Bilateral BPPV: When Vertigo Strikes from BOTH the Left and Right Inner Ears!

Benign paroxysmal positional vertigo, or BPPV, is one of the most common causes of dizziness. It happens when tiny calcium crystals in the inner ear, called otoconia, become dislodged and move into one of the semicircular canals, typically the posterior semicircular canal. Usually, this occurs only on one side. However, rarely both posterior canals on each side can become affected resulting in bilateral posterior canal BPPV. Treatment requires the displaced crystals from each side to be repositioned in order to fully resolve the vertigo.

In order to diagnose bilateral BPPV, the Dix-Hallpike maneuver is first performed as shown.

If nystagmus, the rhythmic twitching of the eyes, appears when the head is lowered to one side during the Dix-Hallpike maneuver, BPPV is diagnosed on that side. If nystagmus is also observed when testing the opposite side, the condition is diagnosed as bilateral BPPV.

Treatment begins with the side that showed the stronger nystagmus, since this is also the side that produces the more intense spinning sensation. In this case, the right side displayed the stronger nystagmus response compared to the left side.

As such, a right Epley maneuver is performed first as shown here.

If both sides are treated in the same session, the left Epley maneuver can be performed a few minutes after the right. However, most clinicians prefer a staged approach—waiting 3 to 7 days before treating the opposite side. At that follow-up, the Dix-Hallpike maneuver is repeated to confirm that the right-sided BPPV has resolved and that the left-sided BPPV is still present.

Once confirmed that a left side only BPPV is present, a left Epley is performed.

If nystagmus is still present on both sides during a repeat Dix-Hallpike, treatment should again begin with the side showing the stronger nystagmus response. It may take several cycles of Dix-Hallpike testing followed by Epley maneuvers to fully resolve BPPV on both sides. Complete treatment may take a few weeks.

Although the Epley maneuver was used to treat posterior canal BPPV in this video, alternative maneuvers such as the half-somersault, Gans, or Semont maneuvers can be performed instead.