Contributor: Alec Coston, MD

Educational Pearls:

Benign Paroxysmal Positional Vertigo (BPPV)

• Common inner ear condition that can cause dizziness

• Diagnosis of BPPV can help to avoid admissions and extra imaging

• Three categories: positional, horizontal, and anterior

• • Positional is the most common

  • • Dizziness is not a positive indicator, a torsional nystagmus must be induced

    • Dix's hallpike maneuver is done to diagnose and an epley maneuver is then used for treatment

  • Horizontal

  • • Usually determined to be the case if the vertigo seems positional and the dix hallpike does not work. A supine roll test would then be done to help diagnose.

    • Instead of a rotational nystagmus, a unilateral horizontal nystagmus is expected. The two patterns are termed geotropic and apogeotropic.

    • Geotropic means the fast phase beats toward the ground, and is treated by a barbeque roll maneuver. Apogeotropic means the fast phase beats toward the ceiling, and is treated by Gufoni maneuver.

  • Anterior is more rare

  • • Most cases require neuro consults

    • Determined by attempting to induce a down-beating nystagmus, which is a higher risk nystagmus.

    • Treatment is tilting their head back up in a similar way

    • Inducing the nystagmus is not sided and is more central

References

1. You, P., Instrum, R. and Parnes, L. (2019), Benign paroxysmal positional vertigo. Laryngoscope Investigative Otolaryngology, 4: 116-123. https://doi.org/10.1002/lio2.230

2. Ling X, Zhao D-H, Shen B, Si L-H, Li K-Z, Hong Y, Li Z-Y and Yang X (2020) Clinical Characteristics of Patients With Benign Paroxysmal Positional Vertigo Diagnosed Based on the Diagnostic Criteria of the Bárány Society. Front. Neurol. 11:602. doi: 10.3389/fneur.2020.00602

3. Rah YC. Advances in Benign Paroxysmal Positional Vertigo: Updated Insights on Diagnostic Pitfalls and Management. J Audiol Otol. 2026 Jan;30(1):1-12. doi: 10.7874/jao.2025.00717.

Summarized by Aaryn David | Edited by Aaryn David & Ahmed Abdel-Hafiz, NREMT-P

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