Benign Paroxysmal Positional Vertigo (BPPV): Causes and Symptoms

Benign Paroxysmal Positional Vertigo or BPPV is a condition in the inner ear that causes tiny crystals to get loose and start to float. Individuals become lightheaded due to the fluid and crystal movement. BPPV can occasionally result from an ear injury.

How Can the Displacement of Canaliths Trigger Vertigo?

Canaliths or otoconia are small calcium carbonate crystals in a vestibular structure (balance apparatus) called the utricle (an organ that helps control balance) in the inner ear. Due to an injury, infection, or old age, these crystals can be displaced and move to the fluid in semicircular canals (also help in balancing) located next to the vestibular organs. 

The semicircular canal contains tiny hair-like structures known as cilia. The cilia are responsible for transmitting balance-related information to the brain cells. When a person changes the head position, these canaliths move around the canal and touch the cilia. It stimulates the nerve endings results in false signals confusing the brain, causing dizziness and vertigo.

BPPV is not an indication of a severe problem and typically goes away on its own a few days after the initial episode. The distinction of BPPV is essential since each requires a separate course of treatment.

There are two types of BPPV:

1. Canalithiasis: The crystals can move freely in the fluid of the ear canal. It spins for less than a minute before stopping due to a specific shift in head position. Once the crystals settle down, the movement of the fluids stops, preventing vertigo. 
2. Cupulolithiasis: It is a rare type of BPPV. The crystals are attached to the nerve bundles of the ear, which sense the fluid movement. When there are crystals on the sensory nerve bundle, cupulolithiasis causes nystagmus (uncontrolled rapid eye movement) and vertigo to remain longer until there is a change in the position of the head.

The primary symptom of BPPV is vertigo. This dizziness feeling can be minor to severe and persist for a few seconds or up to a minute. Other benign paroxysmal positional vertigo symptoms could coexist with it. Besides vertigo, people with BPPV may also experience the following symptoms:

1. Dizziness
2. A sudden spinning sensation
3. Nausea and vomiting
4. Loss of balance
5. Unclear vision
6. Nystagmus (involuntary abnormal eye movements)

BPPV frequently has no identified cause. It is known as idiopathic BPPV. BPPV is commonly linked with minor to severe head injuries. BPPV can also result from conditions that harm the inner ear, ear surgery, or spending extended periods lying on the back. These conditions are less common causes of BPPV. Additionally, there is an established link between BPPV and migraines.

The causes of BPPV include:

1. Blow or trauma to the head
2. Changes in the position of the head, like moving the head up and down
3. Migraine

If the inner ear gets damaged due to the following conditions, it may also cause BPPV:

1. Labyrinthitis - Inflammation in the labyrinth or the inner ear. The inner ear is responsible for both hearing and balance.
2. Vestibular Neuritis - Inner ear disorder affecting the vestibulocochlear nerve of the ear, causing vertigo. This nerve sends information related to balance and head position changes to the brain, so when the nerve gets inflamed, this information gets disrupted. 
3. Acoustic Neuroma - Noncancerous ear tumour affecting the hearing and balance.

Benign Paroxysmal Positional Vertigo is experienced mainly by individuals over 50 years, while it can happen to anyone. In addition, women are more likely to develop BPPV than men. The susceptibility to BPPV may increase if an individual suffers from a head injury or any other condition affecting the balance.

1. Age - BPPV can affect people of all age groups, but it is prevalent among people over 50. It is rare in children
2. Gender - Due to increased hormonal fluctuations, especially during menopause, women are more likely to be affected by BPPV 
3. Accidents and sports injuries
4. Disorder in the inner part of the ears, which is responsible for the balance of the body
5. Vitamin D deficiency
6. Osteoporosis (a disease that weakens bones)

In many cases, the risk factors mentioned in BPPV have little or nothing to do with the condition. Studies show that maintaining an inactive lifestyle for a long time can cause BPPV. Therefore, to prevent BPPV, it is important to:

1. Avoid remaining in a lying position for long hours
2. Include regular physical activities in the daily routine
3. Exercises should involve the rotation of the whole body, including multiple positions of the body and head, to stimulate the vestibular system in the ear.
4. Go out and get sunlight to avoid the risk of vitamin D deficiency, especially during the winter.
5. Make sure to wear helmets while driving a bike or participating in contact sports (basketball, kabaddi, football, etc.) to prevent BPPV through a trauma or head injury.

