eMedicine Specialties > Neurology > Neuro-otology
Benign Positional Vertigo: Differential Diagnoses & Workup
Updated: Apr 27, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Differential Diagnoses
Other Problems to Be Considered
The differential diagnosis of benign paroxysmal positional vertigo can be divided into 3 main areas of pathology—labyrinthine, vestibular nerve, and central. These are further subdivided as follows:
Alcohol intoxication: This can cause positional nystagmus that is persistent in a given position and varies according to the position of the head.
Brainstem syndromes
Central positional nystagmus: This may indicate a posterior fossa lesion such as acoustic neuroma or meningioma.
Cervical disk syndromes
Cervical vertigo or head-extension vertigo: A somewhat ill-defined entity of symptoms that arise with head extension, this could be a manifestation of vascular compression (eg, vertebral arteries).
Inner ear concussion: This may cause transient positional vertigo and nystagmus, which can be confused with benign paroxysmal positional vertigo.
Labyrinthitis: The nystagmus is spontaneous, persistent, predominantly linear-horizontal, and minimally affected by head position. Caloric testing often reveals unilateral hypofunction.
Ménière disease: Chronic benign paroxysmal positional vertigo is misdiagnosed most frequently as Ménière disease because patients fail to recognize the positional provocation. Benign paroxysmal positional vertigo can occur concomitantly with Ménière disease, thus increasing the diagnostic difficulty. Furthermore, some evidence suggests that Ménière disease may actually cause canaliths to form (unpublished data, personal communications with Gerald Gianoli, MD, Tulane University).
Orthostatic hypotension: Low blood volume or poor systemic arterial tone can account for hypoperfusion of the brain and cause dizziness. Symptoms are relieved by lying down and triggered by the sitting position.
Positional down-beating nystagmus: This often is associated with a lesion of the nodulus (which normally inhibits vertical vestibulo-ocular reflex gain) from stroke, multiple sclerosis, Arnold-Chiari malformations, cerebral ischemia, cerebellar degeneration, or intoxication.
Positional nystagmus of central origin: This is seldom transient, and may be down-beating, whereas benign paroxysmal positional vertigo is usually up-beating. Frequently, other CNS signs are present.
Vascular loop syndrome: The diagnostic criteria have been defined poorly. This diagnosis should be considered only after all other possibilities are exhausted. MRI is used to find aberrant loops of the anterior inferior cerebellar artery that may impinge upon the contents of the internal auditory canal.
Vertebral artery insufficiency
Vestibular neuronitis
Workup
Laboratory Studies
Since the Dix-Hallpike test is pathognomonic, laboratory tests are not required to make the diagnosis of benign paroxysmal positional vertigo. However, keep in mind that since benign paroxysmal positional vertigo is strongly associated with inner ear disease, lab workup might be needed to delineate other associated conditions.
Imaging Studies
If objective abnormalities are confirmed in the general physical or neurologic examination, or clinical history warrants it, strong consideration should be given to obtaining neuroimaging (ie, MRI of the brain) with particular attention to the brain stem and posterior fossa structures.
Other Tests
- Electronystagmography (ENG): Torsional eye movement cannot be demonstrated directly. Occasionally ENG is helpful in detecting the presence and timing of nystagmus.
- Caloric test can be normal or hypofunctional (unpublished data, personal communication from Mohammed Hamid, MD).
- Vestibular response can be reduced secondary to the sluggishness of the particle-laden endolymph.
- Benign paroxysmal positional vertigo can originate in the ear with an absent caloric response because the nervous and vascular supply to the horizontal canal is separate from that of the posterior semicircular canals.
- Infrared nystagmography: Torsional eye movement can be demonstrated directly.
- Audiogram: Findings may be normal.
- Posturography: Findings are often abnormal but follow no predictable or diagnostic pattern.
More on Benign Positional Vertigo |
| Overview: Benign Positional Vertigo |
 Differential Diagnoses & Workup: Benign Positional Vertigo |
| Treatment & Medication: Benign Positional Vertigo |
| Follow-up: Benign Positional Vertigo |
| Multimedia: Benign Positional Vertigo |
| References |
| Further Reading |
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References
Boniver R. Benign paroxysmal positional vertigo: an overview. Int Tinnitus J. 2008;14(2):159-67. [Medline].
Epley JM. The canalith repositioning procedure for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992;107(3):399-404. [Medline].
Parnes LS, McClure JA. Posterior semicircular canal occlusion in the normal hearing ear. Otolaryngol Head Neck Surg. Jan 1991;104(1):52-7. [Medline].
Li JC, Epley J. The 360-degree maneuver for treatment of benign positional vertigo. Otol Neurotol. Jan 2006;27(1):71-7. [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. May 1994;15(3):321-6. [Medline].
Roberts RA, Gans RE, DeBoodt JL, Lister JJ. Treatment of benign paroxysmal positional vertigo: necessity of postmaneuver patient restrictions. J Am Acad Audiol. Jun 2005;16(6):357-66. [Medline].
Prokopakis EP, Chimona T, Tsagournisakis M, et al. Benign paroxysmal positional vertigo: 10-year experience in treating 592 patients with canalith repositioning procedure. Laryngoscope. Sep 2005;115(9):1667-71. [Medline].
Lynn S, Pool A, Rose D, et al. Randomized trial of the canalith repositioning procedure. Otolaryngol Head Neck Surg. Dec 1995;113(6):712-20. [Medline].
Li JC. Mastoid oscillation: a critical factor for success in canalith repositioning procedure. Otolaryngol Head Neck Surg. Jun 1995;112(6):670-5. [Medline].
Li JC, Li CJ, Epley J, Weinberg L. Cost-effective management of benign positional vertigo using canalith repositioning. Otolaryngol Head Neck Surg. Mar 2000;122(3):334-9. [Medline].
Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. Nov 2008;139(5 Suppl 4):S47-81. [Medline].
Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1980;88:599-605. [Medline].
Herdman SJ, Tusa RJ, Zee DS, et al. Single treatment approaches to benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg. Apr 1993;119(4):450-4. [Medline].
Schuknecht HF. Cupulolithiasis. Arch Otolaryngol. Dec 1969;90(6):765-78. [Medline].
Keywords
benign paroxysmal positional vertigo, benign positional vertigo treatment, benign positional vertigo symptoms, BPV, BPPV, canalithiasis, canalith repositioning procedure, positional vertigo, benign positional vertigo, canalithiasis, cupulolithiasis, vertigo, inner ear disease, Ménière disease, nystagmus
