Show Notes
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 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
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
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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