A new systematic review and meta-analysis published in Frontiers in Medicine suggests that a classical Chinese herbal strategy may offer these patients meaningful relief. Researchers from Dongzhimen Hospital at Beijing University of Chinese Medicine combed eight Chinese and English-language databases for randomized controlled trials testing what traditional Chinese medicine calls spleen-strengthening and phlegm-resolving therapy, or SSPR, against the stubborn dizziness that lingers after repositioning. Their search, covering records from database inception to May 5, 2026, initially retrieved 2,437 articles. After rigorous screening, 37 randomized controlled trials involving 2,794 participants made the final cut, all published in Chinese between 2016 and 2026. The team assessed methodological quality with the Cochrane Risk of Bias tool and pooled the data using random-effects models in RevMan 5.4 and Stata 18.0.

The results were strikingly consistent. When SSPR herbal therapy was compared directly with standard-of-care treatments such as betahistine, ginkgo biloba extracts, or vestibular rehabilitation, the herbal approach significantly reduced scores on the Dizziness Handicap Inventory, a validated 0-to-100 quality-of-life measure, with a mean difference of minus 9.24 points. It also lowered visual analogue scale ratings of dizziness intensity by 1.32 points on average and reduced traditional Chinese medicine syndrome scores with a standardized mean difference of minus 1.84. Beyond the symptom scales, patients receiving herbal therapy achieved higher rates of complete dizziness resolution and better overall clinical effectiveness than those on conventional care alone.

Perhaps even more intriguing were the findings for combination therapy. When SSPR formulas were added to standard treatment, the combined approach outperformed standard care alone on every outcome the researchers evaluated. The Dizziness Handicap Inventory fell by an additional 9.33 points, visual analogue scores dropped by a further 1.39 points, and dizziness resolution rates rose by a factor of 1.66 compared with conventional treatment alone. Most notably, at the six-month follow-up, the recurrence rate in the combination group was just 4.24 percent, versus 14.97 percent among patients receiving only standard care, a relative risk of 0.35 that suggests the herbal strategy may help keep the disabling symptom from coming back.

The numbers carry real clinical weight. Previous research has established that a reduction of at least 18 points on the Dizziness Handicap Inventory represents the minimum clinically important difference, while a more recent analysis suggested that patients begin to perceive meaningful change at around an 11-point reduction. The meta-analysis found that SSPR therapy consistently cut DHI scores by approximately 9 to 11 points, whether used alone or in combination with conventional medicine, approaching that patient-perceived threshold. In subgroup analyses, when the herbal therapy replaced regimens containing central psychotropic drugs, the reduction reached 11.35 points, and when combined with vestibular rehabilitation plus Western medicine, the advantage over standard treatment climbed to more than 20 points.

The therapy itself is rooted in a centuries-old theoretical framework. In traditional Chinese medicine, residual dizziness falls under the category of vertigo, and classical physicians held that neither deficiency nor phlegm should be overlooked. The influential Ming dynasty physician Zhang Jingyue declared that no dizziness arises without deficiency, while his contemporary Zhu Danxi countered that no dizziness arises without phlegm. According to this model, a weakened spleen fails to transform fluids, allowing dampness to condense into a pathological substance called phlegm-turbidity, which is heavy and viscous and blocks the clear yang from ascending to nourish the sensory orifices, producing dizziness and unsteady gait. The SSPR strategy aims to fortify the spleen to cut off the source of phlegm production while simultaneously resolving the phlegm that has already accumulated.

The prescription patterns identified across the 37 trials reveal a remarkably coherent herbal core. Among the 69 distinct herbs used, the five most frequently appearing were Pinelliae Rhizoma, known as Banxia, which appeared 34 times; liquorice root, or Gancao, and Atractylodis Macrocephalae Rhizoma, known as Baizhu, each appearing 31 times; Poria, or Fuling, appearing 30 times; and Gastrodiae Rhizoma, or Tianma, appearing 28 times. Those five herbs are precisely the constituents of Banxia Baizhu Tianma Decoction, a foundational formula for resolving phlegm, extinguishing internal wind, and strengthening the spleen. Warm-natured herbs dominated the prescriptions, appearing 182 times, in keeping with the classical instruction that phlegm-fluid disorders should be harmonized using warm herbs to activate yang qi and assist the spleen’s transformative work.

