J Clin Neurol.  2010 Jun;6(2):51-63. 10.3988/jcn.2010.6.2.51.

Benign Paroxysmal Positional Vertigo

• Lee SH
• Kim JS

• KMID: 2287635
• DOI: http://doi.org/10.3988/jcn.2010.6.2.51

Abstract

Benign paroxysmal positional vertigo (BPPV) is characterized by brief recurrent episodes of vertigo triggered by changes in head position. BPPV is the most common etiology of recurrent vertigo and is caused by abnormal stimulation of the cupula by free-floating otoliths (canalolithiasis) or otoliths that have adhered to the cupula (cupulolithiasis) within any of the three semicircular canals. Typical symptoms and signs of BPPV are evoked when the head is positioned so that the plane of the affected semicircular canal is spatially vertical and thus aligned with gravity. Paroxysm of vertigo and nystagmus develops after a brief latency during the Dix-Hallpike maneuver in posterior-canal BPPV, and during the supine roll test in horizontal-canal BPPV. Positioning the head in the opposite direction usually reverses the direction of the nystagmus. The duration, frequency, and symptom intensity of BPPV vary depending on the involved canals and the location of otolithic debris. Spontaneous recovery may be expected even with conservative treatments. However, canalithrepositioning maneuvers usually provide an immediate resolution of symptoms by clearing the canaliths from the semicircular canal into the vestibule.

Keyword

vertigo; nystagmus; benign paroxysmal positional vertigo; canalith-repositioning maneuver

MeSH Terms

Gravitation
Head
Otolithic Membrane
Semicircular Canals
Vertigo
Vertigo

Figure

• 

  Fig. 1 Mechanism of benign paroxysmal positional vertigo (BPPV). The detached otolith debris may be attached to the cupula (A: Cupulolithiasis) or free-floating in the semicircular canals (B: Canalolithiasis).

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  Fig. 2 Deflection of the cupula due to either endolymphatic flow induced by a hydrodynamic drag of the particles (A: Canalolithiasis) or a direct gravitational effect of the otolithic debris (B: Cupulolithiasis).

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  Fig. 3 Dix-Hallpike maneuver for the diagnosis of BPPV involving the right posterior semicircular canal (right PC-BPPV). After seating the patient upright (A), the head is turned 45° in the direction of the involved ear (B: right ear in this figure). The patient is then moved from the sitting to the supine position, ending with the head hanging at 20° off the end of the examination table (C). The corresponding illustrations demonstrate the orientation of the semicircular canals and location of the otolithic debris in the posterior canal (viewed from the patient's right side). BPPV: benign paroxysmal positional vertigo.

• 

  Fig. 4 Side-lying test for the diagnosis of right PC-BPPV. After seating the patient on the examination table (A), the head is turned 45° away from the involved ear (B). The patient then lies on the side of the involved ear (C). The corresponding illustrations demonstrate the orientation of the semicircular canals and location of the otolithic debris in the posterior canal (viewed from the front). PC-BPPV: posterior canal benign paroxysmal positional vertigo.

• 

  Fig. 5 Supine roll test (Pagnini-McClure maneuver) for the diagnosis of BPPV involving the horizontal semicircular canal (right HC-BPPV). The head is turned about 90° to each side while supine. A: Canalolithiasis. B: Cupulolithiasis. The corresponding illustrations demonstrate the location of the otolithic debris in the horizontal canal during each maneuver, and the direction of the induced nystagmus (arrows). BPPV: benign paroxysmal positional vertigo.

• 

  Fig. 6 Modified Epley's maneuver for the treatment of right PC-BPPV. After the Dix-Hallpike maneuver (A-C) for right PC-BPPV, the head is turned 90° toward the unaffected ear (D) and the head and trunk continue turning another 90° in the same direction (E). The patient is then moved to the sitting position (F). Each position should be maintained for at least 1 or 2 minutes, or until the induced nystagmus and vertigo are resolved. The corresponding illustrations demonstrate the orientation of the semicircular canals and location of the otolithic debris in the posterior canal (viewed from the camera angle). PC-BPPV: posterior canal benign paroxysmal positional vertigo.

• 

  Fig. 7 Semont maneuver for the treatment of right PC-BPPV. After being seated on the examination table (A), the patient is rapidly moved into the side-lying position to the affected side after the head is turned 45° to the unaffected side (B). The patient is then rapidly taken to the opposite side-lying position through the seated position without pausing (C). The head should be rotated toward the unaffected side throughout these movements. Finally, the patient is returned to a seated position. Each position should be maintained for at least 1 or 2 minutes, or until the induced nystagmus and vertigo are resolved. The corresponding illustrations demonstrate the orientation of the semicircular canals and location of the otolithic debris in the posterior canal (viewed from the camera angle). PC-BPPV: posterior canal benign paroxysmal positional vertigo.

• 

  Fig. 8 Barbecue maneuver for the treatment of geotropic right HC-BPPV. After head turning toward the involved ear (A), the head is then turned 270° toward the unaffected side through a series of stepwise 90° turns (B-D) before resuming the sitting position (E). Each position should be maintained for at least 1 or 2 minutes, or until the induced nystagmus and vertigo are resolved. The corresponding illustrations demonstrate the orientation of the semicircular canals and the location of the otolithic debris in the horizontal canal. HC-BPPV: horizontal canal benign paroxysmal positional positional vertigo.

• 

  Fig. 9 Brandt-Daroff exercise. Patients are instructed to rapidly lie on their side, sit up, lie on the opposite side, and then again sit up. Each position should be maintained for at least 30 seconds. These exercises are repeated serially 5-10 times a day until resolution of the symptoms.

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