BPPV (Benign Paroxysmal Positional Vertigo)

What is benign paroxysmal positional vertigo?

It’s an inner ear condition in which a person experiences episodes of vertigo where it feels as if the world is spinning around them. These episodes are generally triggered by sudden head movements, rolling over in bed or lifting your head up. Often these dizzy spells last for under a minute, however they may return frequently. BPPV can range from mild to severe forms in which daily living is greatly disrupted.

Who is affected by benign paroxysmal positional vertigo?

BPPV can affect anyone, however it rarely occurs in children and more often occurs in the elderly. It is also more likely for people with osteoporosis to suffer from BPPV.

What are the signs and symptoms of benign paroxysmal positional vertigo?

Along with the sensation that the world is spinning people may feel nauseous or lightheaded. Between episodes a person may experience no symptoms or feel slightly imbalanced. Hearing loss is not an accompanying symptom, however it can be a symptom of other forms of vertigo.

Involuntary eye movements (nystagmus) can be seen during episodes of vertigo. This sign helps clinicians differentiate between BPPV and other forms of vertigo. BPPV does not cause hearing loss.

What causes benign paroxysmal positional vertigo?

The vestibular system sits within the inner ear next to the cochlear (a structure essential for hearing). It’s responsible for sending information to our brain about balance. The semicircular canals are structures filled with fluid that are part of the vestibular system. When we move our heads the fluid in these canals moves and sends information to our brain about the direction, speed and distance of the head movements.

BPPV Treatment

In BPPV calcium carbonate crystals (otoconia) enter the semicircular canals after being dislodged from the utricle and/or saccule (these are other parts of the vestibular system). These crystals interfere with the fluid movement in the semicircular canals and subsequently our brain receives incorrect information about head movements. This results in episodes of vertigo.

The dislodgment of calcium crystals can be caused by head injury, an inner ear disorder, aging that results in vestibular system degeneration or may be due to an unknown cause.

Are there different types of benign paroxysmal positional vertigo?

Yes, there are two types of BPPV. Canalithiasis is the more common form whereby the calcium crystals freely move around the semicircular canals. Whereas, cupulolithiasis is a rarer form in which the calcium crystals are stuck on the nerve endings that send information to the brain about the fluid movement in the semicircular canals.

CanalithiasisCupulolithiasis
MechanismCrystals move freely in fluidCrystals are stuck on nerve bundles
DescriptionAn episode of vertigo ceases after less than a minute when the crystals stop spinning which causes the fluid movement to stop.Episodes of vertigo will last longer. Generally, moving the head into a different position will stop the episode.

How is benign paroxysmal positional vertigo examined and diagnosed?

If you are concerned about vertigo you should see a doctor, a vestibular audiologist or specialist physiotherapist.

A case history will be gathered in which your medical history and your vertigo will be discussed. A doctor may refer you to another health professional who specialises in vestibular assessment and treatment. This health professional could be a vestibular audiologist, a physiotherapist or occupational therapist specialising in this area or sometimes a patient may be referred to an ENT doctor.

bppv examination

A physical examination will also be conducted along with a balance assessment. A Dix-Hallpike or another similar assessment may be conducted in which the vertigo is triggered so that the clinician can observe it. By observing the nystagmus (involuntary eye movements) that accompanies the dizzy spells, the clinician is able to determine what type of BPPV the patient has and the location of the crystals within the semicircular canals. This information allows the appropriate treatment to be selected.

Nystagmus accompanies the dizzy spells because the vestibular system and the visual system work together to help us maintain balance. When false information is sent to the brain about our head position due to the presence of crystals in the semicircular canals, this causes the eyes to move as well.

What treatment options are available?

Some people with BPPV find that their vertigo disappears within a few weeks and no treatment is required. However, if the condition persists there are treatment options available. Manoeuvres, exercises, medications and surgery are all used to treat the condition. The most suitable treatment will depend on your individual circumstances and the characteristics of your vertigo. The treatment options are described below.

Medications

There is little evidence to support the use of medications in treating BPPV. However, short term use of motion sickness medication may be of benefit to some individuals to manage the nausea that may accompany the condition.

Surgery

It is very rare for surgery to be carried out, however it may be suitable for those with severe cases. Other non-invasive treatments will be trialled first and surgery will only be considered if other treatment options do not resolve the condition. Surgical procedures may include denervation (interrupting the nerve) of part or all of the vestibular nerve or occlusion of the semicircular canals.

Manoeuvres

bppv manouvers

These are performed by a health professional with training and experience in vestibular disorders. The manoeuvres aim to move the calcium crystals out of the semicircular canals back to where they belong. This is achieved through head movements. The type of manoeuvre will be selected by the health professional based on the type of BPPV the individual has and the location of the crystals within the canals.