eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Vertigo & Dizziness

Benign Paroxysmal Positional Vertigo: Differential Diagnoses & Workup

Author: John C Li, MD, Private Practice in Otology and Neurotology; Medical Director, Balance Center
Coauthor(s): John Epley, MD, Director, Portland Otologic Clinic
Contributor Information and Disclosures

Updated: Sep 25, 2009

Differential Diagnoses

Inner Ear, Meniere Disease, Medical Treatment
Inner Ear, Meniere Disease, Surgical Treatment
Labyrinthitis Ossificans

Other Problems to Be Considered

Differential diagnoses for benign paroxysmal positional vertigo (BPPV) can be divided into 3 main areas of pathology: labyrinthine, vestibular nerve, and central sites of lesions. These are subdivided further as follows:

  • Ménière disease is probably the most frequent misdiagnosis applied to chronic BPPV because patients may fail to recognize the positional provocation. It is also confusing because BPPV can occur concomitantly.
  • Inner ear concussion may cause transient positional vertigo and nystagmus and can be confused with BPPV.
  • Alcohol intoxication can cause positional nystagmus, is persistent in a given position, and varies according to head position.
  • With labyrinthitis, the nystagmus is spontaneous, persistent, predominantly linear-horizontal and affected little by head position. Caloric testing often reveals unilateral weakness.
  • For vascular loop syndrome, the diagnostic criteria have been defined poorly. This diagnosis should be considered only after all other possibilities are exhausted.
  • Positional nystagmus of central origin is seldom transient and may be down-beating, whereas BPPV is usually up-beating. Frequently, other CNS signs are present.
  • Positional down-beating nystagmus is often associated with a lesion of the nodulus (which normally inhibits vertical vestibuloocular reflex gain) from stroke, multiple sclerosis, Arnold-Chiari malformation, ischemia, cerebellar degeneration, and intoxication.
  • Central positional nystagmus may indicate a posterior fossa lesion such as acoustic neuroma or meningioma.
  • Vertebral artery insufficiency is also a differential diagnosis for BPPV.
  • Cervical vertigo, or head extension vertigo, is a somewhat ill-defined entity of symptoms that arises with head extension, quite possibly a manifestation of vascular compression (vertebral arteries).
  • With orthostatic hypotension, low blood volume or poor systemic arterial tone can account for hypoperfusion of the brain and cause dizziness. Patients feel better when lying down and are symptomatic when sitting up.

Workup

Laboratory Studies

Because the Dix-Hallpike maneuver is pathognomonic, laboratory tests are not needed to make the diagnosis of benign paroxysmal positional vertigo (BPPV). However, since a high association with inner ear disease exists, laboratory workup may be needed to delineate these other pathologies.

Imaging Studies

Imaging studies are not needed in the workup of a patient in whom BPPV is suspected.

Other Tests

  • The Dix-Hallpike maneuver is the standard clinical test for BPPV (see Physical).
  • Electronystagmography
    • Torsional eye movement cannot be demonstrated directly, but occasionally electronystagmography (ENG) is helpful in detecting the presence and timing of nystagmus.
    • Caloric test results can be normal or hypofunctional.
    • According to Mohammed Hamid, MD, a reduced vestibular response can occur secondary to the sluggishness of the particle-laden endolymph.
    • BPPV can originate in an ear with an absent caloric response because the nervous and vascular supply to the horizontal canal is separate from that of the PSCs.
  • Infrared nystagmography: Torsional eye movement can be demonstrated directly.
  • Audiogram: The result of an audiogram may be normal.
  • Posturography: Posturography results are often abnormal but follow no predictable or diagnostic pattern.

More on Benign Paroxysmal Positional Vertigo

Overview: Benign Paroxysmal Positional Vertigo
Differential Diagnoses & Workup: Benign Paroxysmal Positional Vertigo
Treatment & Medication: Benign Paroxysmal Positional Vertigo
Follow-up: Benign Paroxysmal Positional Vertigo
Multimedia: Benign Paroxysmal Positional Vertigo
References
Further Reading
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References

  1. Epley JM. New dimensions of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. Sep-Oct 1980;88(5):599-605. [Medline].

