V

ICD-9-CM Code

• 386.11 Benign paroxysmal positional vertigo

ICD-10-CM Codes

• H81.1 Benign paroxysmal (positional)
• H81.10 unspecified
• H81.11 right ear
• H81.12 left ear
• H81.13 bilateral

Preferred Practice Patterns

• Pattern 5A: Primary Prevention/Risk Reduction for Loss of Balance and Falling1
• Pattern 5F: Impaired Peripheral Nerve Integrity and Muscle Performance Associated with Peripheral Nerve Injury2

Key Features

Description

• Disorder of the inner ear
• Vestibular part of inner ear has three semicircular canals and two otolith organs (utricle, saccule) that are interconnected and fluid-filled
• Calcium carbonate crystals (otoconia, otoliths, ear stones) break free from utricular macula and float into one or more of the semicircular canals, making hair cells sensitive to gravity
• Causes episodic feelings of rotary vertigo (illusion that the room or oneself is spinning) that occurs with head position changes and usually lasts less than one minute

Essentials of Diagnosis

• Physical exam, including neurotologic exam, typically normal
• Thorough and detailed history is essential to distinguish from other vestibular disorders and central pathology
• Positive positioning tests: Dix-Hallpike maneuver, roll test, or side-lying test
• Positioning maneuver results in particular pattern of nystagmus and simultaneous report of vertigo
• Must rule out central nervous system pathology, which may mimic BPPV, especially if symptoms associated with head trauma

General Considerations

• Patients feel like either they or the room is spinning
• Typically triggered by tilting the head backward, rolling over in bed, or bending over
• Can feel disoriented and off-balance between episodes of spinning

Demographics

• More common in women than men (2:1 ratio)
• Onset can range from 11 to 84 years of age; most common age of onset between 5th and 7th decades of life
• Uncommon in children
• Can run in families

Clinical Findings

Signs and Symptoms

• Patient reports spinning sensation triggered by specific head positions or head position changes
• Observe nystagmus and patient reports spinning during positioning test postures
• Reports of dizziness (disorientation, wooziness, lightheadedness) between episodes of vertigo
• Reports of loss of balance and falls
• May also have nausea and vomiting when spinning sensation is provoked
• No central signs (diplopia, dysarthria, dysphagia, dysmetria, numbness, or weakness)

Functional Implications

• Difficulty performing normal head movements (bed mobility, looking up, bending over) because symptoms are provoked
• Impedes balance and contributes to falls
• Reduced or lost ability to perform tasks in home, at work, driving

Possible Contributing Causes

• Primarily idiopathic
• Secondary etiology most commonly head trauma
• Other secondary causes are inner ear pathologies (Meniere’s, post-acute vestibulopathy, migraines)

Differential Diagnosis