Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. It is also very treatable.

What does it stand for?

Symptoms

The following are possible symptoms of BPPV;

• Feeling like you are spinning or moving
• Feeling like the world is spinning or moving
• Loss of balance
• Nausea
• Vomiting

Cause

BPPV is caused by the displacement of tiny calcium carbonate crystals, known as otoconia, within the inner ear. These crystals normally sit in a structure called the utricle, but can become dislodged and move into one of the semicircular canals. The inner ear contains three semicircular canals — posterior, horizontal, and anterior — each aligned in a different plane and responsible for detecting head movement. When otoconia enter one of these canals, they interfere with the normal movement of fluid inside the canal. This disruption sends incorrect signals to the brain about head position, resulting in brief episodes of dizziness or vertigo, particularly with certain head movements.

Here are the main causes and contributing factors for BPPV:

Aging Ears

• Accelerated Breakdown: As we age, the otoconia undergo structural changes, leading to a higher rate of breakdown and an increased likelihood of becoming dislodged over time.
• Weakened Membrane: The otoconia rest atop a gelatinous membrane within the utricle. Age-related alterations in the inner ear can weaken this membrane, making it more susceptible to allowing crystals to detach more easily.

Head Injury or Trauma

• A blow to the head, neck, or ear can cause the otoconia to dislodge. People who have had concussions, car accidents, or other head injuries are at higher risk of developing BPPV.

Inner Ear Disorders

• Some inner ear infections or disorders, such as vestibular neuritis or Meniere’s disease, may increase the risk of BPPV. Inflammation of the inner ear structures can disrupt the position of the otoconia.

Migraine

• People who suffer from migraines may also be more prone to BPPV. Migraine-associated vertigo is common, and migraine is thought to affect the inner ear or brain areas involved in balance.

Genetic Predisposition

• Some people may have a genetic predisposition to BPPV or a family history of balance disorders, though this is not as well understood as other factors.

Osteoporosis

• Osteoporosis, especially in postmenopausal women, has been linked to an increased risk of BPPV. This may be related to calcium metabolism, as calcium is a key component of the otoconia in the inner ear.

Vitamin D Deficiency

• Low levels of vitamin D have also been associated with BPPV recurrence, as vitamin D is essential for calcium regulation in the body.

Diabetes

• Diabetes, particularly poorly managed or long-term diabetes, may lead to blood vessel changes, affecting circulation to the inner ear. This can impair the ear’s balance system, increasing the risk of BPPV.

Hyperthyroidism

• Hyperthyroidism (overactive thyroid) may be associated with a higher risk of BPPV, possibly due to changes in metabolism and calcium levels, which could affect the stability of otoconia in the inner ear.

Prolonged Bed Rest or Immobility

• Extended periods of bed rest, as may occur after surgery, during illness, or with prolonged hospital stays, can lead to BPPV. Immobility can affect the balance system and make it easier for the otoliths to shift out of place.

Anxiety and Stress

• Although not a direct cause, high levels of anxiety or stress can exacerbate vertigo symptoms and may contribute to the recurrence of BPPV in individuals who are already susceptible.

Alcohol Use

• Alcohol affects the inner ear and can increase the likelihood of dizziness and imbalance. Excessive alcohol intake can impact the fluid levels in the inner ear, potentially increasing the risk of BPPV episodes.

Ear Surgery or Procedures

• Surgical procedures involving the ear or surrounding areas, such as cochlear implant surgery or other invasive ear procedures, can dislodge otoliths and increase the risk of developing BPPV.

Idiopathic (Unknown Cause)

• In many cases, BPPV occurs without any known cause. This is known as idiopathic BPPV, and it accounts for the majority of cases.

Diagnosis

When we assess for BPPV, we’re not just looking to see if dizziness occurs — we’re carefully observing the direction of your eye movements, known as nystagmus (an involuntary repetitive eye movement) .

At Ears in Balance, we use videonystagmography (VNG) to precisely record and analyse eye movements, helping ensure an accurate diagnosis. By identifying the specific pattern of nystagmus, we can determine which semicircular canal is affected. BPPV most commonly involves the posterior canal, but it can also affect the horizontal canal or, rarely, the anterior canal. Identifying the involved canal is essential, as it allows us to select the most appropriate and effective treatment.

Treatment

Treatment involves Canal Reposition Procedures (CRPs). These non-invasive, evidence based manouvres are designed to move the crystals from the affected semicircular canal back to the utricle. We treat all types of BPPV. The treatment will depend on the diagnoses. The most common diagnosis is posterior canalithiasis and the treatment is the Epley manoeuvre.