Modern pharmacology offers tentative mechanistic explanations for why these botanicals might help a vestibular disorder. Network pharmacology studies indicate that the Fuling-Baizhu herb pair may act through calcium and estrogen signaling pathways to modulate inner ear microcirculation and reduce the risk of otolith dislocation. Alkaloids from Banxia appear to damp neuronal hyperexcitability through gamma-aminobutyric acid, or GABA, signaling, and also show anxiolytic effects, while extracts of the herb reduce oxidative stress and may help restore the vestibular microenvironment. Tianma’s active components likewise elevate GABA levels and have demonstrated anti-vertigo, antidepressant, and circulatory effects, enhancing recovery in animal models of vestibular dysfunction. Traditional theory also maps phlegm-turbidity onto abnormal blood rheology, and studies of Banxia Baizhu Tianma Decoction show it can regulate blood lipids and the vasoactive factors endothelin-1 and calcitonin gene-related peptide, potentially improving inner ear blood flow.

Safety data, however, remain the soft underbelly of the evidence. Twenty-four of the included trials mentioned adverse events, fourteen of which reported none in either group. Among the ten trials that documented adverse events, the effects were predominantly mild gastrointestinal complaints such as nausea, abdominal distension, and diarrhea, and no severe adverse events were recorded anywhere in the dataset. Statistically, SSPR therapy showed no significant difference in adverse event rates compared with no intervention, placebo, or standard care, and combining it with conventional treatment raised the incidence only negligibly. Yet the review’s authors are candid that this apparent safety rests on incomplete and possibly underreported data, with low event counts and inconsistent adverse event documentation across the included studies, leaving the true safety profile uncertain.

That caveat is emblematic of the broader limitations the researchers themselves acknowledge. All 37 trials were conducted in China, raising questions about generalizability to other populations. Only 25 trials described their randomization methods, just 7 employed allocation concealment, and none of the studies reporting dropouts used intention-to-treat analysis, contributing to elevated risk-of-bias assessments in a substantial portion of the evidence base. Under the GRADE framework, most outcomes were downgraded one or two levels, yielding evidence of low or very low certainty for many comparisons, with only a handful of outcomes, such as DHI in the combination analysis and visual analogue scores, reaching moderate quality. Publication bias signals also emerged for some secondary outcomes like traditional Chinese medicine syndrome scores and clinical effective rates, likely reflecting heterogeneous rating scales and subjective evaluation criteria. The authors conclude that SSPR therapy shows genuine potential both as an alternative for patients who respond poorly to conventional regimens and as an adjunct that may reduce recurrence, but they call for high-quality, large-sample, adequately blinded randomized trials with objective vestibular outcome measures before the therapy can be firmly recommended. For now, an ancient prescription for phlegm and a weakened spleen has earned a place on the modern research agenda, even if the final verdict on this herbal remedy for stubborn dizziness is still awaiting its most rigorous test.

Subject of Research: Efficacy and safety of spleen-strengthening and phlegm-resolving herbal therapy for residual dizziness after canalith repositioning in benign paroxysmal positional vertigo

Article Title: Efficacy and safety of spleen-strengthening and phlegm-resolving herbal therapy for residual dizziness after repositioning of benign paroxysmal positional vertigo: a systematic review and meta-analysis of randomized controlled trials

Article References: Zhang, Y., Sun, Y., Li, Q., Li, Q., Du, Y., Zhang, B., & Wu, S. (2026). Efficacy and safety of spleen-strengthening and phlegm-resolving herbal therapy for residual dizziness after repositioning of benign paroxysmal positional vertigo: a systematic review and meta-analysis of randomized controlled trials. Frontiers in Medicine, 13, Article 1949948. https://doi.org/10.3389/fmed.2026.1949948

Image Credits: AI Generated

DOI: 10.3389/fmed.2026.1949948

Keywords: benign paroxysmal positional vertigo, residual dizziness, traditional Chinese medicine, spleen-strengthening and phlegm-resolving therapy, meta-analysis, randomized controlled trials, canalith repositioning, Dizziness Handicap Inventory, vestibular rehabilitation, herbal medicine, recurrence rate, GRADE evidence certainty

Obstructive sleep apnea, or OSA, is defined by repeated interruptions or reductions of breathing during sleep, each lasting more than ten seconds and occurring at least five times per hour. The condition is extraordinarily common and extraordinarily underdiagnosed. An estimated 80 to 90 percent of affected adults do not know they have it, and recent estimates place the prevalence in the United States at 32.4 percent, roughly 83.7 million people, a dramatic rise from figures recorded in the 1990s. Severity is graded by the apnea-hypopnea index, with mild disease involving 5 to 15 breathing events per hour, moderate disease 15 to 30, and severe disease 30 or more.

