Diagnostic Considerations

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 Furthermore, some evidence suggests that Ménière disease may actually cause canaliths to form (unpublished data, personal communications with Gerald Gianoli, MD, Tulane University).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

Differential Diagnoses

Workup

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Media Gallery

The steps involved in performing left-sided canalith repositioning procedure (CRP). The head is positioned 30 degrees toward the affected ear (left ear in this example). Next it is brought gently back to a reclining position. Note how the labyrinthine particles gravitate.
Continuation of the canalith repositioning procedure (CRP). Once supine, the head is rotated 180 degrees (ie, away from the affected side).
Another view of the canalith repositioning procedure treating the left ear.