BPPV: Understanding the Crystals in My Ear
By Collette Rhoden, PT, DPT
July 25, 2018
Category: BPPV
Tags: Austin   Vertigo   dizzy   spinning   BPPV   doctor  

BPPV: Understanding the Crystals in My Ear


Inner Ear Cochlea, Semi-Circular Canals Hearing & Balance Center of Austin

Picture retrieved from


What Is BPPV?

BPPV-Benign Paroxysmal Positional Vertigo is the most common vestibular disorder that causes a false sense of room spinning dizziness. This issue is due to the disruption of the crystals in your inner ear. This occurs when the otoconia (calcium carbonate crystals) get dislodged from the utricle, where they are normally embedded, and migrate into one or more of the 3 semicircular canals also known as “canalithiasis” ¹. During head movement, the free floating otoconia crystals shift disrupting the normal fluid movement in the semicircular canals thus causing the brain to send signals of false movement in relation to gravity ¹. The information perceived by the brain does not match what the eyes are seeing and what the body muscles are doing nor what the other ear is sensing therefore causing the person to feel an imbalance or false sense of spinning ¹.


What Causes BPPV to Happen?


There is no known exact cause as to why this happens but research has shown that risk factors that may influence the occurrence of BPPV are: direct trauma to the head, prolong periods of inverted head positions, inner ear infections or diseases, migraines, reduced blood flow, sickness causing prolonged periods of lying in bed and or inactivity, and one’s preferred sleep position ¹.


Am I Making This Up? Is BPPV all in My Head? Why Me?


You are not alone nor are you going crazy! BPPV has an estimated incidence of 107 people per 100,000 per year ¹. BPPV has a recurrence rate of about 15% per year with a high of 56% ² of individuals having a recurrence of BPPV.  It is more prevalent in people 50 and older and more likely prevalent amongst females ³. At least 20% of patients that have symptoms of dizziness are diagnosed with BPPV by their physician ². Other symptoms that can also occur due to this condition other than the routine nausea, room spinning dizziness and vomiting are high levels of anxiety, frustration, anger, fatigue and depression. It is completely normal to feel helpless and frustrated and depressed when dealing with BPPV due to the functional limitations that occur as a result of this condition but please seek counselling if symptoms worsen as the emotional component can actually make the symptoms persist.


Who Do I See if I Think I Have BPPV?

After visiting your family doctor or general practitioner and upon diagnosis of BPPV, you may be referred to a more specialized physician for treatment or further assessment such as an Audiologist, ENT (Ear Nose and Throat Doctor), and/or Physical Therapist (specifically trained to rehab patients with vestibular disorders) ¹. Beware that not all Doctors are familiar with vestibular rehabilitation and may fail to refer you to a Physical Therapist for treatment, which has been proven highly effective for recovery, so don’t be afraid to bring up the idea of seeing a Physical Therapist for treatment to your doctor if have been diagnosed with BPPV.


How is BPPV Diagnosed?


BPPV is diagnosed through symptom clustering and checking the semicircular canals via the Dix Hallpike and Supine Horizontal (Roll) tests. During your assessment  your Physical Therapist may ask you question in regards to positions and whether or not they tend to elicit your symptoms. BPPV is commonly triggered by activities such as getting in and out of bed, rolling over in bed, tipping the head back to look up, bending over forward, and quick head movements ¹ (i.e turning your head when someone calls your name). After collecting a list of activity provokers, the Therapist and/or other healthcare professional trained in vestibular assessment will perform the Dix Hallpike [Figure 1] ⁴ to check for loose floating otoconia in the posterior semicircular canals which tend to be the most common area of BPPV.


The Supine Horizontal test will also be performed to assess the horizontal canals for BPPV. Positive test is the presence of rapid eye movement whether torsional or up or down beating on the side that is tested which is noted as “nystagmus”. The rapid eye movement is triggered when the free floating otoconia is moving in the canal and should last in short duration under 30 seconds ¹. This can last longer if the otoconia are stuck to the cupula (organ in inner ear that senses spatial orientation) instead of free floating in the canals which is called cupulolithiasis, another form of BPPV where the rapid eye movement nystagmus will occur as long as the patient is held within the testing position. Since the otoconia are stuck on the cupula, the brain perceives constant input of movement therefore causing constant nystagmus when in the tested position but symptoms should subside once taken out of the tested position with head in neutral positioning in relation to gravity. In addition, a series of visual and vestibular test will also be performed to rule out other pathologies.

Dix Hallpike Testing for BPPV Austin, TXFigure 1: Dix Hallpike

[Picture retrieved from http://epomedicine.com/clinical-medicine/vestibular-examination-dix-hallpike-maneuver-for-bppv


Ahhhh Yes! The Good Part: How is BPPV Treated?


Upon assessment and determining whether or not it is canalithiasis or cupulolithiasis and determining which canal is affected. The Physical Therapist will perform evidence based highly effective corrective maneuvers to clear the crystals from the canal. The maneuvers utilize head on body movement along with gravity to transfer the crystals back into their rightful place in the inner ear. One of the maneuvers that can be performed is called the Epley maneuver [Figure 2] ⁵ or also known as the Canal Repositioning Maneuver which is performed to clear the otoconia out from the posterior semicircular canal. This maneuver can also be self performed for the individual to treat at home ONLY IF your Therapist recommends it, however, caution should be

taken because if performed wrong can make symptoms worse. The maneuver that can be used to clear the crystals in the horizontal/lateral canals is called the Lempert Roll Maneuver or “BBQ roll’. Both maneuvers can be modified for patients that may have neck injuries or postural deformities that may affect their ability to get into some positions. If the therapist suspect cupulolithiasis, then he/she will perform the Liberatory Maneuver which incorporates rapid head movement to dislodge the crystals from the cupula.


Epley Maneuver Diagram BPPV Dizziness Treatment Austin,TX


Figure 2: Epley Maneuver

[Picture retrieved from https://athenatech.us/epley-maneuver-diagram/epley-maneuver-diagram-unique-check-your-balance]



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