Dizziness can feel different from person to person, ranging from light-headedness and imbalance to a spinning sensation known as vertigo. While inner-ear and vestibular problems are common causes, dizziness may also be linked to migraine, neurological conditions, medications or other health issues. An otolaryngologist can assess symptoms and determine the underlying cause.
One common inner-ear condition is benign paroxysmal positional vertigo (BPPV), which causes brief episodes of spinning triggered by movements such as turning in bed, bending down or looking upwards. Once the affected canal is identified, BPPV can often be treated effectively with appropriate repositioning manoeuvres.
What causes dizziness and vertigo?
Dizziness and balance depend on signals from the inner ear, eyes and body, which the brain combines to maintain stability. When the vestibular system is disrupted, it can cause vertigo, dizziness, nausea or unsteadiness. However, dizziness is not always caused by an inner-ear disorder and may also be linked to vestibular migraine, neurological or cardiovascular conditions, or medications. Common inner-ear causes include BPPV, acute vestibulopathy and Ménière’s disease, but the correct diagnosis depends on the individual’s symptoms and clinical assessment.
Recognising benign paroxysmal positional vertigo
BPPV occurs when tiny calcium carbonate particles, commonly called otoconia or inner-ear crystals, become displaced from their normal location and enter one of the semicircular canals.
Normally, these particles contribute to the body’s ability to sense gravity and movement. When they enter a semicircular canal, changes in head position can cause the particles to move through the fluid inside the canal. This produces abnormal stimulation of the balance sensors and can trigger a brief spinning sensation.
Typical BPPV symptoms include:
- Sudden episodes of spinning or vertigo
- Symptoms triggered by turning over in bed
- Dizziness when looking upwards or downwards
- Brief episodes that usually last seconds to around a minute
- Nausea or unsteadiness during or after an episode
BPPV can occur at any age but becomes more common with increasing age. It may occur spontaneously or following head or ear trauma and other inner-ear problems.
However, not every episode of dizziness triggered by movement is BPPV. Identifying the pattern of symptoms and observing the eye movements produced by specific head positions are important parts of diagnosis.
How is dizziness and vertigo diagnosed?
A detailed assessment usually begins with the patient’s medical history. An ENT specialist may ask about when the dizziness began, how long episodes last, what triggers them, whether hearing has changed and whether symptoms such as tinnitus, headache, nausea or imbalance are present.
The examination may include assessment of eye movements, balance, hearing and vestibular function. For suspected BPPV, positional tests such as the Dix-Hallpike manoeuvre and, when appropriate, the supine roll test can help identify the affected semicircular canal. Clinical guidelines recommend canalith repositioning treatment for appropriate cases of posterior-canal BPPV.
For patients with more complex, persistent or unexplained vestibular symptoms, additional vestibular function testing may provide useful information.
Video Head Impulse Test (vHIT)
The video head impulse test (vHIT) is a modern, non-invasive assessment of the vestibulo-ocular reflex, or VOR.
During the test, specialised goggles record eye movements while the patient’s head is moved rapidly in different directions. The test helps assess how effectively the semicircular canals detect rapid head movements and how well the eyes compensate to maintain a stable visual image.
Unlike some conventional vestibular assessments that focus primarily on the horizontal semicircular canals, vHIT can assess the function of all six semicircular canals. It can therefore provide quantitative information about vestibular function and may be particularly useful when assessing conditions such as acute vestibular dysfunction.
Vestibular Evoked Myogenic Potentials (VEMP)
VEMP testing provides another way of assessing parts of the vestibular system.
Cervical VEMP, or cVEMP, and ocular VEMP, or oVEMP, examine vestibular reflex pathways associated mainly with the otolith organs. Depending on the type of VEMP performed, the test can provide information about pathways involving the saccule or utricle.
VEMP may be useful as part of a broader vestibular assessment when the clinical picture suggests a particular vestibular disorder. However, it is important to understand that VEMP is not a standalone test for every cause of dizziness and is not used to diagnose BPPV by itself.
