostic investigations
Dix-Hallpike test: as per AAO-HNSF 2017 guidelines, perform the Dix-Hallpike maneuver (by bringing the patient from an upright to supine position with the head turned 45 degrees to one side and the neck extended 20 degrees with the affected ear down) to elicit provoked vertigo associated with torsional, upbeating nystagmus for the diagnosis of posterior semicircular canal BPPV. Repeat the maneuver with the opposite ear down if the initial maneuver is negative.
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Supine roll test
Diagnostic imaging
Vestibular function testing
Medical management
Watchful waiting: as per AAO-HNSF 2017 guidelines, consider offering observation with follow-up as an initial management strategy in patients with BPPV.
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Vestibular suppressants