Benign paroxysmal positional vertigo (BPPV) is the most common cause of positional vertigo, primarily affecting women, often due to displaced otolithic debris in the semicircular canals. Symptoms include sudden episodes of vertigo triggered by specific head movements, with diagnosis typically confirmed through the Dix-Hallpike maneuver. Management options include the Epley maneuver for particle repositioning, various medications, and surgical interventions if necessary.

1. BENIGN PAROXYSMAL
POSITIONAL VERTIGO (BPPV)
Sunil Kumar Daha

2. Introduction
• Most common cause of positional vertigo
• Women > Men
• D/t presence of otolithic debris from saccule or utricle
affecting free flow of endolymph in semicircular canals
(cupulolithiasis)
• Occurs secondary to free-floating canalith within
posterior semicircular canal
• It may follow head injury but typically is spontaneous
/idiopathic

3. Causes
• Idiopathic
• Infection (viral neuronitis)
• Head trauma
• Surgical damage to the labyrinth
• Ischemic complication of Giant Cell Arteritis
(GCA)

4. Clinical Features
• Sudden and distressing onset
• Recurrent episodes of vertigo lasting < 1 min
• Symptoms provoked by specific head movements
• Looking up while standing and sitting
• Lying down or getting up from bed
• Rolling over in bed
• Waxing and waning pattern of vertigo
• Sometimes associated nausea and vomiting
• No neurological symptoms

5. Pathophysiology
• Otoliths (CaCO3 particles) are normally attached to a membrane
inside the utricle and saccule
• Utricle is connected to the semicircular ducts
• Otoliths may become displaced from the utricle to enter the
posterior semicircular duct since this is the most dependent of
the 3 ducts
• Changing head position relative to gravity causes the free
otoliths to gravitate longitudinally through the canal
• Concurrent flow of endolymph stimulates the hair cells of the
affected semicircular canal, causing vertigo

6. Variants of BPPV
• Posterior Canal BPPV (most common!!)
• Anterior Canal BPPV
• Horizontal Canal BPPV
• Pure Torsional BPPV

7. Diagnosis
• Dix-Hallpike Maneuver:
• The Dix-Hallpike/Barany Maneuver, along with patient's history 
diagnostic of BPPV

8. Cont…
• Investigations: generally not needed
• Electronystagmography (ENG): for detecting
preexisting vestibular pathology
• Neuroimaging: If nystagmus doesn’t fit classical
BPPV symptoms

9. Management
• Particle Repositioning Maneuver:
• Epley Maneuver (choice of T/t)
• Semont Maneuver
• Brandt-Daroff Exercise (self home treatment)
• Medications:
• Antiemetics
• Antihistaminics
• Anticholinergics
• Surgeries: (better avoided d/t possibility of hearing loss)
• Singular neurectomy
• Posterior Canal Plugging Procedure
• Vestibular Nerve Section

10. (Epley maneuver)
Epley Maneuver

11. Epley Maneuver
• Treatment of choice for BPPV
• The patient is positioned in a series of steps so as to slowly
move the otoconia particles from the posterior semicircular canal
back into the utricle
• Takes approximately 5 minutes
• The patient is instructed to wear a neck brace for 24 hours and
to not bend down or lay flat for 24 hours after the procedure
• One week after the Maneuver, the Dix-Hallpike test is repeated
• If the patient does experience vertigo and nystagmus, then the
maneuver is repeated with a vibrator placed on the skull in order
to better dislodge the otoconia

12. Semont Maneuver

13. Brandt-Daroff Exercise

14. Surgical
Singular neurectomy
•Old procedure
•Section the nerve that transmits information from the posterior
semicircular canal ampulla toward the brain.
•Can cause hearing loss in 7-17% of patients and fails in 8-12%
Posterior Canal Plugging Procedure
•The canal is gently, firmly packed off with tissue so the debris can
no longer move within the canal and strike against the nerve
endings
•<20% hearing loss

15. Contd..
Vestibular Nerve Section
•Done if medication fails
•An incision is made behind the ear and balance-hearing nerve is
located
•The balance part of the nerve is cut
•The success rate (no vertigo attacks) is over 90%
•The hearing is usually not affected

16. References
• Uptodate 21.6
• Kumar and Clark’s Clinical Medicine, 8th Edition

17. Thank you