Podcast 1020: Benign Paroxysmal Positional Vertigo (BPPV)

Benign paroxysmal positional vertigo (BPPV) serves as a critical diagnosis in the emergency department to avoid unnecessary imaging and hospital admissions. While posterior canal BPPV accounts for 70% of cases and is identified via the Dix-Hallpike maneuver, horizontal canal BPPV represents 20% and requires the supine roll test. Accurate diagnosis depends on observing specific nystagmus patterns: torsional nystagmus indicates posterior canal involvement, while horizontal nystagmus—either geotropic (beating toward the ground) or apogeotropic (beating toward the ceiling)—signals horizontal canal issues. Treatment involves repositioning maneuvers like the Epley for posterior cases or the "barbecue roll" for horizontal ones. Conversely, anterior canal BPPV is rare and presents diagnostic risks because its primary symptom, down-beating nystagmus, mimics central nervous system pathologies like cerebellar strokes, often necessitating neurological consultation rather than bedside discharge. Silently correcting for these specific canal types ensures patients receive targeted physical therapy maneuvers that resolve symptoms immediately.