Which physical findings are characteristic of benign paroxysmal positional vertigo (BPPV)?

Answer

See the list below:

The physical examination findings in patients affected by BPPV are generally unremarkable. All neurotologic examination findings except those from the Dix-Hallpike maneuver may be normal. However, the presence of neurotologic findings does not preclude the diagnosis of BPPV.
The Dix-Hallpike maneuver is the standard clinical test for BPPV. The finding of classic rotatory nystagmus with latency and limited duration is considered pathognomonic. A negative test result is meaningless except to indicate that active canalithiasis is not present at that moment.
- This test is performed by rapidly moving the patient from a sitting position to the supine position with the head turned 45° to the right. After waiting approximately 20-30 seconds, the patient is returned to the sitting position. If no nystagmus is observed, the procedure is then repeated on the left side.
- Dix-Hallpike maneuver tips include the following:
  - Do not turn the head 90° since this can produce an illusion of bilateral involvement.
  - Tailor briskness of the Dix-Hallpike test to the individual patient.
  - Consider the Epley modification. From behind the patient, performing the maneuver is easier, since one can pull the outer canthus superolaterally to visualize the eyeball rotation.
  - In typical nystagmus, the axis is near the undermost canthus. Minimize suppression by directing the patient gaze to the anticipated axis of rotation.
Classic posterior canal BPPV produces geotropic rotatory nystagmus. The top pole of the eyes rotates toward the undermost (affected) ear.
Purely horizontal nystagmus indicates horizontal canal involvement.
Sustained or nonfatiguing nystagmus may indicate cupulolithiasis rather than canalithiasis.

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Palmeri R, Dulebohn SC. Vertigo, Benign Paroxysmal Position (BPPV). 2017 Jun. [Medline]. [Full Text].
Anagnostou E, Kouzi I, Spengos K. Diagnosis and Treatment of Anterior-Canal Benign Paroxysmal Positional Vertigo: A Systematic Review. J Clin Neurol. 2015 May 28. [Medline].
Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1980 Sep-Oct. 88(5):599-605. [Medline].
Yetiser S, Ince D. Diagnostic Role of Head-Bending and Lying-Down Tests in Lateral Canal Benign Paroxysmal Positional Vertigo. Otol Neurotol. 2015 May 1. [Medline].
Chang TP, Lin YW, Sung PY, Chuang HY, Chung HY, Liao WL. Benign Paroxysmal Positional Vertigo after Dental Procedures: A Population-Based Case-Control Study. PLoS One. 2016. 11 (4):e0153092. [Medline]. [Full Text].
Faralli M, Cipriani L, Del Zompo MR, et al. Benign paroxysmal positional vertigo and migraine: analysis of 186 cases. B-ENT. 2014. 10(2):133-9. [Medline].
Picciotti PM, Di Cesare T, Tricarico L, De Corso E, Galli J, Paludetti G. Is drug consumption correlated with benign paroxysmal positional vertigo (BPPV) recurrence?. Eur Arch Otorhinolaryngol. 2020 Feb 20. [Medline].
Messina A, Casani AP, Manfrin M, Guidetti G. Italian survey on benign paroxysmal positional vertigo. Acta Otorhinolaryngol Ital. 2017 Aug. 37 (4):328-35. [Medline].
Tirelli G, Nicastro L, Gatto A, Tofanelli M. Repeated canalith repositioning procedure in BPPV: Effects on recurrence and dizziness prevention. Am J Otolaryngol. 2017 Jan - Feb. 38 (1):38-43. [Medline].
Yoon J, Lee JB, Lee HY, Lee BD, Lee CK, Choi SJ. Potential Risk Factors Affecting Repeated Canalith Repositioning Procedures in Benign Paroxysmal Positional Vertigo. Otol Neurotol. 2018 Feb. 39 (2):206-11. [Medline].
Power L, Murray K, Szmulewicz DJ. Characteristics of assessment and treatment in Benign Paroxysmal Positional Vertigo (BPPV). J Vestib Res. 2019 Dec 13. [Medline].
Shim DB, Kim JH, Park KC, Song MH, Park HJ. Correlation between the head-lying side during sleep and the affected side by benign paroxysmal positional vertigo involving the posterior or horizontal semicircular canal. Laryngoscope. 2012 Feb 16. [Medline].
[Guideline] Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017 Mar. 156 (3_suppl):S1-S47. [Medline]. [Full Text].
[Guideline] Garcia J. New guidelines for benign paroxysmal positional vertigo. Medscape Medical News. 2017 Mar 1. [Full Text].
[Guideline] Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov. 139(5 Suppl 4):S47-81. [Medline].
Picciotti PM, Lucidi D, De Corso E, Meucci D, Sergi B, Paludetti G. Comorbidities and recurrence of benign paroxysmal positional vertigo: personal experience. Int J Audiol. 2016 May. 55 (5):279-84. [Medline].
Tan J, Deng Y, Zhang T, Wang M. Clinical characteristics and treatment outcomes for benign paroxysmal positional vertigo comorbid with hypertension. Acta Otolaryngol. 2016 Nov 14. 1-3. [Medline].
[Guideline] Fife TD, Iverson DJ, Lempert T, et al. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008 May 27. 70(22):2067-74. [Medline]. [Full Text].
Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992 Sep. 107(3):399-404. [Medline].
Fung K, Hall SF. Particle repositioning maneuver: effective treatment for benign paroxysmal positional vertigo. J Otolaryngol. 1996 Aug. 25(4):243-8. [Medline].
Herdman SJ, Tusa RJ, Zee DS, et al. Single treatment approaches to benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg. 1993 Apr. 119(4):450-4. [Medline].
Li JC. Mastoid oscillation: a critical factor for success in canalith repositioning procedure. Otolaryngol Head Neck Surg. 1995 Jun. 112(6):670-5. [Medline].
Li JC, Epley J. The 360-degree maneuver for treatment of benign positional vertigo. Otol Neurotol. 2006 Jan. 27(1):71-7. [Medline]. [Full Text].
Massoud EA, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol. 1996 Apr. 25(2):121-5. [Medline].
Roberts RA, Gans RE, Montaudo RL. Efficacy of a new treatment maneuver for posterior canal benign paroxysmal positional vertigo. J Am Acad Audiol. 2006 Sep. 17 (8):598-604. [Medline].
Smouha EE, Roussos C. Atypical forms of paroxysmal positional nystagmus. Ear Nose Throat J. 1995 Sep. 74(9):649-56. [Medline].
Weider DJ, Ryder CJ, Stram JR. Benign paroxysmal positional vertigo: analysis of 44 cases treated by the canalith repositioning procedure of Epley. Am J Otol. 1994 May. 15(3):321-6. [Medline].

