Vestibular disorders
Benign paroxysmal positional vertigo
This information is intended as a general introduction to the topic. Since every person is affected differently by balance and dizziness problems, you should consult your doctor for individual advice.
For reasons of readability, the generic masculine form is used and the simultaneous use of the male, female, and diverse (m/f/d) forms is omitted. Unless otherwise specified, the personal designations used in this patient information refer to all genders.
What is benign paroxysmal positional vertigo?
Benign paroxysmal positional vertigo (BPPV) is the most common inner ear disorder. It causes sudden, short attacks of vertigo, which are usually triggered by certain changes in head position.
Each word in the name describes a part of the disorder:
- Benign – non-cancerous – not a life-threatening health problem
- Paroxysmal – the symptoms come and go quickly
- Positional – occurs with certain changes in head position
- Vertigo – This corresponds to a spinning sensation (either as if you are spinning in space or the space around you is spinning)
BPLS can affect one or more of the semicircular canals in the inner ear at the same time. In 80 - 90 % of cases, the posterior (back) semicircular canal is affected. In 10 - 20 % of cases the horizontal semicircular canal is affected and in 3 % of cases the anterior semicircular canal (also known as the anterior or superior semicircular canal).
BPPV affects around 2.5% of people at some point in their lives. Between 20 - 30 % of patients with vertigo have BPPV.
BPPV becomes more common with age. In half of all people over the age of 50, BPPV is the main cause of dizziness. BPPV can increase the likelihood of falling, especially as you get older.
Women are 2 to 3 times more likely to develop BPPV than men.
Summary
- One of the most common causes of vertigo.
- Occurs most frequently in middle-aged and older people.
- May increase the likelihood of a fall.
- Usually only one ear is affected.
- Tiny calcium carbonate crystals (otoconia) dislodge from the otolith organ (the utricle) and fall into a semicircular canal (one of the three semicircular canals in the inner ear).
- Slipped crystals cause a sudden, brief spinning vertigo after a certain change in head position, e.g. when lying down or turning over in bed.
- To feel better and stop the spinning, the crystals must be returned to the otolith organ (the utriculus).
- A doctor or vestibular therapist can achieve this through repositioning maneuvers. In most cases, only one treatment is necessary.
- A few people have rarer forms - these are difficult to diagnose and treat.
- BPLS is unlikely if the vertigo lasts longer than one minute.
What causes benign paroxysmal positional vertigo?
To understand what causes BPPV, it is important to know how the balance system in the inner ear (the vestibular system) works.
In the inner ear are the snail-shaped hearing organ (the cochlea) and the vestibular system (the utricle, saccule, and the three semicircular canals). The vestibular system responds to gravity and tells your brain whether you are moving up or down, right or left, forward or backward. In this gravity-sensing area, tiny calcium carbonate crystals (otoliths) sit on a jelly-like membrane.
The semicircular canals are positioned at 90-degree angles to each other. The horizontal canal lies roughly parallel to the ground, the posterior canal is oriented backward, and the anterior canal is oriented upward. The semicircular canals detect rotational movements and measure acceleration. They contain a fluid (endolymph) and have tiny hair cells at their ends. When the inner ear fluid moves, the hair cells bend and activate nerves that connect to the brain, helping to control eye movement. In this way, the eyes essentially follow the vestibular system.
However, when crystals fall into a semicircular canal, the normal interaction between the fluid and the hair cells is disturbed. The canal becomes sensitive to changes in head position that it would not normally respond to. This disturbance causes a spinning sensation (either as if you are moving in the room, or as if the room around you is spinning).
Most cases of BPPV are idiopathic, meaning they occur without any identifiable cause. This type of BPPV is also called primary BPPV. The following factors may make you more susceptible to idiopathic BPPV:
- older age
- female gender
- unusual head postures, e.g. when you lean your head back for a long time at the dentist or hairdresser
- Vitamin D deficiency: can contribute to a seasonal form of BPPV
- Osteopenia and osteoporosis: Age-related deterioration of the structures in the inner ear or crystals can contribute to the shifting of crystals and the development of BPPV. There is a possible link between osteopenia (low bone mass) or osteoporosis (a disease that causes bones to become weak and brittle) and BPLS. Postmenopausal women with osteopenia or osteoporosis are about three times more likely to develop BPLS than the general population of the same age. The role of oestrogen (female sex hormone) in calcium metabolism could explain why age and female sex are risk factors for BPLS.
A secondary BPPV an be caused by a number of conditions that damage the inner ear and cause crystals to dislodge. These include:
- Operations on the ear
- Head injuries, including minor traumatic brain injuries (concussions)
- Inner ear infections
- Inner ear diseases such as Ménière's disease or neuritis vestibularis
- Medication that damages the vestibular organ in the inner ear
- Prolonged bedriddenness
Some studies suggest a link between BPPV and dental interventions.
In contrast to idiopathic BPPV, both ears can be affected (bilaterally) in secondary BPPV. This requires more than one treatment and recurs more frequently
The characteristic symptom of BPPV is vertigo, which usually lasts less than 60 seconds. It typically occurs in episodes. The dizzy spells may happen frequently for several weeks and then disappear, only to return again after a few months.
The severity of symptoms can vary widely. Most people experience only mild vertigo. In some cases, however, the attacks are so intense that they cause nausea and vomiting and significantly interfere with daily activities.
