Benign paroxysmal positional vertigo

What is benign paroxysmal positional vertigo?

Benign paroxysmal positional vertigo (BPPV) is a condition of the inner ear. It is a common cause of intense dizziness and vertigo, especially in older people.

• Benign means that the cause is neither cancerous nor serious.

• Paroxysmal means recurring sudden episodes of symptoms.

• Positional means that the symptoms are usually triggered by certain positions. In the case of BPPV, certain positions of the head typically trigger symptoms.

• Vertigo is a sensation of movement. If you have vertigo you feel as if the world is moving around you or that you are moving when you aren't. You feel very unsteady, a bit like being on a ship. Often you will also feel sick, although you will not usually be sick (vomit).

Understanding the inner ear

The inner ear includes the cochlea and semicircular canals. These are small shell-like structures in which there is a system of narrow fluid-filled channels called the labyrinth. The semicircular canals sense movement of your head and help to control balance and posture. The cochlea is the part of the inner ear that is responsible for hearing.

Cross-section of the ear

Inner ear diagram

There are three semicircular canals (anterior - 'front', lateral - 'side' and posterior - 'back'). These are roughly at right angles to each other and sense movement in different directions. The three semicircular canals are connected to a larger fluid-filled chamber called the vestibule, which in turn is connected to the fluid-filled canal in the cochlea.

Patient picks for Dizziness

Signs and symptoms

When to worry about dizziness

The list of causes of dizziness is almost endless - but problems with your inner ear cause a special kind of dizziness called vertigo. If you have vertigo, the world spins around you - rather than other kinds of dizziness which make you feel woozy or light-headed. Vertigo can make you very unsteady on your feet, and generally unwell - you may also feel sick or vomit.

by Dr Sarah Jarvis MBE, FRCGP

Signs and symptoms

Dizziness

Dizziness is a feeling of being unsteady. People use the word 'dizzy' to refer to different sensations - the most important distinction is between dizziness and the spinning sensation which is medically known as vertigo. This leaflet gives a brief overview of the causes of dizziness. There are separate, more detailed leaflets for some of the conditions listed.

by Dr Toni Hazell

Head movements are sensed because when you move your head, the fluid in the labyrinth within the semicircular canals moves too. The movement of the fluid moves tiny fine hairs that are on the inside lining of the labyrinth.

When the hairs move, this triggers nerve messages to be sent to the brain via a nerve called the vestibular nerve. This gives the brain information about the movement and position of your head, even when your eyes are closed.

Three things are required to help you balance and maintain good posture:

• a labyrinth in each ear

• your vision

• nerve messages from the joints and muscles of the body.

Signals from these three systems provide information to the brain in order to help you balance.

What happens in benign paroxysmal positional vertigo?

Benign paroxysmal positional vertigo is caused by one or more tiny solid fragments (otoconia) that float about in the fluid of the labyrinth. The fragments are made up of calcium carbonate crystals which are thought to have broken off from the inside lining of the vestibule part of the labyrinth. These cause no problems if the fragment remains in the vestibule. However, problems occur if a fragment gets into one of the semicircular canals.

Debris for removal

The posterior canal is the one that is affected 8 or 9 times out of 10. In this situation, when your head is still, the fragment sits at the bottom of the posterior canal. But when the head moves in certain directions the fragment gets carried along with the flow of fluid.

The fragment brushes along the delicate hairs that line the semicircular canal and this bombards messages down the vestibular nerve. The extra nerve messages sent from the affected ear conflict with the normal messages sent from the other unaffected ear and from the eyes and the rest of the body. The brain becomes very confused and reacts with vertigo.

It is not clear why these otoconia form or drop off from the inside lining of the labyrinth. Most cases of benign paroxysmal positional vertigo occur in people over the age of 40 years. Age-related BPPV is one of the most common causes of vertigo in older people.

However, some younger people develop BPPV following an injury to the head, or following a previous infection in the inner ear. Sometimes it occurs for no apparent reason.

Symptoms of benign paroxysmal positional vertigo

The main symptom of benign paroxysmal positional vertigo is vertigo itself. The vertigo lasts just a short time - typically just for 20-30 seconds and usually no longer than a minute. It then goes away completely if you keep your head still. The vertigo is usually triggered by a change in head position.