As the episodes of vertigo are often sudden or unexpected, patients with BPPV must consider the following tips to prevent any risk of falling or injury:

1. When feeling dizzy, the patient must sit down immediately
2. Carefully observe what head movements or positions cause the BPPV symptoms and avoid them as much as possible
3. Use canes or a medical walker for support while walking if there is a risk of falling
4. The patient must always remain in proper lighting conditions, especially at night, while going from one room to another 

BPPV cannot be diagnosed using conventional medical imaging, such as an MRI, because those images do not reveal the crystals that have entered the semi-circular canals. The eyes of a person with BPPV move rapidly, known as nystagmus, and the head is moved in a way that causes the dislodged crystals to move within a canal. The doctor physically examines the patients with BPPV to determine its causes. The test often involves:

1. Triggering the symptoms of dizziness by particular eye and head movements. The doctor also observes if the symptoms decrease or stop in less than one minute. 
2. Place the patient on the examination table in a supine position with their head slightly over the table's edge. The doctor examines if specific eye movements can trigger dizziness by keeping the patient’s head on one side. 
3. Look for any signs of abnormality in the eye movements and if the patient cannot control them.

The patient may require additional tests such as:

Electronystagmography (ENG) or Videonystagmography (VNG): This test helps to determine the presence of any abnormal eye movements. The doctor measures the eye movements of the patient by either using electrodes (ENG) or small cameras (VNG). During this, the patient’s head is placed in different positions to detect an inner ear disease, which may be causing involuntary eye movements. The doctor also checks if the patient's balance system is being stimulated by water or air. 

How to Prepare For the Doctor’s Consultation

1. The patient must note all the BPPV symptoms they have been experiencing lately. 
2. The patient must also prepare a list of medication, vitamins, and supplements that they have been taking. If the patient has any medical conditions for which they are undergoing treatment, it should also be mentioned to the doctor. 
3. Writing down the questions that are needed to be asked will also be helpful.

What to Expect from the Doctor? 

The doctor may ask the following questions:

1. What are the symptoms, and when did they first occur?
2. How often does the patient experience the symptoms? 
3. For how long do the symptoms last?
4. Which activity or movement triggers the symptoms in the patient? 
5. Do the patient experience troubled vision during the symptoms?
6. Are the symptoms followed by nausea, vomiting, or a headache? 
7. Does the patient have any trouble hearing? 
8. Are there any other medical conditions for which the patient is getting treatment? 

What to Ask The Doctor? 

1. What are the causes of BPPV symptoms? 
2. What tests would be required for diagnosis? 
3. Would there be any additional tests required? 
4. Are there any restrictions to follow before the procedure? If yes, then for how long? 
5. Can BPPV be treated using home remedies?
6. Is there a requirement for the surgery? 
7. How to manage other medical conditions along with BPPV? 

Within a few weeks or months, Benign Paroxysmal Positional Vertigo may go away on its own. The Canalith Repositioning Procedure is a procedure where a doctor, (audiologist, or physical therapist) may use to assist resolve BPPV sooner.

Canalith Repositioning Procedure

In many cases, the symptoms of BPPV go on their own within a few weeks or months. But these symptoms can come back and again cause discomfort to the patient. This is why it is recommended to consult a doctor for a Canalith Repositioning Procedure. In this procedure, the doctor moves canalith particles from the semicircular canal into the part of the inner ear where they would no more cause any symptoms. All of this is done with the help of a series of physical movements, which involve changing the position of the head and body to shift the displaced canalith particles. The Canalith Repositioning Procedure typically takes about 15 minutes to complete. It is found to be effective in 80-90% of cases. The doctor also suggests specific exercises that the patient can easily do at home to get relief from the symptoms.

BPPV rarely results in complications, despite being uncomfortable. Driving, working, and daily activities might be affected by vertigo. It may also result in falls, which may cause various injuries, such as hip fractures.

When to See a Doctor?

If the patient experiences sudden and intense symptoms of vertigo or dizziness, they must contact a doctor for treatment advice. If any of the following conditions accompanies these symptoms, the patient must seek immediate medical help:

1. Chest pain
2. Irregular heartbeat
3. Severe headache which feels different than usual
4. Fever
5. Double vision or no vision
6. Loss of hearing
7. Slurred speech
8. Unconsciousness
9. Numbness 
10. Loss of balance while walking

Risks If Not Treated In Time

Benign paroxysmal positional vertigo can be dangerous for an individual if not treated in time. The symptoms of BPPV make an individual very uncomfortable, affecting their daily life. It significantly increases the risk of accidents or falls, which may cause severe injuries and fractures.