Benign Paroxysmal Positional Vertigo (BPPV)

Benign Paroxysmal Positional Vertigo (BPPV) is a condition of the inner ear. As a sensory receptor, the inner ear provides information to the brain about the position and motion of the head and the direction of gravity. Small hair cells within the inner ear bend with a change in head position and the pull of gravity, sending information to the brain about the position of the head and body. Under normal conditions, one portion of the inner ear, the utricle, contains carbonate crystals, sometimes known as “ear rocks”, which increases the sensitivity to gravity. BPPV results when the crystals dislodge and move to another portion of the inner ear called the semi-circular canals. When carbonate crystals are floating within one of the three semi-circular canals they make the canal abnormally sensitive to gravity. This increased sensitivity distorts the information that the brain receives when the head is moved, rendering a sensation that the room is spinning. This sensation is usually brief and intense, lasting approximately 20-30 seconds. It is often accompanied by a feeling of nausea.

The cause of BPPV is unknown. It is most common in older adults, in individuals with other ear problems and sometimes occurs after head trauma or after prolonged positioning as with surgery or dental work. Since the body is always generating new crystals within the utricle and reabsorbing old crystals there is also some thought that BPPV may occur in people who have difficulty reabsorbing “old” crystals.

BPPV can be simple to diagnose and treat by a properly trained clinician. BPPV can be identified by a physical therapist specifically trained in vestibular rehabilitation, primary care physician, or an ear, nose and throat specialist (ENT). The patient’s history and description of symptoms is very important. Patients often describe a scenario of waking up in the morning, sitting up at the edge of the bed and observing that the room begins to spin. The diagnosis is confirmed by a simple test called positional testing. In patients with BPPV, this position provokes symptoms of vertigo lasting about 30 seconds and is accompanied by a particular involuntary movement of the eyes, which is observed by the examiner. Two simple, non-invasive treatments can eliminate symptoms of BPPV in 80% of cases.

The Canalith Repositioning maneuver is a procedure performed by a trained physical therapist or a physician, which involves turning the head and body in a way that re-routes the crystals from the semi-circular canal back to the utricle. Often this maneuver is successful on the first attempt, in others it may need to be repeated several times. A second form of treatment often used in conjunction with the Canalith Repositioning Maneuver is a specific exercise called a habituation exercise. The exercise is performed 3x per day and gradually lessens the symptoms of vertigo over the course of 4–6 weeks. The overall success rate for treatment of BPPV through Canalith Repositioning and/or habituation exercises is 80-90%.

A feeling of disequilibrium or unsteadiness is often a consequence of BPPV, especially in older patients. This sensation is often resolved once the symptoms of vertigo are resolved and the crystals are “back in place”. Frequently, the patient is given specific exercises and is encouraged to walk to help eliminate this sensation of unsteadiness. In older adults, it may be necessary to use a cane or walking stick until symptoms of disequilibrium are fully resolved. There is a 30% recurrence rate for BPPV, especially in older adults.