Benign Paroxysmal Positional Vertigo (BPPV)

In Benign Paroxysmal Positional Vertigo (BPPV) dizziness and vertigo are triggered by particular positions because of debris that has collected within a part of the inner ear.  This debris can be thought of as “ear rocks”, although the formal name is “otoconia”. Ear rocks are small crystals of calcium carbonate derived from a structure in the ear called the “utricle” (figure1 above ). While the saccule also contains otoconia, they are not able to migrate into the canal system. The utricle may have been damaged by head injury, or infection, or may have degenerated because of advanced age.

Physically, BPPV results when the otoconia are dislodged from the utricle, become loose within the labyrinth and fall back into one of the canals (usually the posterior). The animation above shows this process. Otoconia may be dislodged due to wear/tear, trauma, or disease. Usually, it is blamed on wear/tear.

Who gets BPPV?

BPPV is a common cause of dizziness but it depends on your age. On average, about 1.6% of the population has BPPV each year (Neuhauser and Lempert, 2009), of whom about 0.6% had it begin that year. About 20% of all dizziness seen in medical offices is due to BPPV. BPPV can occur in children (Uneri and Turkdogan, 2003) but it is rare. BPPV is much more common in older persons, and the number of people (i.e. prevalence) in the population increases linearly with age (Froehling et al, 1991). About 50% of all dizziness in older people is due to BPPV. In one study, 9% of a group of urban-dwelling elders were found to have undiagnosed BPPV (Oghalai et al., 2000). If one looks at the number of patients that are seen in dizzy clinics, the peak age for BPPV is roughly 60 (see below). This is due to a combination of the age risk of BPPV combined with the larger number of persons in the population at certain ages. Above the age of 60, 3.4% of the population has BPPV every year (Neuhauser and Lempert, 2009).

The symptoms of BPPV include dizziness or vertigo, lightheadedness, imbalance, and nausea. Activities that bring on symptoms will vary among persons, but symptoms are almost always precipitated by a change of position of the head concerning gravity. Getting out of bed or rolling over in bed are common “problem” motions. Because people with BPPV often feel dizzy and unsteady when they tip their heads back to look up, sometimes BPPV is called “top shelf vertigo.” Women with BPPV may find that the use of shampoo bowls in beauty parlors brings on symptoms. Some Yoga postures or Pilates positions are triggers. An intermittent pattern is common. BPPV may be present for a few weeks, then stop, then come back again.

WHAT CAUSES BPPV?

BPPV is mainly encountered in persons of advanced age (Froeling et al, 1991). In older people, the most common cause is degeneration of the vestibular system of the inner ear — “wear and tear” involving the otoliths. In these cases, BPPV is called “idiopathic”, but the general opinion is that it is usually due to degeneration. There is no evidence that BPPV is caused by either Covid-19 or Covid vaccination, although presumably there are many people who both have had BPPV and Covid as both are common conditions.

The most common cause of BPPV in people under age 50 is head injury. The head injury need not be that direct – -even whiplash injuries have a substantial incidence of BPPV (Dispenza et al, 2011). Between 8% and 20% of BPPV is attributed to trauma. While one does not usually think of surgery as trauma, nevertheless BPPV can follow surgery, including dental work, where the cause is felt to be a combination of a prolonged period of supine positioning with vibration from drilling, or after surgery to the inner ear (Atacan et al 2001). The resolution rate of BPPV due to trauma and nontraumatic BPPV is similar (Aron et al, 2015, Luryi 2019), but the trauma group may require more maneuvers to cure and also are more likely to recur (Chen et al, 2019).

There is also a strong association between BPPV with migraine (Ishiyama et al, 2000). Viruses affecting the ear such as those causing vestibular neuritis and Meniere’s disease are significant causes (Batatsouras et al, 2012). The combination of vestibular neuritis and BPPV is sometimes called Lindsay-Hemenway syndrome.

While gentamicin toxicity as a cause is rarely encountered, BPPV is common in persons who have been treated with ototoxic medications such as gentamicin (Black et al, 2004).

