AKT · ENT/Vertigo & balance

Benign paroxysmal positional vertigo (BPPV)

Displaced otoconia in the semicircular canals (canalithiasis)

Overview

The commonest cause of vertigo: dislodged otoconia (calcium debris) in the posterior semicircular canal trigger brief, intense, ROTATIONAL vertigo on head movement. No hearing loss or tinnitus. Diagnosed with Dix-Hallpike and cured with the Epley repositioning manoeuvre.

Recognise

Brief (seconds, <1 minute) episodes of rotational vertigo triggered by HEAD MOVEMENT (rolling in bed, looking up, lying down)
NO hearing loss or tinnitus (purely vestibular)
Positive Dix-Hallpike: rotational/torsional nystagmus with a latency and that fatigues

Red flags

Persistent/vertical/non-fatiguing nystagmus or other neurology → central cause (posterior fossa) → image

Differentials & how to tell them apart

Vestibular neuritis/labyrinthitisa single PROLONGED (days) episode of constant vertigo, not brief positional attacks

Ménière diseaseepisodic vertigo lasting hours WITH hearing loss, tinnitus and aural fullness

Central (posterior fossa) vertigoother neurology, vertical/non-fatiguing nystagmus — image

Orthostatic hypotensionlight-headedness on standing, not rotational vertigo

Investigations

Dix-Hallpike manoeuvre (provokes the characteristic torsional nystagmus). No imaging unless central features.

Management

Epley repositioning manoeuvre (often curative); no vestibular sedatives

1Confirm with Dix-Hallpike, then perform the Epley repositioning manoeuvre (frequently curative); teach Brandt-Daroff exercises for residual symptoms.Gate: Do NOT prescribe vestibular sedatives (prochlorperazine/betahistine) for BPPV — they do not help and hinder central compensation; the treatment is mechanical (Epley)
2Persistent/recurrent → repeat manoeuvres, ENT/vestibular physiotherapy; reconsider a central cause if atypical.

Epley repositioning manoeuvre — first-line — repositions the otoconia, often curative

Brandt-Daroff exercises — home exercises if manoeuvres incomplete

(Vestibular sedatives are NOT recommended) — avoid — they do not treat BPPV and impair compensation

Key points

Brief, positional, rotational, NO hearing loss = BPPV → Epley, not drugs. Hearing loss + vertigo points instead to Ménière (with tinnitus) or labyrinthitis (prolonged).

Monitor & prognosis

Symptom resolution; recurrence.

Often resolves with repositioning; can recur.

Source: NICE CKS BPPV