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If you’ve ever laid down to go to sleep at night, and suddenly found that your room is spinning around you, or that your walls appear to be sliding up and down, you may have experienced Benign Paroxysmal Positional Vertigo (BPPV). BPPV is the most common form of vertigo, and it will be obvious to you if you have it. It is triggered by:

Although very common, researchers don’t know why it happens to some people and not others. Sometimes it can be triggered by an underlying ear condition but this is not the most common cause.

Benign Paroxysmal Positional Vertigo is a long string of words that defines exactly what it is:

The Basics

BPPV is a mechanical issue in your inner ear. You can see in the photo below your outer, middle, and inner ear.

 

Your outer ear refers to the part you can see, and the canal that leads toward your ear drum. It helps us hear by catching sound waves and transmitting them to your ear drum so they can reach your hearing organ, the cochlea. Your ear drum, or tympanic membrane, separates the outer ever from the middle ear. The middle ear is the part inside our ear that regulates pressure. It connects the backside of your ear drum to your throat via the Eustachian tube. This is a vital structure for pressure regulation. At baseline, the Eustachian tube is shut, when you change elevation, or f eel congested, it quickly opens and then shuts again, that open and shut mechanism is what causes your ear to “pop”. Some people can do this on command, it is the same mechanism of pressure regulation. Lastly, deep in our skull, but still connected to our ear, is the inner ear. The inner ear houses two parts, the first is the vestibular system and the second is the cochlea. The cochlea senses vibrations from your outer ear, tympanic membrane, and ossicles. In turn, it sends a signal to your brain, which perceives the sound, turning it into what you hear. Connected to the cochlea is the vestibular system, this organ senses where your head is in space, and is responsible for your feeling of equilibrium.

The vestibular system, deep in your skull, is where your BPPV comes from. Within your vestibular system, there are a few parts. The first is the utricle and saccule, which are your otolith organs, the second important structure here are the three semicircular canals. These two systems work collaboratively to ensure you know where your head is in space at all times.

The otolith organs contain tiny calcium carbonate crystals, otoconia. Otoconia, often referred to as ‘ear crystals’, detect linear movement. They are “stuck” like rocks on jelly to a gelatinous layer, which is connected to hair cells. When you look down into neck flexion, the otoconia slide forward with gravity, which pull the hair cells forward, and transmit a signal to your brain via your vestibulocochlear nerve. This happens in all directions that would cause rocks to move with gravity. Through this mechanism, always know where our head is in space when moving linearly. Separately, angular movements like twisting, turning, and moving at an angle are detected by the semicircular canals. Three canals, anterior, horizontal, and posterior, detect motion within those planes. When the systems work together, you should always know where your head is in space.

Symptoms

Symptoms of Benign Paroxysmal Positional Vertigo are:

BPPV is frequently misdiagnosed in those who have other types of vertigo or experience chronic dizziness lasting longer than 1 minute.

Why Do I See the Room Spin?

Semicircular canals don’t just detect and transmit motion signals, they are also responsible for your vestibuloocular reflex, or VOR. VOR is the reflex involved with your keeping objects still while you are moving your head. When the vestibular system is working properly, you can easily look left and right, or up and down, quickly, while keeping your eyes still. You can experiment with this by choosing a spot on the wall to stare at, and shaking your head left and right.

 

VOR is important in order to maintain equilibrium, and our semicircular canals are responsible for making sure it works. When you look left, the fluid in your semicircular canals moves, stimulating the ampulla at the end of the semicircular canal in the plane of movement. That will cause a reflex to be sent through the vestibulocochlear nerve to your brain, to move your eyes in an equal and opposite direction. Then, if you turn back to the right, your eyes will move again, but to the left. This stillness is what keeps our gaze stable when we are walking, and helps us keep our eyes on objects even when we are moving around.

BPPV is what happens when there is an error in the system causing brief spontaneous nystagmus [involuntary eye movement]. The error that occurs is mechanical in nature, your otoconia move off their jelly layer into a semicircular canal. Most often, the otoconia slide into the left or right posterior canal. When this happens, you will experience vertigo that lasts 15-60 seconds and then stops until you move again. The most irritating times of day will likely be getting up in the morning, or going to bed at night. The act of laying down or rolling over in bed often places the canals in a dependent position. The dependent position will force the crystals to move and stimulate the receptors in the semicircular canal that is impacted. This causes the eye to move to correct for the head movement you’ve made. But instead of stopping like it would with your VOR as discussed above, the crystals keep moving because of gravity and inertia. When you have canalithiasis, otoconia are stuck in the canal, the nystagmus is very brief because the rocks settle in the canal and don’t move again until you move your head again. Your canals are sending a signal to your brain that says “we are still moving” even when you’ve stopped, which causes nystagmus.

