Benign paroxysmal positional vertigo (BPPV)

Benign paroxysmal positional vertigo (BPPV)

Benign paroxysmal positional vertigo (BPPV) is the most common form of vertigo and dizziness originating from the inner ear. It is characterised by spells of short duration vertigo and dizziness evoked by certain head positioning like turning over in bed, or looking up or down. Hearing is not affected and during the episode the patient also has abnormal eye movements called nystagmus. There are many causes of BPPV such as previous head trauma or virus infections of the inner ear. The symptoms of BPPV are the result of displacement of the crystals of the inner ear into the semi circular canals where they should not be. Although medication such as vestibular suppressants may help to reduce the symptoms, it does not cure the condition. Manoeuvres and exercises are the treatment of choice. Unfortunately BPPV recurs in a large number of patients. In some cases of chronic persistent attacks, surgery is indicated.

50% of all dizziness in older patients is due to benign paroxysmal positional vertigo (BPPV)

Image showing the different mechanisms of BPPV
Different mechanisms of BPPV

Benign paroxysmal positional vertigo (BPPV)

Benign paroxysmal positional vertigo (BPPV) is the most common form of spinning dizziness (vertigo) that originates from the ear. It is estimated that 10% of people above 65 years will at least get one spell in their lifetime.  50% of all dizziness in older patients is due to BPPV. It is slightly  more common in female patients and very rare in children. In males it is often related to previous trauma. It occurs equally in the right and left ears and may involve both sides.  The posterior canal is most often involved in 85% to 90% of cases, the horizontal in 8% to 10%  and the superior in less than 2%. More than one canal can be involved and it may change from one canal to another canal.

Possible causes 

  1. Unknown – 60%
  2. After whiplash, head and neck trauma – 18%
  3. Virus infections of the inner ear – 9%
  4. Bloodflow impairment to the inner ear – 3%
  5. After any surgery, toxic medication to the ear, ear infections, possible Vitamine D deficiency and Menière’s disease – 10% 

Mechanism for symptoms

The most acceptable explanation is that some of the calsium carbonate crystals(otoconia) of the balance organ(utricle) of the inner ear become loose or dislodged and then move into one of the semicircular canals by mistake. When enough of these otoconia enter the canal they can clot together and this clot or rock can then create the symptoms due to the inappropriate stimulation.

In the semicircular canal the otoconia most often float in the canal itself (canalithiasis) but can also adhere to the cupula (cupulolithiasis). It can also change from cupulolithiasis to canalithiasis and vice versa. When the patient keeps still the otoconia stop moving and the symptoms go away untill the head is moved again. Sometimes the clot can break up and the otoconia absorped or they can spontaneously move back to the utricle and then the symptoms dissappear for a longer period of time.

Another possible explanation is that a virus can affects the nerves of the semicircular canals leading to misfire and inappropriate signals during head movements , which then can cause the symptoms.


Symptoms may include:

  1. Spinning dizziness (vertigo)
  2. Balance impairment
  3. Lightheadedness, floating sensation, difficulty walking and nausea.
  4. Blurring of visison
  5. Hearing is usually not affected

Because of the variety of symptoms all patients with dizziness should be tested for BPPV.

Classical presentation 

The classical presentation of benign paroxysmal positional vertigo(BPPV) is the sudden onset of severe spinning dizziness(vertigo) that is triggered by a change in head position. It can occur when a patient turns over in bed, look up or down, turn around or perform any other head movement. The patient is often nauseous. The vertigo is accompanied by abnormal fast repetitive jerking eye movements (nystagmus). The vertigo is short and lasts only a few seconds. When the head is kept still it is better but occurs again if the head is moved. There is often a specific movement that triggers it for instance turning to a specific side. Patients therefore often choose only to sleep on the back or on a specific side and move as little as possible during the night. It can last for days to weeks and then dissapear by itself.  It recurs in 30% to 50% of patients. When a patient gets an attack, loss of balance can lead to falls and injuries. 

The diagnosis 

The diagnosis of benign paroxysmal positional vertigo (BPPV) is made by a combination of  clinical and special investigations. The Dix Hallpike and Side lying tests are routinely utilized With the clinical examination the aim is to elicit the symptoms and demonstrate abnormal involuntary repetitive eye movements (nystagmus). The type and direction of the nystagmus determine whether it is true BPPV of the ear or whether it is central and originating in the brain. Central BPPV is uncommon. Other conditions can mimic BPPV. The nystagmus also identifies the canal involved and the localization of the loose otoconia. Special investigations include videonystagmoscopy, videonystagmography(VNG)and magnetic resonance imaging(MRI). MRI is performed to exclude brain or central conditions that may mimic BPPV. It may be that there are no symptoms when seeing  the doctor and the examination may be normal but this does not exclude BPPV.

How can BPPV be managed?

Management of benign paroxysmal positional vertigo (BPPV) includes life style modification, medication, manoeuvres, exercises and surgery.

Life style modification means that the patient should avoid the movements or positioning of the head that elicits the symptoms.

Medication is of little help, may reduce symptoms temporarily but cannot really cure BPPV.

Manoeuvres are specifically designed and performed by a doctor or trained professional and the aim is to replace the otoconia out of the canals back to the utricle of the inner ear or loosen it from the cupula. The manoeuvres include the Epley manoeuvre, Parnes manoeuvre, Semont manoeuvre, Aprella manoeuvre, Guffoni manoeuvre, Log roll, BBQ rotation and other variants.

Manoeuvres, if performed correctly, have more than 90% chance of curing the BPPV within 2 attempts. The manoeuvre may unfortunately cause the loose otoconia to move from one canal to another and thus convert BPPV of one canal to BPPV of another canal.

Specific exercises like the Brandt and Daroff exercises may benefit some patients where more than one canal is involved or where the manoeuvres are not successful.

After a successful manoeuvre or exercise program BPPV can recur in 30%- 50% of patients.

In cases where all the above fail a surgical  operation can be performed. This is seldom neccesary in less than 5% of all the patients seen with BPPV. The canal causing the symptoms must be positively identified with the examination, on more than one occasion. It should be restricted to one canal and the abnormal involuntary repetitive eye movements (nystagmus) must be recorded before surgery.

It is not a life threatening condition but does impair functioning and quality of life. In a lot of cases it can lead to psychological problems and depression in patients.

Patients may also be at risk of becoming dizzy, losing their balance, falling and injuring themselves and others during an attack.

The different operations

A surgical operation can either be performed through the mastoid (back of the ear) or through the middle ear by lifting the eardrum.

The two types of operations in order of most to least preferred are:

  1. Fenestration and occlusion of a semicircular canal (FOS)
  2. Singular neurectomy(SN)

The canal can be opened and sealed off (FOS)or the nerve that goes to the canal can be cut (SN).

FOS is more commonly performed.

Open semicircular canal
Open semicircular canal

Dr Hofmeyr’s experience 

Dr Hofmeyr has managed more than 1000 patients with benign paroxysmal positional vertigo (BPPV) and has performed successful surgery on numerous patients. 

Further reading