Benign paroxysmal positional vertigo may have the following differential diagnoses:

• Ménière disease[rx]
• Inner ear concussion
• Alcohol intoxication
• Labyrinthitis or vestibular neuronitis[rx]
• Vascular loop syndrome
• Positional nystagmus of central origin
• Lesion of the nodulus from conditions such as stroke, Arnold-Chiari malformation, multiple sclerosis, cerebellar degeneration, ischemia, and intoxication[rx][rx]
• Acoustic neuroma and meningioma
• Vertebral artery insufficiency
• Orthostatic hypotension

HOW IS THE DIAGNOSIS OF BPPV MADE?

The test for BPPV can be made more sensitive by having the patient wear Frenzel goggles or video goggles. Most doctors and physical therapists that specialize in seeing dizzy patients have these in their offices.

Concerning history, the key observation is that dizziness is triggered by lying down or rolling over in bed. Most other conditions that have positional dizziness get worse on standing rather than lying down (e.g. orthostatic hypotension). Some conditions have symptoms that resemble BPPV. Patients with certain types of central vertigo caused by cerebellar injuries can have similar symptoms. Patients with migraine-associated vertigo can also sometimes show eye movements resembling bilateral BPPV.

Electronystagmography (ENG) testing may be needed to look for the characteristic nystagmus (jumping of the eyes) induced by the Dix-Hallpike test (also see here PC BPPV). For diagnosis of BPPV with laboratory tests, it is important to have the ENG test done by a laboratory that can measure vertical eye movements. A magnetic resonance imaging (MRI) scan will be performed if a stroke or brain tumor is suspected. An oven and rotatory chair test can be helpful for difficult diagnostic problems. It is possible but uncommon (5%) to have BPPV in both ears (bilateral BPPV).

HOW IS BPPV TREATED?

• Wait it out
• Office Treatment
• Home Treatment
• Surgical Treatment (this is wildly uncommon)

BPPV has often been described as “self-limiting” because symptoms often subside or disappear within 1-2 months of onset (Imai et al, 2005). BPPV is not life-threatening. Loose otoconia are probably actively reabsorbed by the “dark cells” of the labyrinth (Lim, 1973, 1984), which are found adjacent to the utricle.

No active treatment (wait/see)

One can certainly opt to just wait it out. If you decide to wait it out, certain modifications in your daily activities may be necessary to cope with your dizziness. Use two or more pillows at night. Avoid sleeping on the “bad” side. In the morning, get up slowly and sit on the edge of the bed for a minute. Avoid bending down to pick up things, and extending the head, such as to get something out of a cabinet. Be careful when at the dentist’s office, the beauty parlor when lying back having one’s hair washed, when participating in sports activities and when you are lying flat on your back. Similarly, be cautious with chiropractic treatments that may jostle the head.

Symptoms tend to wax and wane. Motion sickness medications are sometimes helpful in controlling nausea associated with BPPV but are otherwise rarely beneficial.

As BPPV can last for much longer than 2 months, in our opinion, it is better to treat it actively and be done with it rather than taking the wait/see approach.

Repositioning Maneuvers

The first-line treatment option for posterior canal BPPV is a repositioning maneuver designed to rid the affected semicircular canal of any debris. The repositioning maneuvers are efficacious in improving posterior canal BPPV.[rx][rx] There are some contraindications to their use, such as:

• Severe cervical disease
• Suspected vertebrobasilar disease
• Unstable cardiovascular disease
• High-grade carotid stenosis

There are many variants of PRM, such as the Semont or liberatory maneuver, the Epley maneuver, and the 3-position maneuver.[rx] It has been established through trials that all these maneuvers are highly efficacious. The PRM is like the Epley maneuver, except it is simpler, and sedation or mastoid vibration is not usually necessary.[rx] The PRM and Semont maneuvers are equally efficacious; however, the PRM is more widely used in North America as it is easier for the provider and patient, particularly in overweight and older patients.[rx] Post-maneuver instructions and postural restrictions are not needed.[rx][rx][rx][rx]

