Benign Paroxysmal Positional Vertigo
What is BPPV?
Benign Paroxysmal Positional Vertigo (BPPV) is an inner ear disorder in which changes to the position of the head, such as tipping the head backward, lead to sudden vertigo -- a feeling that the room is spinning. Vertigo can vary in intensity 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.
Particle repositioning therapy moves the otoconia out of the semicircular canals and into the utricle where they dissolve naturally.
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 individuals. The unsteadiness associated with BPPV can lead to falls. About half of all people over age 65 experience an episode of BPPV, and falls are a leading cause of fractures in this age-range.
What causes 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 controls balance). The otoconia make up a normal part of the structure of the utricle, a vestibular organ next to the semicircular canals. (see illustration to the right.)
In the utricle, the otoconia may be loosened as a result of injury, infection, or age, and 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 hairs that line the semicircular canals. Those hairs act as sensors to give the brain information about balance. Vertigo develops when the hairs are stimulated by the rolling otoconia.
What head positions trigger BPPV?
Movements that can trigger 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.
How is 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 addendum below.)
How can I identify the affected side?
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.
How successful is the treatment?
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 persist.
Can BPPV recur? If so, what can I do?
A new episode of BPPV can develop after successful treatment -- on average there is a 15 percent rate of recurrence each year. However, it may be possible to treat recurrent BPPV at home by performing a series of movements at the time an episode occurs. Patients will receive information on ways to handle recurrences on their own or they can work with a physical therapist to develop a plan.
In general, if you wake up with positional vertigo, 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. Follow the same steps as described in the boxed instructions on the next page.
Without treatment, the symptoms of BPPV may worsen. However, with time, the otoconia dissolve on their own, which is usually within 6 weeks. Until the time the otoconia dissolve on their own, the number and severity of episodes may be reduced simply by paying careful attention to head position. In addition, anti-motion sickness drugs can be given to 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.
Particle repositioning procedure: Step-by-step instructions
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 is 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.
Hold each of the following positions for 1 to 2 minutes.
Step 1: Turn your head toward your affected ear.
Step 2: Lay back quickly. Hold.
Step 3: Keep your head back against the bed and turn it toward the good ear. Hold.
Step 4: Roll onto your side with your good ear down. Your nose should be turned toward the floor. Hold.
Step 5: Sit up, keeping your chin tucked in toward your shoulder. Hold. When you end, you should be sitting over the side of your bed so your feet touch the floor.
Step 6: Follow your post-particle repositioning instructions.
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 and sent to the brain.
- Crane BT, Minor LB. Richardson MA. Peripheral Vestibular Disorders. In: Cummings Otolaryngology, Head and Neck Surgery, 3-Volume Set. Saunders; 2014.
- Hornibrook J. Benign Paroxysmal Positional Vertigo (BPPV): History, Pathophysiology, Office Treatment and Future Directions. International Journal of Otolaryngology. 2011;2011:835671.
- Kim JS, Zee DS. Clinical practice. Benign paroxysmal positional vertigo. N Engl J Med. 2014 Mar 20;370(12):1138-47.
- LeBlond RF, Brown DD, Suneja M, Szot JF. The Head and Neck. In: LeBlond RF, Brown DD, Suneja M, Szot JF. eds. DeGowin’s Diagnostic Examination, 10e. New York, NY: McGraw-Hill; 2015.
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