Benign Paroxysmal Positional Vertigo (BPPV)
Diagnostic Worksheet
Dolores Umapathy
dolores.umapathy@bolton.nhs.uk
Endorsed by BAAP Audit group
Clinical Features
BPPV is a benign inner ear condition. It is generally sudden in onset with paroxysmal
and positional symptoms triggered by head position. The main symptom is vertigo
having the following features
1) Triggered by rapid change in head position-characteristically lying
down/turning in bed, sitting up from supine, bending over and neck extension
2) Duration usually few seconds to rarely over a minute
3) Latent period prior to onset of symptoms in provoking position generally
between 1 and 40 seconds
4) Vertigo is described generally as being intense and brief, with a complaint of
light headedness and imbalance persisting for a short duration with a few
complaining of the symptoms persisting for several days after the vertigo
5) Nystagmus may be described by others but patient is usually unaware of it
6) Often associated with autonomic symptoms like nausea and sweating.
Vomiting is rare. Diarrhoea is less common
7) In between attacks there may be no symptoms if there is no other vestibular
pathology
8) Clusters of attacks may last for a couple of days upto several months
Diagnosis –Hallpike Manoeuvre
Before Manoeuvre
Explain procedure and possible side effects such as temporary dizziness. Sit patient
on couch such that when lying down the shoulders will be level with end of couch.
Instruct patient to fix eyes on a point directly in front (eg. Clinician’s forehead). Start
with the affected ear
Absolute Contraindications
Musculo-skeletal: Recent history of neck surgery, recent vertebral disc prolapse,
cervical spine fracture or trauma particularly if it restricts rotation or extension of
neck, Instability of atlanto-axial and occipito-atlantal joints
Neurological: Cervical myelopathy or radiculopathy
Vascular: Dissection of carotid or vertebral artery
Nb: A history of posterior circulation ischaemia or a neck bruit is not an
absolute contraindication.
Caution exercised in following conditions:
Cervical involvement of Rheumatoid arthritis, carotid sinus hypersensitivity, cardiac
surgery within 3 months, severe back pain, severe orthopnoea
Technique
Hold patient’s head in both hands and turn 450 towards the test ear. Support neck and
maintaining torsion along with fixed gaze, move head rapidly backwards to head
hanging position, 30 – 450 (optimally) below horizontal as rapidly as possible.
Maintain the head hanging position for 30 –60 seconds and observe patient’s eyes. If
nystagmus is present note the latent period, magnitude and direction of rotation of the
fast phase. Maintain position for about 1 minute after onset to determine if nystagmus
adapts, changes direction or alters. Return patient to upright position while
maintaining 450 neck rotation and observe for reversal of nystagmus.
Wait till patient is settled and then repeat on same side to assess fatigability. Proceed
to opposite side if no nystagmus is seen on the first side or when the patient has
settled from the first test.
Positive response
Posterior canal BPPV is the commonest and the type of nystagmus seen would
indicate the canal involved
Posterior canal BPPV: Geotropic torsional nystagmus (towards undermost ear)
Anterior canal BPPV: Geotropic torsional nystagmus with downbeat component
Horizontal canal BPPV: Horizontal nystagmus (geotropic if canalithiasis, ageotropic
if cupulolithiasis)
Nb: Hallpike test is not the ideal test of horizontal canal BPPV
Modification to the Hallpike Test
Anterior canal BPPV can sometimes be better elucidated by making the patient lie
supine with the head extended in the primary position i.e. straight back or ‘Rose’
position. Torsional nystagmus with a major downbeat component is seen. The side is
indicated by the torsional element beating towards the affected side
Horizontal BPPV is best seen on the roll test. The patient is made to lie on a couch
with the head position raised to 300(Caloric position). The head is then rolled quickly
from one side to the other. Horizontal nystagmus is seen on both sides but the side in
which the nystagmus is more marked determines the side affected.
Differential Diagnosis
Main differential diagnosis is from a central positional nystagmus where the
nystagmus is usually downbeat but could be in any direction and there is no latency,
adaptability or fatigability. Vertigo is generally absent or mild.
Investigations
No investigations are generally required unless other co-existing vestibular or
audiological pathology is suspected. Video-oculography can be used to document the
nystagmus for teaching or research purposes.
References
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oculographic features in 240 cases. Neurol 1987; 37: 371-8
2. Honrubia V, Baloh RW, Harris MR, Jacobson KM. Paroxysmal Positional
Vertigo Syndrome. Am J Otology 1999. 20: 465-470
3. Norre ME. Diagnostic problems in patients with Benign Paroxysmal
Positional Vertigo. Laryngoscope 1994, 104, 11: 1385- 1389
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Positional Vertigo. Arch Otolaryngol Head Neck Surg. 1994;120: 1339-1341.
5. Smouha EE, Roussos C. Atypical forms of paroxysmal positional nystagmus.
Ear Nose Throat Journal 1995,74, (9), pp649-656
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manoeuvre in benign paroxysmal positional vertigo with and without
additional vestibular pathology.
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downbeating nystagmus in 50 patients: Cerebellar disorders and possible
anterion semicircular canal lithiasis. J Neurol Neurosurg Psychiatry. 2002; 72:
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common disorders of the vestibular system. Ann otol Rhinol Laryngol. 1952;6
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