Advances in Benign Paroxysmal Positional Vertigo: Updated Insights on Diagnostic Pitfalls and Management

The diagnosis and treatment of benign paroxysmal positional vertigo (BPPV) rely on the observation of characteristic nystagmus elicited by specific diagnostic and repositioning maneuvers, making clinician expertise essential. Accurate diagnosis requires careful simulation of the position of otoconial debris within the semicircular canals, both at rest and during dynamic maneuvers. Diagnostic and repositioning maneuvers for posterior and horizontal canal BPPV are well established. However, caution is required in cases of cupulolithiasis, especially involving the vertical canals, where the direction of nystagmus may resemble that seen in canalolithiasis. Key features such as minimal latency and fatigability are important for differential diagnosis. Anterior canal BPPV typically presents with predominantly down-beating nystagmus accompanied by a minimal torsional component. Accordingly, recent therapeutic approaches for anterior canal BPPV have emphasized straight head-hanging and head-flexion maneuvers. In general, repositioning maneuvers achieve high cure rates. Nevertheless, the complex microanatomy and pathophysiology of BPPV may limit treatment efficacy. In such cases, clinicians should reassure patients regarding the benign and non-life-threatening nature of BPPV. A careful and systematic approach can then be adopted to reassess the diagnosis and optimize treatment strategies while minimizing vertigo.