  2. [Guideline] Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, 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. May 27 2008;70(22):2067-74. [Medline].

  3. [Guideline] 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].

  4. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. Sep 1992;107(3):399-404. [Medline].

  5. Fung K, Hall SF. Particle repositioning maneuver: effective treatment for benign paroxysmal positional vertigo. J Otolaryngol. Aug 1996;25(4):243-8. [Medline].

  6. 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].

  7. Li JC. Mastoid oscillation: a critical factor for success in canalith repositioning procedure. Otolaryngol Head Neck Surg. Jun 1995;112(6):670-5. [Medline].

  8. Li JC, Epley J. The 360-degree maneuver for treatment of benign positional vertigo. Otol Neurotol. Jan 2006;27(1):71-7. [Medline]. [Full Text].

  9. Massoud EA, Ireland DJ. Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol. Apr 1996;25(2):121-5. [Medline].

  10. Roberts RA. Efficacy of a new treatment maneuver for posterior canal benign paroxysmal positional vertigo.

  11. Roberts RA. Efficacy of a new treatment maneuver for posterior canal benign paroxysmal positional vertigo.

  12. Smouha EE, Roussos C. Atypical forms of paroxysmal positional nystagmus. Ear Nose Throat J. Sep 1995;74(9):649-56. [Medline].

  13. 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].

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Further Reading

Clinical guidelines

Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, Tusa RJ, Hain TC, Herdman S, Morrow MJ, Gronseth GS, Quality Standards Subcommittee, American Academy of Neurology. 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. 2

Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, Chalian AA, Desmond AL, Earll JM, Fife TD, Fuller DC, Judge JO, Mann NR, Rosenfeld RM, Schuring LT, Steiner RW, Whitney SL, Haidari J, American Academy of Otolaryngology-Head and Neck Surgery Foundation. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2008 Nov;139(5 Suppl 4):S47-81. 3

Turski PA, Seidenwurm DJ, Davis PC, Brunberg JA, De La Paz RL, Dormont PD, Hackney DB, Jordan JE, Karis JP, Mukherji SK, Wippold FJ II, Zimmerman RD, McDermott MW, Sloan MA, Expert Panel on Neurologic Imaging. Vertigo and hearing loss. [online publication]. Reston (VA): American College of Radiology (ACR); 2006. 8 p.

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Keywords

vertigo, dizziness, benign paroxysmal positional vertigo, vertigo treatment, causes of vertigo, vertigo inner ear, positional vertigo, paroxysmal positional vertigo, benign positional vertigo, vertigo causes, vertigo symptoms, benign, benign vertigo, BPPV, posterior superior semicircular canal, lateral semicircular canal, posterior superior SCC, lateral SCC, canalithiasis, cupulolithiasis, dizziness, nystagmus, Ménière disease, whirling vertigo, vertigo, canalith repositioning procedure, CRP, Dix-Hallpike test, cupulolithiasis theory, canalithiasis theory

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Contributor Information and Disclosures

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, and North American Skull Base Society
Disclosure: Nothing to disclose.

Coauthor(s)

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.

Medical Editor

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: American biloogical group Royalty Other

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Peter S Roland, MD, Professor, Department of Neurological Surgery, Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery, Director of Clinical Center for Auditory, Vestibular and Facial Nerve Disorders, Chief of Pediatric Otology, University of Texas Southwestern Medical Center; Adjunct Professor of 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 Laryngological Rhinological and Otological Society, American Neurotology Society, American Otological Society, North American Skull Base Society, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Alcon labs Honoraria Speaking and teaching; GSK Honoraria Speaking and teaching; Advanced Bionics Honoraria Board membership; Cochlear corp Honoraria Board membership; Med El corp travel grants Consulting

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, 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, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
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