Otolithiasis (benign paroxysmal positional vertigo, BPPV) may sound like an obscure medical term, but in fact many people have experienced or are experiencing problems caused by it. Every day, a considerable number of patients seek care for vertigo symptoms, and most of them obtain effective relief after otolith repositioning treatment. However, some patients do not improve after repositioning; their vertigo may even worsen, and a few require hospitalization as a result.

1. Worsening vertigo after otolith repositioning

1. "Recovery symptoms" after benign paroxysmal positional vertigo

First, it should be made clear that worsening of symptoms after canalith repositioning is not always bad. For the vast majority of patients, symptoms gradually improve after repositioning. However, some patients, especially during the initial or repeated repositioning maneuvers, may feel that their vertigo actually worsens, which often leaves them confused and even anxious.

In fact, this phenomenon of "symptom worsening" is usually a short-term sequela after repositioning. Patients often experience dizziness, lightheadedness, and unsteady standing, and the duration may range from a few days to a week. This symptom does not indicate failure of the maneuver, but is a common occurrence as the vestibular system recovers. Because the repositioning procedure actually clears dislodged otoconia from the semicircular canals, it may transiently stimulate the vestibular system and cause temporary discomfort. Fortunately, these symptoms usually ease within a few days and do not require undue worry.

2. Incomplete repositioning or inaccurate diagnosis

However, if the worsening of symptoms persists and the treatment effect is unsatisfactory, it may be that the benign paroxysmal positional vertigo (BPPV) itself is more complex, or the treatment method is inappropriate. There are many types of BPPV; the most common is posterior semicircular canal BPPV, but some patients have involvement of other semicircular canals or vestibular structures. If the physician did not clearly identify the “culprit” during diagnosis and used an incorrect repositioning maneuver, or if the otoliths were not completely repositioned, this may lead to ineffective control of symptoms or even worsening.

In this situation, the patient should return for follow-up promptly to undergo more detailed examinations to determine the type of BPPV, and the treatment plan should be adjusted if necessary. To ensure treatment accuracy—especially for patients with complex or recurrent symptoms—it is recommended to perform detailed vestibular function testing and imaging examinations to develop an individualized treatment plan for the patient.

2. When is hospitalization required?

Most BPPV patients achieve good relief with outpatient treatment, but a portion of patients, due to complex conditions or poor treatment response, require hospitalization. So, which patients need inpatient treatment?

1. Patients with complex conditions or unclear diagnosis

If the patient's benign paroxysmal positional vertigo is complex, or the diagnosis remains unclear, especially when the patient experiences recurrent symptoms, hospitalization is often necessary. During the hospital stay, physicians can observe symptom changes more closely and perform further diagnostics to ensure precise treatment.

2. Patients for whom conservative treatment is ineffective

For those patients who have not improved after prolonged conservative treatment, particularly those with confirmed vestibular dysfunction, hospitalization can help clinicians implement more systematic interventions. Inpatient care can combine pharmacotherapy and vestibular rehabilitation to accelerate recovery of vestibular function.

3. Patients with other chronic diseases

Many patients with benign paroxysmal positional vertigo may also have chronic conditions such as hypertension, diabetes, or osteoporosis, and the presence of these diseases can affect the recovery process of BPPV. Therefore, these patients often need hospitalization for more comprehensive treatment to ensure the health of various body systems is improved, thereby promoting recovery from BPPV.

3. Recurrent episodes require focused screening

When treating BPPV, some patients may undergo multiple otolith repositioning maneuvers but still experience little improvement. For these patients, simple repositioning of the otoliths often cannot achieve the desired effect and may require more in-depth examinations and treatments.

1. Vestibular function testing

For patients with multiple ineffective treatments, the physician should first consider whether vestibular function impairment is present. The vestibular system is the body’s key system for sensing balance and spatial orientation; if it is dysfunctional, patients may still experience dizziness or postural instability even if otolith repositioning has restored the otoliths to their normal position. Vestibular function testing can help clinicians understand the patient’s vestibular status and thereby formulate a more appropriate treatment plan.

2. Combined medication and rehabilitation training

In cases of vestibular function impairment, isolated otolith repositioning may not effectively treat otolithiasis. In such cases, patients need adjunctive pharmacotherapy and vestibular rehabilitation training to help restore vestibular function. Medications can alleviate symptoms, while rehabilitation training—through specific positional maneuvers and exercises—can help the vestibular system readapt, achieving long-term therapeutic effects.