The review’s central question is what happens to the vestibular system, the network of fluid-filled semicircular canals and otolith organs in the inner ear that detects head motion and gravity. Vestibular dysfunction shows up objectively as a reduced vestibulo-ocular reflex gain on the video head impulse test, asymmetrical or absent vestibular-evoked myogenic potentials, or weakened caloric responses. Subjectively, it manifests as dizziness, vertigo, oscillopsia, imbalance, and a heightened risk of falls and accidents that can uproot daily life.

The evidence linking OSA to these deficits is striking. In one study, all 32 patients with moderate-to-severe OSA showed decreased vestibulo-ocular reflex gain compared with healthy controls, and patients with the most severe disease had a significantly higher fall-risk index than those with mild disease or controls. Both ocular and cervical vestibular-evoked myogenic potentials appear significantly lower in OSA patients than in healthy people, indicating damage across the semicircular canals, the saccule and the utricle. A meta-analysis from February 2025 quantified the risk: adults with OSA were significantly more likely to show abnormal vestibular testing, with an odds ratio of 4.8 for abnormal caloric tests, 7.9 for absent cervical vestibular-evoked potentials, and 6.2 for absent ocular vestibular-evoked potentials.

Why would a breathing disorder attack the inner ear? The review lays out three converging mechanisms. The ischemic theory holds that intermittent hypoxia, surging sympathetic tone, and endothelial dysfunction, including elevated levels of the vasoconstrictor endothelin, starve the labyrinth of blood. Because the inner ear is fed exclusively by terminal branches of the anterior inferior cerebellar artery with no collateral circulation, vasospasm or pressure swings can quickly translate into localized oxygen deprivation, and laboratory studies confirm that vestibular hair cells and the vestibular nucleus are vulnerable to hypoxia and reactive oxygen species.

The inflammation theory adds a second assault. Chronic inflammation in OSA releases pro-inflammatory cytokines such as tumor necrosis factor-alpha and interleukin-6, which can trigger apoptosis in vestibular hair cells and atrophy of the stria vascularis. Inflammation also activates monocytes, creating microvascular perfusion deficits within the inner ear that may locally ischemize the vestibular neuroepithelium. A third, anatomical explanation notes that the nasopharynx and oropharynx, the very segments that collapse in OSA, are crucial to eustachian tube function; repetitive mechanical stress and high negative intrathoracic pressure can disrupt middle ear pressure, disturb the endolymph and perilymph, and mechanically stimulate vestibular receptors. Recent work even links semicircular canal dysfunction to altered heart rate variability, implicating autonomic dysregulation as a mediator of the vertigo-apnea connection.

The clinical consequences ripple through three classic vestibular syndromes. Benign paroxysmal positional vertigo, the most common cause of vertigo worldwide, arises when calcium carbonate otoconia dislodge into the semicircular canals, producing brief, violent spinning triggered by head movements. Patients with OSA show significantly higher rates of BPPV than healthy controls, and a 2021 study concluded that BPPV is not a random occurrence in these patients but a systemic consequence of sleep-disordered breathing, although no study has yet screened for BPPV specifically within OSA populations.

Meniere’s disease, a chronic disorder marked by vertigo, hearing loss, tinnitus and aural fullness thought to stem from endolymphatic hydrops, is similarly entangled with sleep apnea. A 2025 study found a staggering 75 percent prevalence of OSA among Meniere’s patients, with moderate-to-severe apnea associated with greater hearing loss. A nine-year longitudinal cohort of more than one million South Koreans showed that adults aged 45 to 64 with OSA had twice the incidence of subsequent Meniere’s disease. Shared risk factors such as obesity, hypertension and metabolic syndrome, along with intermittent hypoxia stressing the blood-labyrinthine barrier, likely explain the association, while fragmented sleep worsens tinnitus.

Vestibular migraine, the leading cause of episodic non-positional vertigo, completes the triad. Among 130 patients with severe OSA, 10.8 percent had vestibular migraine, and OSA was significantly overrepresented in vestibular migraine groups compared with controls. Obesity links the two conditions biologically, and the review’s authors suggest that treating OSA may itself relieve vestibular migraine, an intriguing therapeutic hypothesis that deserves further study.

