BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV)

History
Rotational vertigo lasting a few seconds.
Precipitated by head movement - turning the head to the affected side or upwards (eg reaching up to the top shelf
in the supermarket or hanging out the washing) and classically when turning onto the affected side in bed.
May start after a head injury or acute vestibular failure. Often resolves spontaneously.

Aetiology
BPPV is thought to be caused by debris (possibly otoconia) within the posterior semicircular canal of the
affected ear. This alters the dynamics of fluid movement within the semicircular canal as the head moves, thereby
altering the signal passing along the vestibular nerve to the brain and causing vertigo.

Dix-Hallpike positional test (see page 2)

This is the test that confirms the diagnosis.
With the patient sitting on a couch, the head is turned to one side and the patient is laid down with the head over
the end of the couch.
It is important to instruct the patient to keep the eyes open and look at the observer’s nose, to allow the
characteristic nystagmus to be observed.
After a period of a few (but as long as) 20 seconds, the patient develops vertigo and there is a torsional
nystagmus with the eyes rotating downwards towards the affected ear.
The symptoms and nystagmus settle after a period of up to 20 seconds.
On repeating the positional test, the symptoms and nystagmus are less severe.
All these features are necessary to make a diagnosis of BPPV.
If the features are not typical, there may be a central cause for the vertigo.

Particle repositioning (Epley) manoeuvre (see page 3)

This allows the particles in the posterior semicircular canal to fall into the vestibule of the inner ear where they
do not cause symptoms.
An assistant is required to help move the patient.
After repeating the Dix-Hallpike positional test, the patient is lying flat with the head over the end of the couch
turned towards the affected ear (Position 2).
The head is turned towards the other shoulder (this is the position that the patient finishes in after performing the
Dix-Hallpike test for the other ear) (Position 3).
The patient continues to turn so as to be lying on the side opposite to the affected ear with the head still turned
towards the opposite shoulder (Position 4).
The patient is then asked to bring the knees up towards the chest and straighten the knees to bring the feet over
the side of the couch, before being helped up sideways to a position sitting on the side of the couch.
Lastly, the patient’s head which was still turned towards the opposite shoulder is brought back to the front
(Position 5).

After care
The patient should rest for the remainder of the day and should not drive home.
The patient is asked to avoid movements that have previously precipitated BPPV for the next 6 weeks.
After 6 weeks, the symptoms will have settled and the Dix-Hallpike test will be negative in 80% of patient. If
symptoms and nystagmus are still present, they are usually less severe. The particle repositioning manoeuvre can be
repeated.
If the patient does not respond, either the diagnosis was incorrect or the patient may be one of the very small
minority who require surgery for intractable BPPV.

Tim Mitchell
Consultant Otolaryngologist
Southampton University Hospitals NHS Trust

November 2003