In a patient with right-sided BPPV, the Epley procedure will be done as follows:

• Start with the sitting position, and the head is turned in the direction of the affected side. To move the particles, a mastoid bone oscillator is kept behind the affected ear with the help of a headband.
• Position 1 – The patient reclines slowly to the supine position, with head turned 45 degrees to the affected side. The rate is altered to achieve a point of no nystagmus and no symptoms. This usually takes approximately 30 seconds.
• Position 2 – The patient lies supine, 15 degrees Trendelenburg, and head turned 45 degrees toward the affected side. The patient reclines more to the Dix-Hallpike position on the ipsilateral side. It takes around 10 seconds. Then the patient stays in the Dix-Hallpike position for another 20 seconds with the affected ear down.
• Position 3 – The patient lies supine, 15 degrees Trendelenburg, and head turned 45 degrees toward the opposite side. After this, the patient’s head is slowly turned from position 3 to the opposite side.
• Position 4 – The patient lies on the side with the opposite shoulder down, head turned 45 degrees toward the contralateral side. The body is then rolled to bring the shoulders perpendicular to the floor with the affected ear up. Next, the head is turned more so that the nose comes at an angle of 45 degrees below the horizon. This takes 40 seconds more.
• Position 5 – The patient is brought back to the sitting position, and the head is turned away from the affected side.
• Ending position – In the end, the head is brought back to the midline. At this point, the headband and the mastoid bone oscillator are removed.

There are some adverse effects of repositioning maneuvers that the providers should be aware of, such as:

• Conversion of posterior BPPV to a lateral or anterior canal BPPV during a maneuver[rx]
• Emesis[rx]
• Prolonged autonomic dysfunction
• Imbalance

Surgical Treatment

Most patients with BPPV will get better with repositioning maneuvers or resolve completely. However, surgical intervention is reserved for refractory cases. There are two surgical options for BPPV:

• Singular neurectomy
• Posterior canal occlusion

OFFICE TREATMENT OF BPPV: The Epley and Semont Maneuvers

The Epley and Semont maneuvers, named after their inventors, are both intended to move debris or “ear rocks” out of the sensitive part of the ear (posterior canal) to a less sensitive location. Each maneuver takes about 15 minutes to complete. The Semont maneuver (also called the “liberatory” maneuver) involves a procedure whereby the patient is rapidly moved from lying on one side to lying on the other (Levrat et al, 2003). It is a brisk maneuver that is not currently favored in the United States, but it is 90% effective after 4 treatment sessions. In our opinion, it is equivalent to the Epley maneuver as the head orientation concerning gravity is very similar, omitting only ‘C’ from the figure to the right. Because the head positions are the same, the results are the same.

The Epley maneuver is also called the particle repositioning or canalith repositioning procedure. It was invented by Dr. John Epley and is illustrated in figure 2 on the right (for the right ear). Click here for a low-bandwidth animation. It involves sequential movement of the head into four positions, staying in each position for roughly 30 seconds. One starts (B) with the bad ear down — for the left ear, one just mirrors the maneuver starting with the left ear down. The recurrence rate for BPPV after these maneuvers and resolution is about 22 percent at one year, and a second treatment (or more) may be necessary. Use of anti-nausea medication, such as meclizine or ondansetron, before the maneuver, may be very helpful if nausea is anticipated. I also review some Youtube videos of the Epley here and give you my thoughts.

There is also a maneuver called the “Foster maneuver”, which involves moving the head forward rather than backward as in the Semont and Epley. This maneuver can also be used with similar results to the Semont and Epley. We think this maneuver is a little trickier to pull off than the Epley.

When performing the Epley maneuver, caution is advised should neurological symptoms (for example, weakness, numbness, or visual changes other than vertigo) occur. Occasionally such symptoms are caused by compression of the vertebral arteries (Sakaguchi et al, 2003), and if one persists for a long time, a stroke could occur. If the exercises are being performed without medical supervision, we advise stopping the exercises and consulting a physician. If the exercises are being supervised, given that the diagnosis of BPPV is well established, in most cases we modify the maneuver so that the positions are attained with body movements rather than head movements.