That therapeutic angle is where the story turns hopeful. Continuous positive airway pressure, the gold standard OSA treatment, keeps the airway splinted open with a steady stream of pressurized air, maintaining consistent oxygen levels and reducing oxidative stress and inflammation. Early evidence suggests CPAP may benefit vestibular function directly: a pilot study of 20 Meniere’s patients with concomitant OSA found that CPAP alone helped control dizziness and vertigo with potential hearing benefit, and CPAP use in migraine sufferers dramatically reduced attack frequency from 5.8 to 0.1 days per month alongside shorter, less painful attacks and less medication use. A 12-month study tracking vestibulo-ocular reflex gain before and after CPAP found no significant improvement yet, hinting that longer treatment windows may be needed. The authors’ prescription is twofold: patients with OSA, especially those with Meniere’s disease or BPPV, should undergo systematic vestibular screening, and anyone with unexplained balance problems should be evaluated for hidden sleep apnea. In a condition that already affects more than 80 million Americans silently, the spinning room may be the clue nobody thought to chase.

Subject of Research: The impact of obstructive sleep apnea on vestibular dysfunction, vertigo syndromes, and balance

Article Title: Vestibular dysfunction in patients with obstructive sleep apnea: from physiopathology to treatment

Article References: Jihène, M., Selima, J., Aymen, S., & Melek, D. (2026). Vestibular dysfunction in patients with obstructive sleep apnea: from physiopathology to treatment. Frontiers in Sleep, 5, Article 1750104. https://doi.org/10.3389/frsle.2026.1750104

Image Credits: AI Generated

DOI: 10.3389/frsle.2026.1750104

Keywords: obstructive sleep apnea, vestibular dysfunction, vertigo, Meniere's disease, benign paroxysmal positional vertigo, vestibular migraine, CPAP, inner ear, intermittent hypoxia, balance disorders, vestibulo-ocular reflex, fall risk

BPPV arises when small calcium carbonate crystals in the inner ear become dislodged and move into semicircular canals, disrupting normal balance signaling. The resulting vertigo is typically brief, triggered by head position changes such as looking up, turning in bed, or bending forward. While benign, the condition can mimic more serious vestibular disorders and may be overlooked when clinicians focus primarily on injury evaluation.

The study examines why screening matters in a falls-clinic setting, where time pressure and multifactorial risk profiles are the norm. Older patients often have several overlapping contributors to falls, including medication effects, gait impairment, and neuropathy. In that environment, positional vertigo can be misattributed to “unsteadiness,” causing delays in diagnosis and treatment.

To identify BPPV, clinicians commonly use bedside maneuvers designed to provoke characteristic symptoms and eye movements. The findings can then guide canal-specific therapy, most notably canalith repositioning procedures that aim to return displaced crystals to their proper location. These interventions are non-invasive and can be effective when matched to the correct subtype of BPPV.

The authors emphasize that systematic screening is not just an academic exercise—it may change outcomes by converting a reversible vestibular problem into a treatable diagnosis. In practical terms, recognizing BPPV during a falls assessment could shorten the pathway from symptoms to intervention, potentially reducing recurrent dizziness-related unsteadiness.

Importantly, the paper frames BPPV detection as a bridge between emergency or geriatric assessment and rehabilitation planning. When dizziness triggers are documented, clinicians can tailor advice on movement strategies, vestibular precautions, and follow-up, rather than relying solely on generalized fall prevention counseling.

The research also draws attention to the broader concept of diagnostic yield in clinical pathways. If a screening test is simple, inexpensive, and highly actionable, it can be justified even when the patient already has many risk factors. For BPPV, the logic is strong: accurate recognition enables immediate therapeutic action.

By centering BPPV within falls-clinic workflows, the study proposes a shift toward more precise, mechanism-based prevention. For older adults, that means fewer missed opportunities to treat dizziness at its source—before it contributes to the next fall.

Subject of Research: Benign paroxysmal positional vertigo (BPPV) screening in older adults presenting to falls clinics

Article Title: The importance of screening for benign paroxysmal positional vertigo in older patients presenting to falls clinics

Article References: Maas, B.D.P.J., van Leeuwen, R.B., Spies, P.E. et al. The importance of screening for benign paroxysmal positional vertigo in older patients presenting to falls clinics. BMC Geriatrics (2026). https://doi.org/10.1186/s12877-026-07777-0

Image Credits: AI Generated

DOI: 10.1186/s12877-026-07777-0

Keywords: