This study illustrates the relationship between benign positional paroxysmal vertigo (BPPV) and vestibular neuritis (VN) through case examples to improve diagnostic accuracy and patient outcomes.

There is an increased incidence of BPPV after VN (10-15%) compared to idiopathic BPPV (0.6%); however, this relationship is often unrecognized. One possible mechanism is damage to the superior vestibular nerve, which innervates the anterior canal (AC), horizontal canal (HC) and utricle but spares the posterior canal (PC), results in otoconia from the damaged utricle dislodging into most often, the PC. It is typically seen in younger patients, ipsilateral to the affected nerve, and often requires more repositioning maneuvers to treat.

Patients seen in vestibular neurology clinic underwent video-oculography (VOG), video head-impulse testing (vHIT), and ocular motor examination.

Case 1:

History: acute vestibular syndrome (AVS) 4 months prior with chronic disequilibrium worsened with turning in bed

VOG: right-beating nystagmus (RBN), increased after horizontal head-shaking, left Dix-Hallpike: upbeat torsional nystagmus

vHIT: left AC/HC hypofunction, left HC overt catch-up saccades

Diagnosis: left VN, ipsilateral PC BPPV

Case 2:

History: AVS 1 month prior with persistent dizziness worsened with quick head movements

VOG: mild spontaneous RBN, increased with horizontal head-shaking, left Dix-Hallpike: upbeat torsional nystagmus

vHIT: left AC/HC mild hypofunction, left HC overt catch-up saccades

Diagnosis: left VN, ipsilateral PC BPPV

Case 3:

History: AVS 3 months prior with persistent dizziness worsened with left head turn

VOG: mild spontaneous RBN, left Dix-Hallpike: upbeat torsional nystagmus

vHIT: left HC overt catch-up saccades

Neurologists should be familiar with the association between VN and positional vertigo, especially because BPPV is readily treatable. Patients diagnosed with VN should be educated about this relationship to ensure that if BPPV occurs, patients are triaged properly (for outpatient repositioning maneuvers) to avoid an unnecessary return to the emergency department.