After either of these maneuvers, you should be prepared to follow the instructions below, which are aimed at reducing the chance that debris might fall back into the sensitive back part of the ear.

Supplemental material: Animation of Epley Maneuver.

Note that this maneuver is done faster in the animation than in the clinic. Usually one allows 30 seconds between positions. Also note that there are many “youtube” videos of the Epley as well as many other maneuvers, some of which are a little suspicious.

INSTRUCTIONS FOR PATIENTS AFTER OFFICE TREATMENTS (Epley or Semont maneuvers)

Wait for 10 minutes after the maneuver is performed before going home. This is to avoid “quick spins,” or brief bursts of vertigo as debris repositions itself immediately after the maneuver. Don’t drive yourself home.

Sleep semi-recumbent for the next night. This means sleeping with your head halfway between being flat and upright (at a 45-degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a couch (see figure to right). During the day, try to keep your head vertical. You must not go to the hairdresser or dentist for 24 hours. Shampoo only under the shower.

There is some disagreement about the value of this procedure — many authors suggest that no special sleeping positions are necessary (Cohen, 2004; Massoud and Ireland, 1996; Devaiah et al, 2010; Papacharalampous et al, 2012). We, as do others, think that there is the value (Cakir et al, 2006). See this page for a literature review about post-maneuver restrictions.

For at least one week, avoid provoking head positions that might bring BPPV on again.

• Use two pillows when you sleep.
• Avoid sleeping on the “bad” side.
• Don’t turn your head far up or far down.

Be careful to avoid the head-extended position, in which you are lying on your back, especially with your head turned towards the affected side. This means being cautious at the beauty parlor, dentist’s office, and while undergoing minor surgery. Try to stay as upright as possible. Exercises for low-back pain should be stopped for a week. No “sit-ups” should be done for one week and no “crawl” swimming. (Breast stroke is OK.) Also, avoid far head-forward positions such as might occur in certain exercises (i.e. touching the toes). Do not start doing the Brandt-Daroff exercises immediately or 2 days after the Epley or Semont maneuver, unless specifically instructed otherwise by your healthcare provider.

Again, the value of post-maneuver restrictions is probably small, and it is also OK to just go about your life (but we think a little riskier).

4. At one week after treatment, put yourself in a position that usually makes you dizzy. Position yourself cautiously and under conditions in which you can’t fall or hurt yourself. Let your doctor know how you did.

Variant office maneuvers for PC BPPV

While some authors advocate the use of vibration in the Epley maneuver, we have not found this useful in a study of our patients (Hain et al, 2000). There is some rationale for its use in cupulolithiasis or refractory BPPV.

Some authors suggest that position ‘D’ in the figure is not necessary (e.g. Cohen et al. 1999; Cohen et al. 2004 ). In our opinion, this is a mistake as mathematical modeling of BPPV suggests that position ‘D’ is the most important position (Squires et al, 2004). Mathematical modeling also suggests that position ‘C’ is probably not needed. In our opinion, position ‘C’ has utility as it gives patients a chance to regroup between position ‘B’ and ‘D’.

WHAT IS THE PROOF THAT THE EPLEY/SEMONT MANEUVERS WORK ?

Many patients have been reported in controlled studies. The median response in treated patients was 81%, compared to 37.% in the placebo or untreated subjects. A meta-analysis published in 2010 indicated that there is very good evidence that the Epley maneuver (CRP) is effective (Helminski et al, 2010). See here for the details.

WHAT IF THE MANEUVERS FOR BPPV DON’T WORK?

While the Epley maneuver works roughly 50-75% of the time on the first occasion they are used, this means the other 25% are either not “fixed”, or just partially better, or perhaps even worse (about 5%). For this reason, in persons who have continued dizziness, a follow-up visit is scheduled and another nystagmus test with video-Frenzel goggles is done. It is common to have a follow-up visit once/a week for roughly a month.

