Otology
Vertigo and BPPV
BPPV, Ménière disease, vestibular neuritis, and other causes of dizziness — modern diagnosis and management.
What is vertigo and when should I see a doctor?
Vertigo is a specific type of dizziness — the sensation that you or your surroundings are spinning. Most common cause: BPPV (benign paroxysmal positional vertigo), followed by Ménière disease and vestibular neuritis. BPPV: 30–60 second episodes triggered by position change; Ménière: vertigo with hearing loss, tinnitus, and aural fullness; vestibular neuritis: sudden continuous onset. Vertigo with sudden onset, vomiting, and neurologic findings (double vision, speech change, facial weakness) requires urgent assessment. Treatment: Epley/Semont manoeuvres for BPPV (85–90% success), diet + medical therapy for Ménière, acute steroid + vestibular rehabilitation for neuritis.
Diagnostic algorithm
History is the most important diagnostic tool: episode duration, triggers (position, stress, sound), accompanying symptoms (hearing loss, tinnitus, aural fullness, headache). On exam, the Dix-Hallpike manoeuvre is gold standard for BPPV. Head-impulse, head-shaking, and nystagmus testing inform vestibular function.
Advanced testing if needed: videonystagmography (VNG), caloric testing, vHIT, posturography, audiometry. MRI is requested in suspected central vestibular pathology or with unilateral sensorineural hearing loss.
BPPV: the most common vertigo
BPPV results from otoconia (calcium carbonate crystals) entering the semicircular canals. Position changes (rising from bed, tilting head back, lying down) trigger 30–60 second severe vertigo episodes. The posterior canal is most often affected (85–90%).
Treatment: Epley manoeuvre for posterior canal BPPV; Lempert (BBQ-roll) or Gufoni manoeuvre for lateral canal. Single-session success 85–90%; recurrent cases may need 2–3 sessions. Brandt-Daroff exercises can be done at home. Surgery (posterior canal occlusion) is considered only in refractory cases.
Frequently Asked Questions
- 15–50% recurrence within a year. Re-treatment (Epley) remains successful. Falls, head trauma, and vitamin D deficiency increase recurrence.
- No definitive cure, but attack frequency and severity are controlled with treatment. Salt restriction (<2g/day), diuretic, betahistine, intratympanic steroid/gentamicin, and as a last resort surgery (endolymphatic shunt, vestibular neurectomy).
- Acute phase 1–3 days, with substantial improvement in 4–6 weeks for most. Vestibular rehabilitation accelerates recovery. Corticosteroids are beneficial in the acute phase.
- No. Dizziness divides into: vertigo (spinning), presyncope (faintness), disequilibrium (gait imbalance), nonspecific. Treatment differs by category.
- In acute severe attack, vestibular suppressants (meclizine, dimenhydrinate) for 24–48 hours can help. Chronic use delays vestibular compensation; not recommended.
- Initial diagnosis and manoeuvre should be performed by an experienced clinician. For subsequent recurrences, when sure of the affected canal and strategy, home manoeuvres are reasonable.
References
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