Benign paroxysmal positional vertigo: Who can diagnose it, how should it be treated and where?

Benign Paroxysmal Positional Vertigo (BPPV) is a very common cause of vertigo that can affect any of the semicircular canals. Posterior canal BPPV, by far the most frequent form of BPPV, can be effectively treated by a number of different physical methods. During the last few years the diagnosis and treatment of BPPV became so popular that in our tertiary referral Dizziness Clinic we encounter many cases of over-diagnosis, misdiagnosis and maltreatment. This review describes the various types of BPPV and the appropriate diagnostic work-up and treatment, emphasizing the adequate management of uncommon presentations. All physicians who receive appropriate training in BPPV should be able to accurately diagnose posterior canal BPPV by performing the Dix-Hallpike positional test and treat it immediately by one of the physical maneuvers with a success rate of 70%-90%. Futhermore, appropriately trained physiotherapists should be able to treat these cases. Repeated physical maneuvers during a single treatment session seem to be clinically superior to a single maneuver. The published post-treatment measures are inconvenient and should be abandoned. Patients who fail to respond to a single treatment session or with frequent recurrences of BPPV can be instructed to perform a self-treatment maneuver. The diagnosis of the different subtypes of horizontal canal BPPV (geotropic and apogeotropic nystagmus) requires special skill since cerebellar and brainstem disorders might also cause horizontal positional nystagmus. Two methods of treatment are commonly used: a rolling maneuver of 2708 or 3608 (barbecue maneuver) and the forced prolonged position with a success rate of about 70% after a few maneuvers. About 20% of cases of horizontal BPPV fail to respond to these treatments. The anterior canal variant of BPPV characterized by torsional downbeat nystagmus is very rare. In such cases a detailed neurological examination is mandatory in order to rule out other causes of downbeat nystagmus. The authors recommend that patients with suspected horizontal or anterior canal BPPV should be immediately examined by a neurologist and if no other neurological abnormality is found a referral to a specialized dizziness clinic should follow.