Vestibular disease
Benign paroxysmal positional vertigo
This information is intended as a general introduction to this topic. As everyone is affected differently by balance and dizziness problems, you should speak to your doctor for individual advice.
For reasons of better readability, the generic masculine is used and the simultaneous use of the language forms male, female and diverse (m/f/d) is dispensed with. Unless otherwise indicated, the personal designations used in this patient information refer to all genders.
What is benign paroxysmal positional vertigo?
Benign paroxysmal positional vertigo (BPLS) 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 - benign - not a life-threatening health problem
- Paroxysmal - the symptoms come and go quickly
- Positioning - occurs with certain changes in head position
- Dizziness - in English this is called '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).
BPLS affects around 2.5% of people at some point in their lives. Between 20 - 30 % of patients with vertigo have BPLS.
BPLS becomes more common with age. In half of people over 50, BPLS is the main cause of dizziness. BPLS can increase the likelihood of falling, especially if you are older.
Women are 2 to 3 times more likely to develop BPLS than men.
Summary
- One of the most common causes of rotary 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 fall from the macular organ (the utriculus) into the semicircular canal (one of the three semicircular canals in the inner ear).
- Slipped crystals cause a sudden, brief spinning dizziness 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 macular organ (the utriculus).
- A doctor or vestibular therapist can achieve this through release maneuvers. In most cases, only one treatment is required.
- A few people have rarer forms - these are difficult to diagnose and treat.
- BPLS is unlikely if the spinning dizziness lasts longer than one minute.
What causes benign paroxysmal positional vertigo?
To understand what causes BPLS, it is important to know how the balance system in the inner ear (vestibular organ) works.
The cochlea and the vestibular organ (utriculus, sacculus and the three semicircular canals) are located in the inner ear. The vestibular organ reacts to gravity and tells your brain whether you are moving up or down, right or left, forwards or backwards. This gravity receptor area contains tiny crystals of calcium carbonate (otoliths) on a gelatinous membrane.
The semicircular canals are at a 90-degree angle to each other. The horizontal semicircular canal is approximately parallel to the ground, the posterior semicircular canal is oriented backwards and the anterior semicircular canal is oriented upwards. The semicircular canals perceive rotational movements and determine acceleration. They contain a fluid (endolymph) and have tiny hair cells in the end region. When the inner ear fluid moves, the hair cells move and activate nerves that are connected to the brain and help control eye movement. The eyes follow the vestibular organ, so to speak.
However, when crystals fall into the semicircular canal, the normal interaction between the fluid and the hair cells is disrupted. The semicircular canal becomes sensitive to changes in head position to which it would not normally respond. This disruption leads to a spinning sensation (either as if you are spinning in space or the space around you is spinning).
Most cases of BPLS are idiopathic, i.e. they occur for no apparent reason. This type of BPLS is also known as primary BPLS. The following factors can make you susceptible to idiopathic BPLS:
- 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 BPLS
- 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 BPLS. 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.
Secondary BPLS can 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 BPLS and dental interventions.
In contrast to idiopathic BPLS, both ears can be affected (bilaterally) in secondary BPLS. This requires more than one treatment and recurs more frequently
The characteristic symptom of BPLS is spinning vertigo, which usually lasts less than 60 seconds. It usually occurs in episodes. The dizzy spells can occur frequently for several weeks and then disappear again. They may recur after a few months.
The symptoms vary greatly in severity. Most people only suffer from mild vertigo. For some, the attacks are so severe that they cause nausea and vomiting and significantly impair daily activities.
Those affected often feel fine between the brief dizzy spells. They may feel slightly off balance, but are usually able to continue their daily activities. Some people are sensitive to visually stimulating environments (visually induced vertigo).
Abnormal, uncontrollable eye movements (nystagmus) accompany the symptoms of BPLS.
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
BPLS is usually diagnosed by a general practitioner or a specialist such as an ENT or neurologist. These doctors will take a thorough medical history, perform a neurological examination and various tests to assess the function of your vestibular system.
The doctor will place your head in different positions called positional probes; this sets the crystals in the semicircular canal in motion. As they move with gravity, the fluid moves with them. This activates the receptors in the semicircular canal so that your eyes move rapidly (nystagmus) and you feel as if you are spinning. The positioning test can be repeated several times if necessary.
