What is BPPV?

Benign Paroxysmal Positional Vertigo (BPPV) is one of the most common causes of dizziness and one of the easiest to diagnose and treat. It has been estimated that at least 20% of patients who complain to their physician about vertigo problems have BPPV. However, because BPPV is frequently misdiagnosed, this figure may not be completely accurate, and is probably underestimated. The symptoms of BPPV include dizziness or vertigo, light-headedness, imbalance, and nausea. Activities which bring on symptoms will vary among persons, but symptoms are almost always evoked by a sudden change in head position. Getting out of bed, or rolling over in bed are common evoking motions that can trigger a vertigo episode.

By definition, paroxysmal means a sudden attack or recurrence. So, it’s common for someone who has BPPV to experience an intermittent pattern of vertigo attacks. BPPV may be present for a few weeks, then stop, then come back again. The vertigo episode usually lasts no more than one minute. In general, vertigo episodes and nystagmus tend to lessen in severity with each repetition of the evoking movement.

Many conditions involving dizziness, including BPPV center around a condition known as nystagmus. Nystagmus is defined as involuntary eye movements usually triggered by an inner ear stimulation. Because the type of BPPV is defined by the distinguishing type of nystagmus, defining the type of nystagmus is important for a correct diagnosis. BPPV vertigo is caused by debris which has collected within a part of the inner ear. This debris can be thought of as "ear rocks", or the medical name is otoconia.

Otoconia are small crystals of calcium carbonate derived from a structure in the inner ear called the utricle. Otoconia may fall due to the utricle being damaged by a head injury, infection, or other disorders of the inner ear, or may have degenerated because of advanced age.

These problems cause the otoconia to loosen, fall, and become displaced in the posterior, anterior, horizontal, and also sometimes the cupula canal areas. You can see how these crystal become displaced by clicking on the image to the right. Under normal circumstances, when a person changes position, the movement of endolymph stimulates the hair cells, which then send signals to the brain to register the new position of the head. Endolymph is the fluid inside the semicircular canals. In patients with BPPV, movement of the misplaced debris alters endolymph movement, triggering a false sense of motion, and generating vertigo.

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How do you diagnose someone with BPPV?

To properly diagnose a patient suffering from any dizziness problem, a complete medical history analysis is required to eliminate any other conditions that may be causing the problem. Benign paroxysmal positional vertigo is probably one of the easiest forms of dizziness to correctly diagnose. This is largely due to the simple mechanical nature of the condition.

Doctors should ask patients to very carefully describe their symptoms to help differentiate between dizziness and vertigo. Although the two terms are often used interchangeably, dizziness is a broad, nonspecific term that may describe light-headedness, weakness, nausea, or imbalance. Vertigo on the other hand, is a type of dizziness, and refers to an illusory sensation of motion.

Someone who suffers from BPPV will have a nystagmus condition, and based on the type of nystagmus, you can properly diagnose which form of BPPV they have. The nystagmus present in a person with BPPV is being generated by the otoconia particles that have fallen into the posterior canals of the inner ear.

To make a definitive diagnosis of BPPV, many physicians perform a maneuver called the Dix-Hallpike test. For this test, the patient is seated on an examining table. After the patient’s head is turned to one side, they are quickly moved to a supine (lying on back) position, with the head hanging slightly over the edge of the table.

If a person has BPPV, this maneuver will cause movement of the particles in the posterior semicircular canal, inducing vertigo and a characteristic form of nystagmus within several seconds after they reach the supine position. The nystagmus jerks will be such that the upper part of the eyes will beat (downward) toward the affected ear, indicating a BPPV condition is present.

How do you treat someone with BPPV?

Due to BPPV’s erratic frequency, treatment can sometimes be frustrating for patients. Patients may feel great for weeks or even months, then one morning wake up to a severe vertigo episode. There are three methods currently used today to treat people with BPPV: medications, vestibular rehabilitation, and surgery.

Medications
Medications are used frequently by many physicians to try and control nausea and vertigo episodes, but usually provide little benefit to the patient besides temporary relief. Medications don’t provide a long term benefit.

Vestibular Rehabilitation
Vestibular Rehabilitation is currently the best way to treat BPPV patients. The most common physical therapy procedures are called the Epley and Dix-Hallpike maneuvers named after their inventors. When performed correctly these maneuvers relieve vertigo in nearly 90% of patients after a single treatment. The Epley maneuver and similar particle-repositioning maneuvers are performed with the patient lying supine on the examining table and the head hanging off the edge of the table, the vertex of the head should remain tilted downward. To perform the maneuver, the clinician carefully guides the patient’s head and body through a series of rotations designed to reposition loose ear crystals from the posterior semicircular canal through the vestibular labyrinth to the vestibule, where they adhere and no longer cause vertigo.

The procedure takes advantage of the fact that the free-floating particles are denser than the surrounding endolymph fluid, which means they will move within the labyrinth according to the gravitational forces that the head position is generating. Particle repositioning maneuvers usually cause brief vertigo. Following the procedure, patients are generally advised to remain upright for 24 to 48 hours, to lessen the chances that any remaining loose particles will resettle in the posterior semicircular canal.

Surgery
Surgery should not be considered until all maneuvers have been attempted and failed. A surgical procedure called "posterior canal plugging" may be recommended. Canal plugging blocks most of the posterior canal's function without affecting the functions of the other canals or parts of the ear. This procedure poses a small risk to hearing, but is effective in about 90% of individuals who have had no response to any other treatment.