Media Gallery

The patient is placed in a sitting position with the head turned 45° towards the affected side and then reclined past the supine position.
The patient is then brought back up to the sitting position.
Next, the patient is rolled 180° from the affected side to the opposite side. Note that the position of the head is 45° toward the affected side before the roll. The head winds up facing down, 180° away from the starting position.

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Author

John C Li, MD Private Practice in Otology and Neurotology; Medical Director, Balance Center

John C Li, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Tinnitus Association, Florida Medical Association, North American Skull Base Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Peter S Roland, MD Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director, Clinical Center for Auditory, Vestibular, and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Chief of Pediatric Otology, Children’s Medical Center of Dallas; President of Medical Staff, Parkland Memorial Hospital; Adjunct Professor of Communicative Disorders, School of Behavioral and Brain Sciences, Chief of Medical Service, Callier Center for Communicative Disorders, University of Texas School of Human Development

Peter S Roland, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Auditory Society, American Neurotology Society, American Otological Society, North American Skull Base Society, Society of University Otolaryngologists-Head and Neck Surgeons, The Triological Society

Disclosure: Received honoraria from Alcon Labs for consulting; Received honoraria from Advanced Bionics for board membership; Received honoraria from Cochlear Corp for board membership; Received travel grants from Med El Corp for consulting.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;The Physicians Edge;Sync-n-Scale;mCharts<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa;Proforma;Neosoma<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; .

Additional Contributors

Michael E Hoffer, MD Director, Spatial Orientation Center, Department of Otolaryngology, Naval Medical Center of San Diego

Michael E Hoffer, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Received royalty from American biloogical group for other.

Acknowledgements

John Epley, MD Director, Portland Otologic Clinic

John Epley, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, and Oregon Medical Association

Disclosure: Nothing to disclose.

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