Benign Paroxysmal Positional Vertigo and the Inner Ear

In BPPV, the otoconia crystals migrate into the canals, causing a feeling of movement.

Do you feel a short burst of vertigo (a feeling like you or the room is spinning) when you roll over in bed, tip your head up or down, go to lie down, and/or sit up in bed?

Benign paroxysmal positional vertigo (BPPV) is the most common disorder of the inner ear’s vestibular system, which is a vital part of maintaining balance. BPPV is benign, meaning that it is not life-threatening nor generally progressive.

BPPV produces this sensation of spinning called vertigo that is both paroxysmal (sudden) and positional (it occurs with a change in head position). Each episode of vertigo is short in duration, usually less than one minute.

Approximately 50% of the time, doctors are unable to find a cause for BPPV. It will occur most often in people age 60 years or older. Head injuries have been linked to causing BPPV as well.

The vestibular labyrinth is located in the inner ear. It includes three loop-shaped structures (semicircular canals) that contain fluid and cilia (fine, hair-like sensors that monitor the rotation of your head).

Other structures (otolith organs) in your ear monitor movements of your head — up and down, right and left, back and forth — and your head's position related to gravity. These otolith organs — the utricle and saccule — contain crystals that make you sensitive to gravity.

For a variety of reasons, these crystals can become dislodged.

When they become dislodged, they can move into one of the semicircular canals — especially while you're lying down. This causes the semicircular canal to become sensitive to head position changes it would normally not respond to. As a result, you feel dizzy.

BPPV is diagnosed by visually observing nystagmus (a back and forth movement of the eyes) when the patient is rapidly moved from a sitting to supine position with the head slightly turned.

For a video showing how this maneuver is performed and what the audiologist is looking for, click here .

Once BPPV is diagnosed, there are specific positioning maneuvers the audiologist can perform to help move the dislodged crystals back in place. The maneuvers are called Canalith Repositioning Maneuvers and vary based on which of the three semicircular canals are involved.

If superior canal BPPV is present, the deep head hanging maneuver is performed.

If horizontal canal BPPV is present, the Lempert (also known as the “BBQ”) maneuver is performed.

If posterior canal BPPV is present, the Epley maneuver is performed.

Each of these maneuvers are designed to move the crystals back to the utricle so they will no longer create a false feeling of motion. It is important that an accurate diagnosis is made by an audiologist or ENT specialist and that these maneuvers are completed with the guidance of these professionals or a physical therapist to ensure the best results.

In some cases, cupulolithiasis is present. This means that the crystals are adhered to the canal wall and are difficult to move. The goal of treatment is to first dislodge the crystals and then treat as typical BPPV with the appropriate maneuver.

Head shaking, vibration, and most recently, a head-tilt hopping (HtH) exercise are various methods used to release these crystals.


Benign Paroxysmal Positional Vertigo (BPPV). (nd.) Vestibular Disorders Association. Accessed 2/17/2015 from

Diseases and Conditions: Benign Paroxysmal Positional Vertigo (BPPV). (nd.) Mayo Clinic. Accessed 2/17/15 from

Gans, Richard E. (1996) Vestibular Rehabilitation: Protocols and Programs. Singular Publishing Group, Inc.

Yamanaka T, et al (2014). New treatment strategy for cupulolithiasis associated with benign paroxysmal positional vertigo of the lateral canal: the head-tilt hopping exercise. Eur Arch Otorhinolaryngol. 2014 Dec; 271(12):3155-60.

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