Bridging the Diagnostic Gap: The CLEAR Algorithm for BPPV-Related Residual Dizziness
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In a landmark review, Kingma, Manzari, and Özgirgin (2026) introduced a structured framework to bridge this diagnostic gap: the Clinician-Led Evaluation for Assessment of Residual dizziness (CLEAR) algorithm. This tool moves the focus from acute mechanical correction to long-term functional recovery.
Redefining Residual Dizziness Phenotypes
A primary hurdle in managing RD involves the lack of standardized definitions. The CLEAR algorithm addresses this by categorizing RD into two distinct types based on the initial presentation.
Type 1 RD
This represents the classic clinical pathway. A specialist confirms BPPV through objective nystagmus and performs a successful maneuver. The patient later reports non-specific dizziness despite the absence of vertigo.
Type 2 RD
This novel subtype captures patients who present with dizziness after acute vertigo has resolved. These individuals often provide a history highly suggestive of BPPV regarding timing and triggers, but lack observable nystagmus during the examination. Specialists classify this as ‘probably BPPV, spontaneously resolved’ (pBPPVsr). Recognizing Type 2 RD prevents unnecessary, costly, and often invasive cardiac or neurological workups.
Pathophysiology: A Dual-System Problem
The algorithm emphasizes that RD rarely stems from a single source. It requires a specialist to evaluate both the peripheral organ and the central nervous system’s adaptation.
Peripheral Drivers
Persistent Micro-debris: Incomplete repositioning may leave otoconial debris behind. While these particles remain too small to trigger the cupula and cause nystagmus, they create a sensory ‘noise’ that the brain interprets as instability.
Endolymphatic Environment: High endolymphatic calcium levels slow the dissolution of otoconia. This process is often linked to Vitamin D deficiency, as the active form of Vitamin D regulates epithelial Ca2+ channel transporters, which are essential for inner ear homeostasis.
Microcirculatory Ischemia: Conditions such as hypertension and diabetes cause hypoxia in the utricular macula, leading to further otolith detachment and delayed recovery.
Central Drivers
Maladaptive Compensation: When BPPV persists for a long duration, the brain adjusts its tonic discharge to account for the faulty vestibular input. Once the clinician clears the debris, the brain must ‘un-learn’ this adaptation. This readaptation phase often manifests as the subjective sensation of RD.
The Anxiety Loop: Anxiety and depression act as physiological barriers to recovery rather than mere psychological side effects. Elevated anxiety correlates with incomplete central adaptation, potentially due to disruptions in the dopaminergic pathways that facilitate vestibular compensation.
The CLEAR Algorithm in Practice
The CLEAR tool functions as an interactive, evidence-based decision tree. It guides the vestibular professional through a checklist of risk factors and suggests specific follow-up strategies tailored to the patient profile.
Management Strategies
Strict De-prescribing: Specialists must actively avoid or discontinue ‘vestibular suppressants’ like meclizine. These medications provide temporary symptomatic relief but actively hinder the central nervous system’s ability to compensate, effectively prolonging the RD.
Targeted Vestibular Rehabilitation: While maneuvers correct the mechanical displacement, exercise-based rehabilitation recalibrates the sensory substitution process. This is particularly vital for patients who show signs of dynamic deficits.
Metabolic Optimization: Managing comorbidities remains essential for long-term stability. This includes addressing Vitamin D insufficiency to support otoconia health and controlling vascular risk factors to prevent recurrent ischemia.
Conclusion and Access
The CLEAR algorithm represents a significant advancement in neuro-otology. By identifying the underlying peripheral and central drivers of dizziness, clinicians can resolve symptoms more quickly and mitigate the profound morbidity associated with chronic imbalance.
The authors designed the CLEAR algorithm as a live resource for specialists. It provides impact scores for various risk factors—ranging from age to abnormal VEMP results—to help clinicians predict which patients require more intensive follow-up.
Interactive Clinical Tool:
https://clear-dizziness.org
Reference:
Kingma, H., Manzari, L., & Özgirgin, N. (2026). Enhancing patient care in BPPV-related residual dizziness: introducing the CLEAR algorithm to support BPPV-RD recognition and follow-up strategies. Frontiers in Neurology, 16. https://doi.org/10.3389/fneur.2025.1689617