Over the years, attempts have been made to identify modifiable risk factors for BPPV. Due to the chemical composition of otoconia, the role of calcium metabolism and its associated conditions have been studied with no firm conclusions. The authors studied the relationship between bone mineral density (BMD), 25-hydroxyvitamin D and idiopathic BPPV by examining the records of 130 adults with BPPV compared with 130 age and sex-matched controls without BPPV. Of the study population(n=130), only 41 had BPPV confirmed by physical examination. The other 89, were deemed to have BPPV on the basis of history alone. This crucial limitation was addressed but not fully in my view. Bone mineral densitometry was measured from the lumbar spine and femur in addition to PTH and vitamin D measurements. As a group, BMD scores were significantly lower in BPPV subjects than in controls. Interestingly, there was no significant difference in vitamin D levels between the two groups of female subjects (BPPV versus control) but there was for the males (p = 0.001 BPPV versus control). Recurrent BPPV was defined as one or more episodes one month or more after a successful treatment. Forty-eight subjects reported a recurrence, mostly females. PTH and vitamin D were not related to recurrence. Although osteoporosis appeared to be associated with risk of recurrence, and both osteoporosis and low vitamin D were associated with occurrence of BPPV, regression analysis showed that only age was an independent predictor factor of both occurrence and recurrence of BPPV. The authors suggested that a neurootologist should manage disorders of bone turnover and also check BMD and vitamin D levels as they might be helpful in managing BPPV. I am not sure this is practical for all BPPV patients, but it might be worth checking vitamin D in recurrent cases.