There are several possible reasons for continued dizziness after physical treatment for BPPV:

• The maneuver didn’t work (should keep treating for a reasonable number — about 4 is usually reasonable– attempts)
• Canal conversion (should change treatment to the new canal)
• Another problem in addition to BPPV (e.g. Migraine — should change treatment)
• Canal Jam, or narrow spot in a canal.
• Other complications

It does not appear that the reason for BPPV — idiopathic vs. trauma — affects the symptom resolution rate (Aron et al, 2015; Luryi, 2019).

Bizarrely, some insurance companies, in what we consider a misguided attempt to save money, suggest that positional nystagmus tests for dizziness that guide treatment once/week are “too frequent”. This is despite reports that it often takes a few visits to treat BPPV (Hughes et al, 2016). This insurance company’s logic is seriously flawed. Just imagine — what if insurance companies tried to save money by limiting the number of EKGs that can be done in a person with a heart attack? Insurance would pay less but more people would die. With BPPV, one needs to see the results of the last treatment and be sure that things haven’t changed. Similarly, it would be ridiculous to prevent a cardiologist from checking an EKG on a patient who had sustained a heart attack but was not in chest pain. You can see how this logic applies to follow-up testing for BPPV.

The office maneuvers for BPPV, perhaps provided on 2 or 3 occasions, are effective in 85-95% of patients with BPPV. If you are among the other remainder, or your symptoms are mild enough that the trouble of traveling is more than it is worth, or you live far away,  your doctor may wish you to proceed with the home Epley exercises, as described below. If a maneuver works but symptoms recur or the response is only partial (about 40% of the time according to Smouha, 1997), another trial of the maneuver might be advised. When all maneuvers have been tried, the diagnosis is clear, and symptoms are still intolerable, surgical management (posterior canal plugging) may be offered. This is exceedingly rare.

Occasional patients travel to a facility where a device is available to position the head and body to make the maneuvers more effective. See this page for more information about this option. As one can usually get to any position by moving the head and body around, unless you are very unwieldy, these devices are likely an “overkill”.

BPPV often recurs. About 1/3 of patients have a recurrence in the first year after treatment, and by five years, about half of all patients have a recurrence (Hain et al, 2000; Nunez et al; 2000; Sakaida et al, 2003). If BPPV recurs, in our practice we usually retreat with one of the maneuvers above. While daily use of exercises would seem sensible, we did not find it to prevent recurrence (Helminski et al, 2005; Helminski and Hain, 2008).

In some persons, positional vertigo can be eliminated but imbalance persists. Kitahara et al (2018) reported that nearly 33% of their patients were “intractable” (this seems to us to be a bit high). This may be related to utricular damage (Hong et al, 2008). See this page for some other ideas. In these persons, it may be reasonable to undertake a course of generic vestibular rehabilitation, as they may still need to compensate for a changed utricular mass or a component of persistent vertigo caused by cupulolithiasis. Conventional vestibular rehabilitation has some efficacy, even without specific maneuvers. (Angeli, Hawley, et al. 2003; Fujino et al,1994)

Lateral Canal BPPV, Anterior Canal BPPV, Cupulolithiasis, Vestibulolithiasis, Multicanal patterns

There are several rarer variants of BPPV which may occur spontaneously as well as after the Brandt-Daroff maneuvers or Epley/Semont maneuvers. They are mainly thought to be caused by the migration of otoconial debris into canals other than the posterior canal, such as the anterior or lateral canal. Debris may also migrate into or out of the short arm of the PC (on the diagram, where the arrow says “vestibulolithiasis”). It is also possible that some are due to other conditions such as brainstem or cerebellar damage, but clinical experience suggests that this is very rare.

