Benign Paroxysmal Positional Vertigo: The Daily PANCE Blueprint
A 58-year-old woman presents with 1 week of brief episodes of intense spinning vertigo that start when she rolls over in bed or tips her head back to look up at a shelf. Each episode lasts less than a minute and causes nausea. She has no hearing loss, tinnitus, or ear fullness, no headache or weakness, and her neurologic examination is normal. When she is moved quickly from sitting to lying with her head turned to the right and extended, upbeating torsional nystagmus appears after a few seconds and fades within 30 seconds. Which of the following is the most likely diagnosis?
A. Benign paroxysmal positional vertigo
B. Vestibular neuritis
C. Ménière disease
D. Vertebrobasilar stroke
E. Vestibular schwannoma (acoustic neuroma)
Answer and topic summary
The answer is A. Benign paroxysmal positional vertigo
Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo. Loose calcium crystals (otoconia) drift into a semicircular canal, most often the posterior canal, so head movements trigger brief vertigo lasting under a minute. The Dix-Hallpike maneuver confirms it: torsional, upbeating nystagmus after a short delay that fatigues. Treatment is a canalith repositioning maneuver (Epley), not routine meclizine. Vestibular neuritis causes continuous vertigo for days, often after a viral illness, with normal hearing (add hearing loss and it is labyrinthitis). Ménière disease causes episodes lasting 20 minutes to hours with fluctuating hearing loss, tinnitus, and ear fullness. A stroke gives central signs and nystagmus that changes direction, and a vestibular schwannoma causes slowly progressive one-sided hearing loss.
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