Gordon H. Sun, MD, MS

Disclosures

April 20, 2017

BPPV: The Basic Facts

BPPV, a condition of the inner ear characterized by repeated episodes of positional vertigo, is the most common vestibular disorder across all ages.[1] An estimated 17%-42% of individuals initially complaining of vertigo are ultimately diagnosed with BPPV.[2]

A population-based study from Olmsted County, Minnesota, reported an age- and sex-adjusted BPPV incidence of 64 per 100,000 population annually. With a 38% increase in incidence per decade of life, this condition has a significant impact on the geriatric population.[3] A more recent study based in Germany calculated a 1-year BPPV incidence of 0.6%, a 1-year prevalence of 1.6%, and a lifetime prevalence of 2.4%.[4] Women are more commonly affected than men (female-to-male ratio, 1.5-2.2:1).[5]

Posterior canal BPPV is the most common variant, affecting 85%-95% of all patients with BPPV, whereas the lateral or horizontal canals are involved in 5%-15% of cases.[1,6] Other extremely rare variants also exist, such as anterior canal BPPV. Most cases are primary (idiopathic), whereas the most common secondary cause is head trauma.[6]

The American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) estimated that healthcare costs associated with the diagnosis of BPPV may approach $2 billion annually.[1] A Chinese study[7] calculated that the diagnostic workup of BPPV cost about 5000 renminbi per case (more than $700 in 2017). And a substantial proportion of these diagnostic studies and treatments are unnecessary, leading to delays in care.[8]

Spontaneous recovery from BPPV, without need for any treatment other than watchful waiting, is possible in 35%-50% of cases.[9] Spontaneous recovery can occur in about 20% of patients within 1 month of follow-up and up to 50% within 3 months.[1]

Case 2: Diagnosing BPPV

A 43-year-old postal worker visited a nurse practitioner at his primary care clinic because of intermittent dizziness and unsteadiness on his feet for the past month. He reported that the dizziness sometimes occurred when he stepped out of his van to deliver mail and other times while sorting letters in the office, but beyond this description, he was unable to precisely determine what triggered the symptom. He described the dizziness as severe, though it usually lasted only a few seconds. However, the sensation of imbalance often lasted several minutes or longer.

The patient denied other otologic or neurologic symptoms, such as hearing or vision loss, headache, or facial weakness. He took a single medication for hypertension but had no other medical problems and reported no allergies. He also reported no history of surgery. He reported playing basketball and flag football with friends on a regular basis.

Physical examination demonstrated a well-appearing man in no apparent distress and with normal vital signs. General examination was unremarkable, other than a positive Dix-Hallpike test when facing left. The clinician was determining whether additional workup was necessary to diagnose BPPV.

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