For example, getting out of bed and rolling over in bed are two of the most common movements that trigger a short episode of vertigo. Sometimes just looking up triggers an episode of vertigo.

With each episode of vertigo you may feel sick but people rarely vomit. The nausea may last an hour or so even though the vertigo lasts just seconds. Between episodes of benign paroxysmal positional vertigo you feel well. Many people who develop benign paroxysmal positional vertigo realise which head movements trigger their symptoms and so instinctively avoid those movements.

In most cases, the symptoms clear away within several weeks or months. The solid fragments (otoconia) may dissolve or float out from the posterior semicircular canal and lodge in the vestibule where they cause no symptoms.

However, after the symptoms have gone, some people have recurrences of symptoms months or years later. In some cases, symptoms persist for years.

Diagnosing benign paroxysmal positional vertigo

The symptoms of benign paroxysmal positional vertigo are quite characteristic and so a doctor may well suspect that you have this condition just from your symptoms.

To confirm the diagnosis your doctor may do a test called the Dix-Hallpike manoeuvre. This will involve you sitting on a doctor's couch. The doctor will then ask you to lie back and move your head in certain directions. These set movements in people with BPPV will usually trigger an episode of vertigo.

What else might it be?

Other possible causes of vertigo include vestibular neuritis or labyrinthitis and Ménière's disease. However, these conditions tend to cause vertigo that lasts longer than in the case of benign paroxysmal positional vertigo.

Treatment for benign paroxysmal positional vertigo

Repositioning manoeuvres:

1. The Epley manoeuvre

This simple cure may be tried by your doctor. This often works if you have fragments of debris at the bottom of your posterior semicircular canal (the most common situation). This is done by a series of four movements of the head. After each movement, the head is held in the same place for 30 seconds or so.

The movements of the head cause the posterior semicircular canal to rotate around in such a way that gravity moves the otoconia fragments out from the posterior canal and into the vestibule where they then settle and cause no symptoms.

Studies report that the Epley manoeuvre is successful in stopping symptoms in about 8 in 10 cases with just one treatment. If the first treatment does not work, there is still a good chance that it will work in a repeated treatment session a week or so later.

The Epley manoeuvre is one of the few procedures that can be done in a doctor's surgery in a few minutes to completely cure a patient of symptoms! If symptoms return at a later date, the manoeuvre can be repeated.

2. The Semont manoeuvre

The Semont is an alternative to the Epley manoeuvre. It is also used to treat benign paroxysmal positional vertigo affecting the posterior semicircular canal. The Semont involves moving the patient quickly from lying on one side to lying on the other. This manoeuvre may be more suitable than the Epley for those with neck stiffness.

No treatment

If the Epley or Semont manoeuvres are not successful, or not done, you can still remain optimistic. Benign paroxysmal positional vertigo is a condition that can go away on its own after several weeks or months without any treatment. The otoconia are thought either to dissolve or move to a place in the labyrinth where they cause no symptoms.

Referral

If benign paroxysmal positional vertigo has been diagnosed but is not settling with repositioning manoeuvres or with no treatment, either the lateral or anterior semicircular canal may be affected (rather than the more common posterior canal). Benign paroxysmal positional vertigo affecting the lateral or anterior canals can be harder to treat and alternative manoeuvres are needed. A GP may refer to a doctor who is an ear specialist for review and treatment in such cases. A referral may also be required if the cause of the vertigo is unclear.

Surgery

Treating benign paroxysmal positional vertigo with surgery is extremely rare, as in most cases the condition either improves by itself or can be cured by a repositioning manoeuvre. If symptoms persist for months or years and cannot be eased, an operation of the inner ear to take out the function of the affected semicircular canal may be an option. An ear specialist will advise.

How do I keep safe while I have benign paroxysmal positional vertigo?

• The DVLA states that you should stop driving if you have sudden, unexpected and disabling attacks of dizziness: Dizziness or vertigo and driving - GOV.UK (www.gov.uk).

• You should inform your employer if BPPV could pose a risk to yourself or others in your job. For example, if you use ladders, operate heavy machinery, or drive.

• To avoid falls around the home, get out of bed slowly and avoid jobs around the house that involve looking upwards if possible.