There is presently no data reported as to the frequency and extent of these syndromes following treatment procedures. The author estimates that they occur in roughly 5% of Epley maneuvers. In nearly all instances, except cupulolithiasis, these variants of BPPV following maneuvers resolve within a week without any special treatment, but when they do not, there are procedures available to treat them. It is especially common to have supine down beating nystagmus after a successful Epley maneuver (Cambi et al, 2012). This should not be of any concern as long as it is unaccompanied by updating nystagmus on sitting (which suggests anterior canal BPPV).

In clinical practice, atypical BPPV arising spontaneously is first treated with maneuvers as is typical BPPV, and the special treatments as outlined below are entered into only after treatment failure. When atypical BPPV follows the Epley, Semont, or Brandt-Daroff maneuvers, specific exercises are generally begun as soon as the diagnosis is ascertained. In patients in whom the exercise treatment of atypical BPPV fails, especially in situations where onset is spontaneous, additional diagnostic testing such as MRI scanning may be indicated. The reason for this is to look for other types of positional vertigo.

Lateral canal BPPV is the most common atypical BPPV variant, accounting for about 3-12 percent of cases (Korres et al, 2002; Hornibrook 2004). Many cases are seen as a consequence of an Epley maneuver. It is diagnosed by horizontal nystagmus that changes direction according to the ear that is down. More detail about lateral canal BPPV as well as an illustration of a home exercise can be found here

Anterior canal BPPV is also rare, and a large study suggested that it accounts for about 2% of cases of BPPV (Korres et al, 2002). It is diagnosed by a positional nystagmus with components of downbeat and (sometimes) torsional movement on taking up the Dix-Hallpike position. More detail about anterior canal BPPV as well as an illustration of a home exercise can be found here

Cupulolithiasis is a condition in which debris is stuck to the cupula of a semicircular canal, rather than being loose within the canal. Cupulolithiasis should result in constant nystagmus. This pattern is sometimes seen (Smouha et al. 1995). Cupulolithiasis might theoretically occur in any canal — horizontal, anterior, or vertical, each of which might have its pattern of positional nystagmus. If cupulolithiasis of the posterior canal is suspected, it seems logical to treat with either the Epley with vibration or use the Semont maneuver. Other maneuvers have been proposed for lateral canal cupulolithiasis. There are no controlled studies of cupulolithiasis to indicate which strategy is the most effective.

Vestibulolithiasis is a hypothetical condition in which debris is present on the vestibule side of the cupula, rather than on the canal side. For this theory, there is loose debris, close to but unattached to the cupula of the posterior canal, possibly in the vestibule or short arm of the semicircular canal. This mechanism would be expected to resemble cupulolithiasis, having persistent up-beating nystagmus, but with intermittency because the debris is movable. Very little data is available as to the frequency of this pattern, and no data is available regarding treatment.

Multicanal BPPV. If debris can get into one canal, why shouldn’t it be able to get into more than one? It is common to find small amounts of horizontal nystagmus or contralateral downbeat nystagmus in a person with classic posterior canal BPPV. While other explanations are possible, the most likely one is that there is debris in multiple canals. Gradually literature is developing about these situations (Bertholon et al, 2005). The response to physical therapy-based treatment for multi-canal BPPV is lower than for single-canal BPPV (Song et al, 2015).

WHERE ARE BPPV EVALUATIONS AND TREATMENTS DONE?

The Vestibular Disorders Association (VEDA) maintains a list of doctors, audiologists, and physical therapists who claim that they have proficiency in treating BPPV.

We think it is best to select someone who treats BPPV at least every week, or if this is not possible, someone who has attended a course on vestibular rehabilitation AND who has the equipment in their office to visualize BPPV (i.e. Frenzel goggles). Because BPPV is so common, most major cities will have at least one person who fits these minimal criteria. Of course, someone who treats BPPV and similar conditions as their main work activity are best. These people are usually called “vestibular physical therapists” or PVT.

If a physical therapist starts you with Brandt-Daroff maneuvers or puts their main emphasis on the treatment of neck mobility — they are probably not very knowledgeable about BPPV. Consider looking for another PT.

References

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