This 71-year-old man, with well-controlled Parkinson disease, developed positional vertigo and minimal nausea whenever he changed the position of his head and, particularly, when looking up quickly. He was otherwise stable on levodopa treatment, at a dose of 200 mg q.i.d. with excellent function and only mild motor fluctuations, expressed as tremor reemergence toward the end of each dose cycle.

Our patient with well-controlled Parkinson disease presented with unrelated but classic right posterior semicircular canal variant of benign paroxysmal positional vertigo (BPPV), which was suggested by a history of positional vertigo appearing when in bed and turning or extending his head. The diagnosis of BPPV was confirmed with the Dix-Hallpike maneuver, which elicited nystagmus with a torsional component when rapidly extending the head toward the affected ear, which reproduced the intensity and severity of prior vertiginous episodes. The torsional nystagmus was “geotropic” and more prominent when the eye moved toward affected ear. This form of peripheral nystagmus has a latency of 3 to 20 seconds and exhibits fatigability with repeated testing.

BPPV is the most common cause of vertigo in the general population. It consists of sudden and short-lasting recurrent vertigo elicited by certain rotational movements of the head. It is caused by free-floating debris, typically calcium carbonate crystals (otoliths), that dislocate from the utriculus of the vestibular labyrinth and migrate to the more dependent semicircular canals, most often posterior. The otolith movement alters endolymphatic pressure and causes cupular deflection, triggering the spinning sensation that defines vertigo. Head trauma and labyrinthitis are considered risk factors for the development of BPPV, although they are documented in relatively few such patients. BPPV may be self-limited, but remissions can be induced at the bedside with the Epley maneuver, as illustrated in the video.

The Epley maneuver treats BPPV patients by relocating their free-floating debris from the posterior semicircular canal back into the vestibular labyrinth (Fig. 95.1). The maneuver may need to be repeated until the patient is asymptomatic. There is about 80% success rate after a single treatment. The patient is advised to remain upright for 24 hours following the Epley maneuver at the office in order to minimize the likelihood of debris remigration to the posterior semicircular canal. When relapse develops, a second session is warranted. High-grade carotid stenosis and unstable heart disease are contraindications for this maneuver.