Other vestibular assessments
Depending on the symptoms, a comprehensive dizziness assessment may also involve videonystagmography, caloric testing, hearing tests and other balance assessments.
These tests are not necessarily required for every patient. In straightforward BPPV, clinical examination and positional testing may be sufficient. Current BPPV guidelines specifically recommend against routine vestibular testing when the patient already meets the diagnostic criteria for BPPV and there are no additional findings suggesting another vestibular disorder.
The purpose of advanced vestibular testing is therefore not simply to perform more tests. It is to answer specific clinical questions when the diagnosis is uncertain, symptoms persist or another vestibular condition needs to be considered.
Treating BPPV with repositioning manoeuvres
Once BPPV is diagnosed, treatment aims to move displaced inner-ear crystals out of the semicircular canal. For many patients, this is achieved through canalith repositioning manoeuvres, such as the Epley manoeuvre, which uses specific head and body movements to guide the particles back into place. Repositioning is generally recommended as the initial treatment for appropriate posterior-canal BPPV rather than routinely using medication.
However, recurrent, complex or difficult-to-localise BPPV may require a different approach. Patients with multiple canal involvement or physical limitations affecting the neck or back may also find manual manoeuvres challenging. In such cases, a TRV repositioning chair may provide a controlled alternative for repositioning.
What is a TRV chair?
The Thomas Richard-Vitton (TRV) chair is a specialised, multi-axial chair used to diagnose and treat BPPV. It allows controlled movement of the head and body while eye movements are monitored using video goggles. This can be particularly helpful for complex, recurrent or atypical BPPV, especially when the affected canal is difficult to identify or conventional manoeuvres are challenging.
Research suggests that repositioning chairs can be useful in managing difficult cases. However, the TRV chair has not been shown to be universally superior to manual repositioning manoeuvres. Its main value lies in providing controlled, precise positioning when standard treatment is difficult or unsuccessful.
What can patients expect from BPPV treatment?
The treatment approach depends on the type and location of BPPV, as well as the patient’s overall health and mobility.
After treatment, some people may experience temporary imbalance or mild dizziness before their vestibular system settles. Follow-up may be recommended to confirm that the positional vertigo has resolved.
BPPV can also recur. Singapore’s HealthHub notes that recurrence varies between individuals and that the condition can often be successfully managed with appropriate repositioning manoeuvres.
Patients with ongoing dizziness should not simply assume that persistent symptoms mean the BPPV has returned. Other vestibular or neurological causes may need to be considered, particularly when symptoms change or do not follow the typical pattern of BPPV.
When should you seek medical attention for dizziness?
Not every episode of dizziness requires emergency treatment, but recurrent, sudden, severe, prolonged or unexplained dizziness should be assessed by a doctor.
Urgent medical attention is particularly important when dizziness or vertigo occurs together with symptoms such as severe headache, weakness or numbness, difficulty speaking, double vision, fainting, difficulty walking, chest pain, ongoing vomiting or sudden hearing changes.
For patients experiencing recurrent vertigo, an assessment by an experienced ENT specialist or a clinician experienced in vestibular and balance disorders can help determine whether the symptoms originate from the inner ear or require investigation for another cause.
A targeted approach to dizziness and vertigo
Dizziness is a symptom, not a diagnosis, so identifying its underlying cause is essential for effective treatment. Straightforward BPPV may be diagnosed through clinical and positional testing before canalith repositioning.
For persistent, atypical or complex cases, advanced vestibular tests such as vHIT and VEMP can provide further insight into vestibular function. When conventional BPPV treatment is challenging, the TRV repositioning chair allows controlled, multi-axial repositioning while monitoring eye movements.
Patients experiencing recurrent dizziness or vertigo may benefit from a dizziness and balance assessment to identify the cause and receive appropriate, targeted treatment.
