Benign paroxysmal positional vertigo (BPPV)
Introduction
Benign paroxysmal positional vertigo (BPPV) is the commonest peripheral cause of vertigo. It produces brief, recurrent episodes of rotatory vertigo provoked by changes in head position relative to gravity (for example rolling in bed or looking up). Typical onset is in middle to older age (mean ~55 years). Most episodes are self‑limited but are often rapidly relieved by canalith repositioning maneuvers.
Aetiology and epidemiology
BPPV is caused by displacement of otoconial debris (otoliths: calcium carbonate crystals) from the utricular macula into one of the semicircular canals. When these particles move within the canal endolymph they create an abnormal endolymph flow and cupular deflection, producing a transient mismatch of vestibular input and a brief attack of vertigo.
Distribution:
- Posterior canal: approximately 85-95% of cases.
- Horizontal (lateral) canal: approximately 5-15% of cases.
- Anterior (superior) canal: rare.
Post‑traumatic BPPV is common after head injury, can be multi‑canal or more resistant to single manoeuvres, and commonly requires early ENT/vestibular physiotherapy follow‑up (IMEG/GOV.UK).
Clinical features
- Typical attack: sudden, brief rotatory vertigo provoked by specific head movements; duration is classically seconds to under one minute, often 10-20 seconds.
- Associated symptoms: nausea with or without vomiting.
- Auditory symptoms such as sustained hearing loss or persistent tinnitus are not features of uncomplicated BPPV; their presence suggests an alternative or additional diagnosis and...