This article is on benign paroxysmal positional vertigo, a common problem with the balance organs in the ear. This resource is open to everyone. Patients, Medical Students and Doctors may find this useful. The additional information shown in grey boxes provides more technical information intended for Medical Practitioners.

In order to understand this topic better you may also wish to read these other articles on related topics:

Structure and function of the ear

What is BPPV?

BPPV is caused by a problem in the balance organ in the inner ear. It is one of the most common causes of vertigo – the sensation of the world spinning.

BPPV stands for benign paroxysmal positional vertigo.

  • Benign – not life threatening.
  • Paroxysmal – comes and goes in sudden spells.
  • Positional – related to body positions and movement.
  • Vertigo – causes the sensation of the world spinning.

 

What causes BPPV?

The balance organ in the inner ear allows us to sense where our body is when we move. It also allows us to follow objects with our eyes when we move the head – try focusing your eyes on one word on this page while nodding or shaking your head. A reflex between the balance system and the eyes allows us to keep our eyes focused on one spot while moving the head.

The balance organ is made up of the vestibule, which contains the saccule and utricle, and the 3 semi-circular canals (see diagram). The semi-circular canals face different directions to sense movement in different directions. The utricle sits at the base of the semi-circular canals. The utricle contains tiny hairs with crystals (called otoliths) attached to the ends. The utricle helps us sense horizontal movement, such as when taking off in a car from the traffic lights. The crystals can come loose from the hairs and roll into the semi-circular canals. If this happens, head movements cause the crystals to roll around in the canals, confusing the brain and causing the sensation of movement.

 

Who gets BPPV?

BPPV can occur at any age, but is more common in people aged 50 or older. Women are affected more often than men. Some people get BPPV after a head injury.

 

What are the symptoms of BPPV?

BPPV usually causes short spells of dizziness, vertigo, and nausea. Spells occur after movement of the head. Spells last from seconds to at most a minute at a time. Symptoms can be mild or severe. With severe symptoms people feel sick and may vomit.

People with BPPV often find their symptoms occur with specific movements. Common movements are rolling over in bed, getting out of bed, or looking upwards, e.g. when hanging out washing.

People with BPPV do not have constant vertigo or dizziness. Symptoms come and go with movement. BPPV does not cause other symptoms such as hearing loss, headache, fainting, clumsiness or poor coordination, difficulty speaking, or numbness/pins and needles. These symptoms can be a sign of another inner ear problem, or of a serious illness such as stroke.

 

How is BPPV diagnosed?

BPPV is diagnosed by a Doctor, Physiotherapist, or other medical professional based on their findings when you are examined. Your Doctor or Physio will look at your eye movements when you are still, and when your head and body are moved. They may also do other balance testing. No scans or blood tests are needed to diagnose BPPV.

 

How is BPPV treated?

Most of the time BPPV can be treated easily with repositioning maneuvers. Repositioning maneuvers are exercises performed by your Doctor or Physio. They are a series of body movements to try to move the crystals out of the semi-circular canals, back into the utricle. If the crystals are returned to the utricle symptoms will improve straight away. Sometimes repositioning maneuvers do not cure patients immediately, in which case you may be given exercises to do at home.

 

What are the complications of BPPV?

Sometimes treatment with repositioning maneuvers can cause the crystals to move from one canal to another canal. If this happens, different head movements will cause symptoms to occur.

BPPV can recur. Around one in three patients who have had an episode of BPPV will have BPPV again.

 

Diagnosis of BPPV:

The Dix-Hallpike test is performed to confirm the diagnosis of BPPV. The patient starts in a seated position on a bed. The examiner helps the patient to lie back with the head turned 45 degrees to one side, and the neck extended over the end of the bed. The examiner watches the patients’ eyes, looking for nystagmus (rapid movements of the eyes back and forth). If nystagmus is seen, it should resolve within 30 seconds to one minute. The affected ear is the same as the side the head is turned towards.

 

Types of BPPV:

  • BPPV most commonly affects the posterior semi-circular canal. This causes a rotational, up-beating nystagmus. This is treated with the Epley’s Maneuver.

  • Much less common is BPPV of the lateral/horizontal semi-circular canal. This causes a horizontal nystagmus which changes direction depending on which side the head is turned towards. The Dix-Hallpike test will usually still unmask lateral canal BPPV. However, the supine roll test, where the head is rolled 90 degrees to each side while lying down, may be a better test. Treatment is typically with log roll exercises.

 

Further reading:

https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/benign-paroxysmal-positional-vertigo-bppv/

 

References:

Luryi AL, Lawrence J, Bojrab DI, LaRouere M, Babu S, Zappia J, Sargent EW, Chan E, Naumann I, Hong RS, Schutt CA. Recurrence in Benign Paroxysmal Positional Vertigo: A Large, Single-Institution Study. Otol Neurotol. 2018 Jun;39(5):622-627. doi: 10.1097/MAO.0000000000001800. PMID: 29649052.

 

Author + Affiliation: Dr Rachael Bentall, ENT Registrar, Waikato Hospital

Date of Publication + Review: 28 February 2022

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