Reducing False-Negatives in the Diagnosis of BPPV
A Common Cause of Vertigo, Commonly Misdiagnosed
By Alan L. Desmond, AuD

Benign Paroxysmal Positional Vertigo (BPPV) is by far the most common cause of episodic vertigo. Patients typically report brief episodes (less than one minute) of intense vertigo, usually brought on by lying down, rolling over in bed, or tilting the head back. The typical pattern of BPPV is one of intermittent episodes. The vertigo (spinning sensation) may occur frequently for weeks at a time, disappear for months, then reappear with no warning.

BPPV is believed to be a result of a plug of calcium carbonate and protein crystals (otoconia), which have become dislodged from the utricle, settling most frequently in the posterior semicircular canal. The otoconia cause no problem until the patient moves in a manner stimulating the offending semicircular canal. The otoconia then begin moving, causing abnormal stimulation of the motion sensor in the affected ear. While the otoconia are in motion the patient is experiencing conflicting signals from the two labyrinths of the inner ear. BPPV is a mechanical dysfunction of the inner ear, and does not usually represent an ongoing disease process. It is relatively easily treated once a diagnosis is made. BPPV does not respond to medication, but rather is most effectively treated by canalith repositioning procedures. Unfortunately, many patients with BPPV do not receive timely or correct diagnosis and are often treated with Antivert (meclizine) (Li et al, 2000). BPPV has historically been found to be frequently misdiagnosed at the primary care as well as the ENT and Neurology specialist level ( Li, et al, 2000, Oghalai, et al, 2000; Katsarkis, 1994).



Figure 1 Hallpike maneuver: With the head turned to the side, the patient is quickly placed in the supine position with the head extended over the end of the examining table. (Reprinted with permission from Desmond & Touchette, 1998.)

BPPV can be diagnosed by performing the Dix-Hallpike maneuver (see Figure 1). If vertigo and nystagmus are elicited, the direction of the nystagmus allows for identification of the specific offending canal. Most BPPV involves the posterior semi-circular canal, and a positive response to this maneuver is the elicitation of vertigo and nystagmus which is rotary and beat upward and towards the undermost ear. There is usually a short latency (2 to 15 seconds) before the vertigo and nystagmus occur, and these signs usually have a duration of 15 to 45 seconds. Upon having the patient rise quickly to the sitting position, a milder vertigo may be appreciated with nystagmus typically opposite that noted in the supine position. Repeated maneuvers result in reduced vertigo and nystagmus response. This fatiguing response is believed to be the result of the dispersion of the otoconia throughout the posterior canal.
A positive Dix-Hallpike provides a clear diagnosis of BPPV, delineates the offending semi-circular canal and serves as the first step in performing canalith repositioning. Unfortunately, there are obstacles to arriving at this clear diagnosis, some obvious and easily overcome, some not so obvious.

The nystagmus associated with posterior canal BPPV is torsional (rotary) and is not easily or reliably recorded through electro-oculography. Since these electrodes record eye movements in the vertical and horizontal planes, torsional eye movement may be missed using this technique. The eyes must be visually observed for nystagmus. Optimally, infra-red video goggles (see Figure 2) with recording should be used so that eye movements can be documented and reviewed for latency, direction and duration, however, nystagmus can be easily viewed simply by holding the patients eyes open and observing for rotary nystagmus that may not be recordable through electro-oculography.


Figure 2 Infra-red video: During positional testing the eye can be monitored. (Photo courtesy of Micromedical Technologies)

BPPV can and does occur in the horizontal and anterior semi-circular canals. While a typical Dix-Hallpike test will elicit anterior canal BPPV, this maneuver will generally not elicit a response from the horizontal canal (occasionally, the Dix-Hallpike will elicit a horizontal nystagmus which indicates horizontal canal involvement). To elicit a response from the horizontal canal, the patients head must be rolled back and forth while in the supine position.
A less well known but no less important obstacle is the fact that some patients describing a history consistent with BPPV will be negative at the time of examination due to dispersion of the otoconia within the posterior canal. We (the authors clinic) describe this as “probable fatigued BPPV.” We suspect that this dispertion is a result of the patients’ normal activities as they prepare for and travel to their appointment. Simple tasks such a drinking coffee, tying ones shoes or getting into a car require head tilt that stimulates the posterior canals. Theoretically, by the time they reach the balance clinic, they have dispersed the otoconia and fatigued the response.

Lynn and Brey (1993) describe these patients as possibly being in a period of “spontaneous remission” and recommend that the clinician inquire as to when the patient last experienced an episode of positional vertigo. If the last episode has occurred within the few hours prior to examination, it is suspected that the patient has “probable fatigued BPPV.” Even if the patient has had an episode within the previous few hours, we will complete the Dix-Hallpike test and attempt to elicit a vertiginous episode. If the test is negative, we explain the physiology of BPPV and either have the patient reschedule or, if he/she has traveled a long distance, sit still for an hour or two. After he/she has been still for a period of time, the author will again attempt to provoke an episode of BPPV. If the patient reports that he/she has not had an episode for several days, it is suspected that he/she is in a period of “spontaneous remission” and we ask him/her to contact the clinic if and when the positional vertigo is active.

In our clinic, a retrospective chart review found that 53% (54 of 101) of patients suspected by history of having BPPV had a negative Dix-Hallpike response on the day of initial examination. Of those willing to return for repeat testing (N=25), 40% (10/25) had a positive Dix-Hallpike on follow-up testing. Norre (1994) notes “a re-examination two to three days later showed a positive vertigo and nystagmus reaction in some cases with positional complaints and negative findings on the first day.” Ideally, having the patient return to the clinic after he/she has been careful to avoid any provoking movements for several hours prior to the examination will increase the chances of provoking an episode in the office.
BPPV is a common vestibular disorder that is frequently misdiagnosed both at the primary care and specialist level. Careful planning, appropriate equipment and persistence will increase the likelihood of a correct diagnosis. In the words of the great philosopher Sophocles, “Look and you will find it - what is unsought will go undetected.”

1. Desmond, A.L., & Touchette, D. (1998). Balance Disorders: Evaluation and Treatment; A Short Course for Primary Care Physicians, Micromedical Technologies, Chatham, IL.

2. Katsarkas, A. (1994). Dizziness in aging: a retrospective study of 1194 cases.

3. Otolaryngology-Head and Neck Surgery, 110(3), 296-301.

4. Li Li, J.C., Li, C.J., Epley, J., & Weinberg, L. (2000). Cost-effective management of benign postitional vertigo using canalith repositioning. Otolaryngology-Head and Neck Surgery, 122(3), 334-339.

5. Lynn, S., & Brey, R. (1993). Benign paroxysmal positional vertigo with indeterminate cerebellar lesion: case report. Journal of the American Academy of Audiology, 4, 
384-391.

6. Norre ME, (1994) Diagnostic problems with patients with benign paroxysmal positional vertigo. Laryngoscope, 104 (11), 1383-1388

7. Oghalai JS, Manolidis S, Barth JL, Stewart MG, Jenkins HA, (2000) Unrecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngology - Head and Neck Surgery, 122(5), 630-634

Alan Desmond is the director of Blue Ridge Hearing and Balance Clinic in Princeton and Bluefield, WV