Between the short vertigo attacks, most people feel well. They may experience slight unsteadiness, but are usually able to continue with their daily activities. Some people are sensitive to visually busy environments (visually induced dizziness).
Abnormal, uncontrollable eye movements (nystagmus) accompany the symptoms of BPPV.
The activities that trigger dizziness vary from person to person. It is most frequently triggered by a change in head position, e.g. when lying down, turning in bed, moving the head upwards (e.g. when gargling) or downwards (e.g. when putting on shoes).
Diagnosis of benign paroxysmal positional vertigo
BPPV is usually diagnosed by a general practitioner or a specialist such as an ENT doctor or a neurologist. These doctors will take a detailed medical history, perform a neurological examination, and carry out various tests to assess the function of your vestibular system.
The doctor will move your head into different positions, called positional tests, which set the crystals in the semicircular canal into motion. As they move with gravity, the fluid moves as well. This activates the receptors in the canal, causing your eyes to move rapidly (nystagmus) and giving you the sensation that you are spinning. The positional test can be repeated several times if needed.
The doctor will observe your eye movements and ask you how you feel. The direction of your eye movements provides a clue to diagnosing which ear and which semicircular canal the crystals are in. Because the movements are sometimes very fast, you may be asked to wear special goggles. These goggles are connected to a computer monitor that clearly records your eye movements.
Dizziness and eye movements do not start immediately when you perform the positional test. Because the crystals are heavy and sluggish, it takes a few seconds for them to follow gravity. This is why it usually takes several seconds for symptoms to appear when you move your head into a position that triggers dizziness.
When dizziness begins, it starts suddenly but also fades away again. The dizziness is short-lived because the crystals eventually reach the lowest part of the semicircular canal. At first, the crystals move clumped together like a snowball. If the positional test is repeated several times, the crystals separate, and your symptoms become less pronounced. When you sit up, vertigo and nystagmus appear again. This is a good diagnostic indicator.
Treatment of benign paroxysmal positional vertigo (BPPV)
An effective treatment depends on correctly identifying the affected ear and semicircular canal. Treatments include:
Therapy option
Repositioning maneuvers
Repositioning maneuvers are an effective, long-lasting, and non-invasive treatment for all types of BPPV. A doctor, a physiotherapist or occupational therapist trained in dizziness therapycan treat you during an office visit. The head is guided through a series of movements to move the crystals back to where they belong. Symptoms usually improve immediately after the treatment, and the crystals are reabsorbed over the following hours.
If the repositioning maneuvers are not performed correctly, some crystals may fall into another semicircular canal. Sometimes the therapist observes a different and unexpected eye movement, which indicates that the crystals have migrated into another canal and a different maneuver is needed to fix the problem. And sometimes the procedure moves some of the crystals but not all of them, so another treatment may be required.
If the nystagmus (involuntary eye movements) triggered by a change in head position cannot be resolved with repositioning maneuvers, further examinations are necessary to rule out a central cause (originating in the brain).
Therapy option
Medication
Since BPPV is essentially a mechanical disorder, it cannot be cured with medication. Some medicines, such as antihistamines and sedatives, act as suppressants and reduce the sensation of dizziness. Taken for a short period, they can help control severe nausea and vomiting. However, because suppressants slow down the brain’s ability to adapt to the abnormal signals caused by the crystals in the inner ear, they should not be taken over a long period of time.
Therapy option
Surgery
Surgery to block the semicircular canal may be considered if multiple repositioning treatments have been unsuccessful or if BPPV keeps recurring.
Blocking the semicircular canal is not a common procedure and is only performed when all other treatment methods have been tried. Because fluid may leak when the canal is blocked, there is a risk of complete hearing loss in that ear.
Affected semicircular canals
BPPV in the posterior semicircular canal
The posterior semicircular canal is most commonly affected by BPPV. More than 95% of affected patients are successfully treated with the Epley or Semont maneuver .
Rare variants of BPPV
A minority of patients suffer from rare variants of BPPV. In these cases, several semicircular canals or even both ears may be affected. These patients are more difficult to diagnose and treat. Their eye movements are complex.
Cupulolithiasis is a variant that is difficult to treat. The eye movements last longer, are very intense, and persist as long as the head remains in the triggering position. No number of repositioning maneuvers will move the clumped crystals that are stuck to the cupula of the semicircular canal.
BPPV in the horizontal semicircular canal are very bothersome for most patients. The symptoms can be quite severe. With this variant, it is difficult to determine which ear is affected. Most ENT doctors are uncertain, because the eye movements are completely different depending on whether the crystals are freely floating or stuck to the cupula.
Our certified IVRT® dizziness and vestibular therapist are trained to correctly diagnose and successfully treat even these rare and complex cases.
What happens next?
What you can expect in the future.
Research shows that repositioning maneuvers relieve the symptoms in 95% of patients with BPPV after a single maneuver. Only 2% of patients need more than three treatments.
Anyone who has had BPPV is likely to experience it again, although the timing is unpredictable. If BPPV occurs several times a year, vitamin D supplementation may help reduce the frequency of recurrences.
In order to keep this patient information as short as possible, we have not included a detailed list of references. However, this can be requested at any time at info@ivrt.de.