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Vestibular disorders: BPPV, vestibular neuritis, Ménière's, third window, bilateral loss and central signs
Most disorders are told apart by how long the vertigo lasts and what triggers it: seconds on changing position — BPPV; minutes to hours in attacks with ear symptoms — Ménière's; days of constant vertigo — vestibular neuritis (or stroke, picked out with HINTS). Third window and bilateral loss are patterns recognised from test findings.
Why it matters in the exam
BPPV: otoconia shed from the utricle enter a canal, most often the posterior one. Brief vertigo (under a minute) on position changes; the Dix-Hallpike test shows, after a short latency, upbeating torsional nystagmus that fatigues. Treatment: a canalith repositioning manoeuvre (Epley), with no drugs and no positional restrictions afterwards. For the horizontal canal the supine roll test is used: geotropic nystagmus to both sides means free particles (canalithiasis), and the side with the stronger response is the sick one. Vestibular neuritis: continuous spinning vertigo for days, nausea, no hearing loss; direction-fixed nystagmus beating away from the affected side, and a positive head impulse toward the affected side. When only the superior nerve is hit, the cVEMP (saccule, inferior nerve) is spared.
Central signs: by HINTS, in an acute vestibular syndrome — a normal head impulse, direction-changing nystagmus and a vertical eye misalignment (skew) point to stroke. Pure downbeating nystagmus with no latency and no fatigue is central too. Ménière's: spontaneous vertigo attacks of 20 minutes to 12 hours with low-frequency loss, tinnitus and fullness. Third window (superior canal dehiscence): a low-frequency air-bone gap with normal tympanogram and reflexes, better-than-normal bone conduction, hearing one's own body sounds and vertigo from loud sounds; a large VEMP with a low threshold; an enlarged vestibular aqueduct also gives a high VEMP. Cholesteatoma can erode the horizontal canal and create a fistula — vertigo with pressure on the ear. Bilateral loss (for example after gentamicin): oscillopsia — the world "jumps" when walking — and unsteadiness in the dark; rehabilitation stresses substitution (vision and sensation from the feet), because there is nothing left to adapt. In one-sided loss gaze-stabilisation exercises (adaptation) are stressed.
Key points
- BPPV: otoconia in a canal, usually the posterior; Epley.
- Neuritis: days, no hearing loss; nystagmus away from the affected side.
- HINTS: normal impulse, direction-changing, skew — stroke.
- Third window: low-frequency gap, normal reflexes, large VEMP.
- Bilateral loss: oscillopsia; rehabilitation by substitution.
Summary table
| Disorder | Presentation | Test or treatment |
|---|---|---|
| Posterior canal BPPV | Seconds, on position change | Dix-Hallpike: upbeating and torsional, fatigues; Epley |
| Horizontal canal BPPV | Lying down and rolling the head | Geotropic — the affected side is the stronger |
| Vestibular neuritis | Days, constant, no hearing loss | Nystagmus away from the affected side; positive head impulse |
| Stroke (central) | Acute syndrome | HINTS: normal head impulse, direction-changing nystagmus, skew |
| Ménière's | 20 minutes to 12 hours, spontaneous | Low-frequency loss, tinnitus, fullness |
| Third window | Low-frequency gap, normal tympanogram and reflexes | Large VEMP; CT |
| Bilateral loss | Oscillopsia, unsteadiness in the dark | Rehabilitation by substitution |
A free exam question
On the supine roll test, horizontal geotropic nystagmus (beating toward the ground) appears on both sides, stronger and longer when the head is turned to the right. What is the most likely diagnosis?
- A. Left horizontal canal BPPV, canalithiasis type
- B. Right horizontal canal BPPV, cupulolithiasis type
- C. Right posterior canal BPPV
- D. Right horizontal canal BPPV, canalithiasis type
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Sources
- Bhattacharyya et al., Otolaryngology–Head and Neck Surgery, 2017 — Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (update)
- Kattah, Talkad, Wang, Hsieh & Newman-Toker, Stroke, 2009 — HINTS to diagnose stroke in the acute vestibular syndrome
- Hall et al., Journal of Neurologic Physical Therapy, 2022 — Vestibular rehabilitation for peripheral vestibular hypofunction: an updated clinical practice guideline
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-02. The text may contain errors; when in doubt, check the source.