Vestibular Disorders: BPPV, Meniere Disease, and Vestibular Neuritis
Core concepts
Know the pathophysiology and bedside diagnosis of benign paroxysmal positional vertigo (BPPV), Meniere disease, and vestibular neuritis. BPPV results from canalithiasis; posterior canal is most common. Dix-Hallpike provokes torsional upbeating nystagmus with latency and fatigability; the Epley maneuver is therapeutic. Meniere disease is episodic vertigo with fluctuating sensorineural hearing loss, tinnitus, and aural fullness; endolymphatic hydrops is the proposed mechanism. Vestibular neuritis is acute prolonged vertigo without hearing loss, often post-viral, with abnormal head impulse toward the affected side.
Traps in questions
- BPPV nystagmus has latency and fatigues; central positional nystagmus does not.
- Meniere disease requires episodic vertigo plus documented fluctuating hearing loss; isolated vertigo is insufficient.
- Vestibular neuritis spares hearing; if hearing loss is present, reconsider labyrinthitis or central causes.
- Horizontal canal BPPV responds to the barbecue roll, not Epley.
- Recurrent episodic vertigo with normal hearing suggests vestibular migraine.
Worked rule of thumb
Provoked brief positional vertigo with a positive Dix-Hallpike and no hearing symptoms is BPPV; perform Epley. Spontaneous prolonged vertigo with abnormal head impulse and no hearing loss is vestibular neuritis. Episodic vertigo with fluctuating hearing loss and aural fullness is Meniere disease.