Abstract
Vertigo is a frequent presentation in general practice, yet distinguishing benign peripheral causes from more serious central pathology remains a key challenge. Benign paroxysmal positional vertigo (BPPV) is the most common cause of episodic positional vertigo in adults. This case describes a middle‑aged patient presenting with recurrent, positionally triggered vertigo significantly affecting daily function. Bedside examination, including a positive Dix–Hallpike test, supported a diagnosis of right‑sided posterior canal BPPV. The report highlights essential features, recognising typical BPPV patterns, differentiating them from other vestibular and neurological conditions, revisiting the relevant inner‑ear anatomy, and applying structured diagnostic pathways in primary care.
Introduction
Vertigo accounts for a substantial proportion of primary care presentations. Causes range from benign peripheral vestibular disorders to cerebrovascular, metabolic, cardiovascular, and psychogenic conditions. For GPs, the key task is early differentiation of benign, self‑limiting conditions from those requiring urgent referral.
BPPV is the most common peripheral cause of vertigo, typically due to dislodged otoconia migrating into a semicircular canal, most often the posterior canal. These crystals disrupt normal endolymph flow, creating abnormal vestibular signalling during positional changes
Although benign, symptoms are often distressing and can lead to functional impairment, sleep disturbance, and anxiety.
Inner Ear Anatomy
- The vestibular system comprises the utricle, saccule, and three semicircular canals: posterior, anterior, and horizontal.
- The canals detect rotational movement; the otolith organs detect linear acceleration and gravity.
- In BPPV, otoconia detach from the utricle and enter a canal (canalithiasis), most commonly the posterior canal due to its anatomical orientation.
- Positional vertigo arises when head movement causes displaced otoconia to shift, stimulating the affected canal inappropriately.
Case Presentation
Clinical History
A 48‑year‑old patient presented with a 1‑week history of brief, intense vertigo triggered by turning in bed, looking upward, and bending forward. Episodes lasted 10–20 seconds and were accompanied by mild nausea. No hearing loss, tinnitus, ear pain, headache, limb weakness, gait disturbance, diplopia, or sensory symptoms were reported. There was no recent infection, trauma, or medication changes. The patient reported increasing anxiety due to unpredictability of symptoms and fear of a more serious neurological disorder. Symptoms usually occurred when rolling onto the right side in bed, or sudden movements on head rotation.
Differential Diagnosis include BPPV, Vestibular neuritis and Central causes.
Management
The patient underwent audio-vestibular testing.
| Audiological Tests | Vestibular Tests |
|---|---|
| Pure tone audiometry with masking | Full neurological examination |
| Tympanometry | Musculoskeletal examination |
| Stapedial reflexes | Full oculomotor examination |
| Otoscopy | Assessment of subjective visual vertical |
| Transient otoacoustic emissions | Videonystagmography with and without visual fixation for head shake, head heave, ocular counter rolling and ectopic eye movements |
| Video head impulse test | |
| Vestibulo-spinal test battery with and without foam cushion for Romberg, Unterberger, tandem gait, one-legged stance and sharpened Romberg | |
| Office rotatory chair tests and suppression of visual fixation | |
| Mastoid vibration test | |
| Dix-Hallpike, supine roll and deep head hanging tests |
The patient was diagnosed with right posterior canal BPPV and an Epley manoeuvre was performed. He was seen two weeks later in clinic and his symptoms had resolved.
Management Cont.
The Epley manoeuvre is effective in treating posterior canal
BPPV because it uses a sequence of controlled head and body movements to guide displaced otoconia out of the affected semicircular canal and back into the utricle, where they no longer trigger abnormal endolymph flow.
Epley Manoeuvre
In posterior canal BPPV, these free‑floating particles generate inappropriate stimulation of the vestibular system during positional changes, causing transient vertigo and characteristic nystagmus. By sequentially reorienting the posterior canal relative to gravity, the Epley manoeuvre facilitates the migration of these particles along the canal’s arc and ultimately out of the lumen. This restores normal canal function and eliminates the pathological stimulus. Clinical studies consistently show high effectiveness, with approximately 70–90% of patients achieving complete or near‑complete symptom resolution after a single manoeuvre, and even higher success rates with repeated treatments.
Learning Outcomes For Primary Care Setting
| Audiological Tests | Vestibular Tests |
|---|---|
| Pure tone audiometry with masking | Full neurological examination |
| Tympanometry | Musculoskeletal examination |
| Stapedial reflexes | Full oculomotor examination |
| Otoscopy | Assessment of subjective visual vertical |
| Transient otoacoustic emissions | Videonystagmography with and without visual fixation for head shake, head heave, ocular counter rolling and ectopic eye movements |
| Video head impulse test | |
| Vestibulo-spinal test battery with and without foam cushion for Romberg, Unterberger, tandem gait, one-legged stance and sharpened Romberg | |
| Office rotatory chair tests and suppression of visual fixation | |
| Mastoid vibration test | |
| Dix-Hallpike, supine roll and deep head hanging tests |
BBPV Characteristics
Benign paroxysmal positional vertigo (BPPV) is the most common cause of episodic vertigo in adults and a condition that GPs can diagnose and treat confidently in primary care. It results from otoconia dislodging from the utricle and entering a semicircular canal—most often the posterior canal—where their movement during positional changes generates inappropriate endolymph flow and transient vertigo. Clinically, BPPV presents with brief, intense episodes of spinning precipitated by movements such as rolling in bed, looking up, or bending forward, typically lasting less than a minute and accompanied by a characteristic positional nystagmus. The Dix–Hallpike manoeuvre remains the gold standard diagnostic test, demonstrating a torsional up‑beating nystagmus in posterior canal disease. Importantly, normal neurological examination, absence of auditory symptoms, and the episodic, fatigable nature of symptoms help differentiate BPPV from central causes of vertigo that warrant urgent referral. The Epley manoeuvre, provides rapid symptom resolution and can be performed safely in general practice. Early recognition avoids unnecessary imaging and reduces patient distress, making BPPV an essential condition for GPs to manage effectively.
Conclusion
BPPV is the most common cause of episodic positional vertigo in adults and should be considered early in primary care. Detailed history-taking, focused neurological examination, and appropriate positional testing allow confident diagnosis and management. Effective treatment with repositioning manoeuvres leads to rapid symptom resolution, minimises patient anxiety, and avoids unnecessary imaging and delay in diagnosis
