Benign paroxysmal positional vertigo (BPPV), the most common cause of dizziness, occurs in all age groups. It presents with vertigo on head movement, but in older patients presentation may be typical and thus accounting for a low recognition rate in the primary care setting. It may be recurrent in up to 50% of cases. BPPV is associated with displacement of fragments of utricular otoconia into the semicircular canals, most commonly the posterior semicircular canal. Otoconia are composed of otoconin and otolin forming the organic matrix on which calcium carbonate mineralizes. Otoconia may fragment with trauma, age, or changes in the physiology of endolymph (e.g., pH and calcium concentration). Presentation varied because otoconia fragments can be displaced into any of the semicircular canals on either (or both) side and may be free floating (canalolithiasis) or attached to the cupula (cupulolithiasis). Most cases of BPPV are idiopathic, but head trauma, otologic disorders, and systemic disease appear to be contributory in a subset. Positional maneuvers are used to diagnose and treat the majority of cases. In rare intractable cases surgical management may be considered. A strong association with osteoporosis suggests that idiopathic BPPV may have diagnostic and management implications beyond that of a purely otologic condition. 1. Epidemiology and Impact Dizziness arising from vertigo is a common morbidity that adversely affects balance and quality of life. A study of a nationally representative sample of 4,869 adults living in Germany who were screened for moderate or severe dizziness found a prevalence of 22.9% for dizziness/vertigo in the prior 12 months [1]. In that study, the prevalence and incidence of vestibular vertigo were 4.9% and 1.4%, respectively. They also found that, compared to nonvestibular dizziness, vestibular vertigo was more frequently followed by medical consultation, sick leave, interruption of daily activities, and avoidance of leaving the house. Population studies such as the above consistently show that benign paroxysmal positional vertigo (BPPV) is the most common cause of dizziness [2]. In a large registry that included data collected from 4,294 patients with vertigo in 13 countries generated over a 28-month period (the Registry to Evaluate the Burden of Disease in Vertigo, the so-called REVERT registry) nearly 1/3 were diagnosed to have BPPV [3]. BPPV can occur throughout the lifespan, from childhood [4] into old age. While presentation with complaints consistent with BPPV is very common, the prevalence of undiagnosed BPPV is
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