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- otoconia of the utricular macule may become dislodged and over time relocated to one of the semicircular ducts (usually the posterior).
-The otoconial debris within the semicircular duct
causes abnormal endolymph displacement and a sensation of
vertigo known as benign paroxysmal positional vertigo, which
may be diagnosed with a Dix-Hallpike Positional Test

• Ask the patient to sit upright on an examination couch, with
their head turned 45° to one side.
• Rapidly lower the patient until their supported head is
angled 30° below horizontal over the top edge of the couch
(or place a pillow for the upper back).
• Ask the patient to keep their eyes open and report any
feelings of vertigo.
• Examine the eyes for nystagmus – BPPV may have a
latent period of up to 20s before vertigo commences,
accompanied by an inferolateral rotary nystagmus which
will fatigue (adapt).
• Repeat the test with the patient’s head turned 45° to the
other side.
BPPV may be mimicked by Ménière’s disease, vestibular
neuritis, head injuries and brain tumours. Central pathologies such as cerebrovascular disease
and MS tend to produce an immediate nystagmus that shows no adaptation.