Editors' note: Questionnaire-based diagnosis of benign paroxysmal positional vertigo

In the article, "Questionnaire-based diagnosis of benign paroxysmal positional vertigo (BPPV)," Kim et al. presented a study of a 6-item questionnaire developed for the diagnosis of BPPV, with the first 3 questions intended to identify BPPV and the next 3 intended to determine the involved canal and type of BPPV. Among 578 patients who completed the questionnaire before positional tests at a dizziness clinic, the questionnaire could diagnose BPPV with a sensitivity of 87.0% and specificity of 89.8%. The questionnaire and positional tests showed similar results in identifying the BPPV subtype and the affected side. In response, Drs. Gold and Newman-Toker noted that although BPPV itself can often be diagnosed by history, the physical examination is traditionally key to identify the site of the culprit otoliths. Although hailing the questionnaire-based method as an important step forward, they raise questions about its reproducibility—particularly in other care settings—and about its potential to facilitate self-treatment by patients at home. In another response, Dr. Lanska is skeptical of the questionnaire's utility for identifying the type of BPPV and contends that the proportion of horizontal canal BPPV (HC-BPPV) was atypically high—potentially because of referral bias—thereby lowering the predicted accuracy of simply classifying all questionnaire-positive cases as the posterior canal subtype (PC-BPPV). Dr. Lanska suggests using a simpler 4-question strategy focused on making a diagnosis of BPPV (presuming a posterior canal [PC] BPPV subtype), determining the side, and pursuing referral to a vestibular expert only if initial side-appropriate self-treatment maneuvers are unsuccessful. Responding to these comments, the authors acknowledge the need to further evaluate the generalizability of their results to other clinical settings and note that they are conducting a clinical trial on the self-application of canalith repositioning maneuvers by patients based on questionnaire results. The authors acknowledge that the PC is much more commonly involved in BPPV but caution against underestimating the frequency of HC-BPPV. However, they acknowledge the potential benefit of a simpler 4-question approach, particularly in practices with a higher PC-BPPV prevalence and note that its performance could be compared with their six-question strategy in further studies. This exchange highlights the potential for questionnaire-based strategies to facilitate diagnosis and streamline referral pathways for common neurologic conditions such as BPPV.

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