Benign Paroxysmal Positional Vertigo (BPPV)
What is benign paroxysmal positional vertigo (BPPV)?
Benign paroxysmal positional vertigo (BPPV) is an inner ear disorder in which changes in the position of the head, such as tipping the head backward, lead to sudden vertigo – a feeling that the room is spinning. The vertigo sensation can range from mild to severe and usually lasts only a few minutes. It may be accompanied by other symptoms, including:
Anatomy of the right inner ear
BPPV is not a sign of a serious problem, and it usually disappears on its own within 6 weeks of the first episode. However, the symptoms of BPPV can be very frightening and may be dangerous, especially in older people. About half of all people over age 65 suffer an episode of BPPV. The unsteadiness caused by BPPV can lead to falls, which are a leading cause of fractures in this age range.
Symptoms and Causes
What causes benign paroxysmal positional vertigo (BPPV)?
BPPV develops when calcium carbonate crystals, which are known as otoconia, shift into and become trapped within the semicircular canals (one of the vestibular organs of the inner ear that control balance). The otoconia make up a normal part of the structure of the utricle, a vestibular organ next to the semicircular canals. (See illustration.)
In the utricle, the otoconia may be loosened because of injury, infection, or age. They land in a sac – the utricle – where they are naturally dissolved. However, otoconia in the semicircular canals will not dissolve. As a person’s head position changes, the otoconia begin to roll around and push on the tiny hair-like processes (cilia) within the semicircular canals. Those cilia help to transmit information about balance to the brain. Vertigo develops when the cilia are stimulated by the rolling otoconia.
Movements that can bring about an episode of BPPV include:
- Rolling over or sitting up in bed;
- Bending the head forward to look down, or;
- Tipping the head backward.
In most people, only a single ear is affected by BPPV, although both ears may be involved on occasion.
Diagnosis and Tests
How is benign paroxysmal positional vertigo (BPPV) diagnosed and treated?
With advances in medical technology, BPPV can easily be diagnosed and treated. The diagnosis can usually be made in the office based on medical history and a physical exam. Treatment also involves a short, simple in-office procedure known as the particle repositioning maneuver. (See the treatment section).
How can I identify the side that is affected by benign paroxysmal positional vertigo (BPPV)?
Steps to determine affected side:
- Sit on bed so that if you lie down, your head hangs slightly over the end of the bed.
- Turn head to the right and lie back quickly.
- Wait 1 minute.
- If you feel dizzy, then the right ear is your affected ear.
- If no dizziness occurs, sit up.
- Wait 1 minute.
- Turn head to the left and lie back quickly.
- Wait 1 minute.
- If you feel dizzy, then the left ear is your affected ear.
Management and Treatment
What is the particle repositioning procedure for benign paroxysmal positional vertigo (BPPV)?
The particle repositioning procedure takes about 15 minutes to complete and involves a series of physical movements that change the position of the head and body. These actions shift the otoconia out of the semicircular canals and back into their proper location in the utricle.
The particle repositioning procedure begins with the patient sitting up and then lying down on a treatment table. The procedure is very easy to perform. Patients should wear comfortable clothing that will allow them to move freely.
A single particle repositioning procedure is effective in treating about 80% to 90% of cases of BPPV. Additional exercise or repositioning maneuvers may be needed if symptoms continue.
Step 1: Start by sitting up on a bed or table. Turn your head 45 degrees toward the affected ear (see how to determine your affected ear above).
Step 2: Quickly lie back, keeping your head turned toward the affected ear as you lie back with your head slightly over the edge of the bed or table. Wait about a minute or until you stop having symptoms.
Step 3: Without raising your head, turn your head quickly in the opposite direction so that your “good” ear is parallel with -- but slightly over the edge of -- the table or bed. Wait about a minute or until you stop having symptoms.
Step 4: Roll onto your side. Continue to turn your head another 45 degrees in the same direction as step 3 so that your nose is now facing the floor. Wait about a minute.
Step 5: Keeping your chin tucked in toward your shoulder, sit up in the direction your body is facing. Follow any post-particle repositioning instructions given to you by your healthcare provider.
Can benign paroxysmal positional vertigo (BPPV) return? If so, what can I do?
A new episode of BPPV can develop after successful treatment. On average, the rate of recurrence (new episode) is 15-50%.
However, it may be possible to treat recurrent BPPV at home by performing a series of movements when an episode occurs. Patients will receive information on ways to handle recurrences on their own, or they can work with an audiologist or physical therapist to develop a plan.
In general, if you wake up with positional vertigo, try the following steps:
- Slowly move into the good-ear-down position and wait for a minute.
- Next, slowly move into a face-down position and slide to the foot of the bed.
- Keep your head down until you reach the end of the bed and are kneeling or standing on the floor.
- Slowly bring your head backward into an upright position. (Hold on to the bed at all times.)
Another method is to sit toward the foot of the bed, leaving enough room to lay back with your head resting comfortably at the end of the bed, slightly extended. Be careful not to overextend your neck, as this may aggravate existing neck problems. If your symptoms are severe, you may need assistance to complete the maneuver.
Without treatment, the symptoms of BPPV may persist. However, with time (usually within 6 weeks), the otoconia dissolve on their own. Until then, the number and severity of episodes may be reduced simply by paying careful attention to head position. In addition, anti-motion sickness drugs can control nausea.
However, before drugs are taken, it is usually best to try the particle repositioning procedure first. It is a very safe and rapid way to relieve symptoms and reduce the chance for falls. Medications should not be taken for a long period of time.
Benign Paroxysmal Positional Vertigo (BPPV): Glossary of Terms
- Semicircular canals: These structures act like a gyroscope, with canals positioned in three dimensions – upward, downward, and horizontal. Together, the canals send signals to the brain about the rotation/positioning of the head (for example, when you bend over or spin around.)
- Cupula: Detects the flow of fluid within the semicircular canals. The flow of fluid gives the body a sense of motion.
- Utricle: An organ located in the inner ear that helps control balance. The utricle contains hair cells, which are covered with otoconia. The otoconia sway with gravity, sending signals to the brain about the position of the head and body (upright, tilted, etc.).
- Otoconia: The tiny calcium crystal particles that become dislodged from within the utricle (where they can dissolve) and move into the semicircular canals (where they can’t dissolve).
- Cochlea: The “snail-shell” sense organ of the inner ear that translates sound into nerve impulses that are sent to the brain.