The doctor will look at your eye movements and ask you how you feel. The direction of your eye movements will be used as a guide to diagnose which ear and semicircular canal the crystals are in. As the movements are sometimes very fast, you may be asked to wear special glasses. The glasses are connected to a computer monitor that clearly records your eye movements.
The dizziness and eye movements do not start immediately when you carry out the positioning test. As the crystals are heavy and therefore inert, it takes a few seconds for them to follow the force of gravity. Therefore, it usually takes several seconds for the symptoms to appear when you put your head in a position that triggers dizziness.
When the dizziness sets in, it starts very suddenly, but also subsides again. The dizziness is short-lived because the crystals eventually reach the lowest part of the semicircular canal. At first, the crystals move together like a snowball. If the positioning test is performed several times, the crystals separate and you become less symptomatic. When you sit up, rotational vertigo and nystagmus occur again. This is a good diagnostic indication.
Treatment of benign paroxysmal positional vertigo
Effective treatment depends on accurate identification of the affected ear and the semicircular canal. Treatments include:
Therapy option
Liberation maneuver
Liberation maneuvers are an effective, long-lasting and non-invasive treatment for all types of BPLS. A physician, physical or occupational therapist trained in dizziness therapy can treat you during an office visit. The head is moved through a series of movements to move the crystals back to where they belong. The symptoms usually subside immediately after the treatment and the crystals will break down again over the next few hours.
If the positioning maneuvers are not performed correctly, some crystals may fall into a different semicircular canal. Sometimes the therapist will see a different and unexpected eye movement; this indicates that the crystals have moved to a different semicircular canal and require a different maneuver to correct the problem. And sometimes the procedure will move some of the crystals, but not all, so further treatment is required.
If the nystagmus (involuntary eye movements) caused by a change in head position cannot be corrected by the positioning maneuvers, further examinations are required to rule out a central cause (which originates in the brain).
Therapy option
Medication
As BPLS is essentially a mechanical disorder, it cannot be cured by medication. Some medications, such as antihistamines and sedatives, act as inhibitors and reduce the feeling of dizziness. If you take them for a short period of time, they can help control severe nausea and vomiting. However, as inhibitors slow down the brain's ability to adjust to the abnormal signals triggered by the crystals in the inner ear, they should not be taken for prolonged periods.
Therapy option
Operation
Surgical intervention to block the semicircular canal may be considered if several treatments with positioning maneuvers have been unsuccessful or if the BPLS keeps recurring.
Blocking the semicircular canal is not a common procedure and is only performed when all other treatment methods have been tried. As fluid can leak when the semicircular canal is blocked, there is a risk of complete loss of hearing in this ear.
Affected semicircular canals
BPLS in the posterior semicircular canal
The posterior semicircular canal is most frequently affected by BPLS. Over 95% of affected patients are successfully treated with the Epley or Semont maneuver.
Rare variants of BPLS
A minority of patients suffer from rare variants of BPLS. In these patients, several semicircular canals or even both ears can be affected. These patients are difficult to diagnose and treat. Their eye movements are complicated.
Cupulolithiasis is a variant that is difficult to treat. The eye movements last longer, are very violent and last as long as the head is in the triggering position. No amount of positioning maneuvers will move the lumpy crystals that are stuck to the cupula of the semicircular canal.
BPLS in the horizontal semicircular canal is very troublesome for most patients. The symptoms can be quite severe. With this variant, it is difficult to determine which ear is affected. Most ENT specialists are at a loss because the eye movements are completely different depending on whether the crystals are free-floating or stuck to the cupula.
Our certified IVRT® vertigo and vestibular therapists are trained to correctly diagnose and successfully treat even these rare and complicated cases.
What happens next?
What you can expect in the future.
Research shows that the liberation maneuver resolves symptoms in 95% of patients with BPLS after a single maneuver. Only 2% of patients require more than three treatments.
Anyone who has had BPLS once is likely to get it again, but the timing is unpredictable. If BPLS occurs several times a year, vitamin D supplementation can reduce the frequency of recurrence.
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.