Diagnosing BPPV:

BPPV is diagnosed based on nystagmus. Nystagmus is incredibly telling because it will move in a very specific direction based on the canal, and the place within the canal, that the otoconia are located. Otoconia can be located in a few different places. The first thing you need to determine is the canal in which the otoconia are residing. All testing for BPPV should be performed with Frenzel or Video Goggles to reduce fixation, an important factor in diagnosis. If your patient can fixate, he or she may be able to stop the nystagmus, which will give you a false negative and will make it more difficult to provide your patient a diagnosis.

 

It is logical to start by testing the most common canal, the posterior canal. This test is called the Dix-Hallpike (DH).

  1. Patient sits on the treatment table, close enough to the edge that their head will hang off if they lay backwards.
  2. Patient turns head to the right 30 degrees
  3. Patient quickly lays backward and extends head off the table into providers hands at about 45 degrees of extension
  4. Patient keeps eyes open, the provider watches eyes on screen or through goggles.
  5. Patient who has positive upsetting torsional nystagmus for 15-60 seconds is positive for Posterior Canal BPPV on the side the head is turned to in the Dix-Hallpike position.
  6. If positive for Posterior Canal Canalithiasis, treat with Epley Maneuver.

If both sides are negative in the Dix-Hallpike position, check the horizontal canals. To test the Horizontal canals, you perform a Supine-Head-Turn maneuver.

  1. Patient lays down with neck flexed to approximately 30 degrees, with either a pillow or with assistance of a provider.
  2. Head is quickly turned left (or right) and left in this position for 15-60 seconds, or until symptoms subside
  3. Patient keeps eyes open throughout the direction of the test, and the provider should observe eyes to determine the direction of the nystagmus.
    1. If nystagmus is geotropic, treat with a Bar-B-Cue maneuver to the direction opposite of the “more intense” nystagmus (if nystagmus is more intense on the left test, roll to the right), or try a Gufoni for geotropic nystagmus.
    2. If nystagmus is ageotropic, treat with Bar-B-Cue maneuver to the direction of the “more intense” nystagmus (if nystagmus is more intense to the right, roll to the right), or try a Gufoni for ageotropic nystagmus.

If all 4 canals are negative for BPPV, but the patient’s subjective interview really makes it seem like BPPV, test for the anterior canal. The head hanging test is for the anterior canal.

  1. Place the patient on the table close enough to the edge so when they lay back, their head will hang off the edge into providers hands
  2. Lay back quickly into cervical extension, look for nystagmus.
  3. Positive test will show down beating nystagmus (with potential torsion) toward the affected ear.

What is the Difference Between Cupulolithiasis and Canalithiasis?

Diagnosing BPPV is the act of determining where the otoconia are stuck within the vestibular system. Otoconia can be misplaced into six different places in either ear. You must determine the affected ear, the canal, and then if it is in the cupula or canal. Within the vestibular system, pictured above, there are the semicircular canals and the ampulla, which houses the cupula. Canalithiasis refers to the otoconia stuck in the semicircular canals. Cupulolithiasis refers to when the otoconia are stuck in the ampullary cupula.

 

This direction and duration of the nystagmus determines whether you have cupulothiasis or canalithiasis. See the guidelines below for features of each kind of nystagmus and the corresponding diagnosis.

How to Treat BPPV

Once the correct canal is diagnosed, treatment is relatively simple. Because the otoconia respond to gravity and have likely just slipped into the wrong place, they can be rolled back out, into your otolith organ. The treatment you should receive is completely dependent on the canal that is being affected. Your physical therapist will determine this via a series of tests and watching your nystagmus, the exact diagnosis, and the direction in which you will need to be treated.

No matter the kind of BPPV you are experiencing, or how it is treated, it is most important that a professional help assist you with the maneuver. When performed independently, I have found that often times patients put the already displaced otoconia into another canal, instead of back into the otolith organs. Although it is still treatable, it does become more difficult; it is recommended you seek treatment from a physical therapist or ENT first.

Why Me?

Annually, about 1.6% of the population gets BPPV, with a lifetime prevalence of 2.4%, making It a very prevalent condition (1). Once diagnosed, it is possible that thee BPPV will recur again in the next few years. Although vertigo can be scary and anxiety provoking, once you know what it is, it is easier to self-diagnose and seek proper treatment. Fortunately, it can be treated easily through Canalith Repositioning Treatments as listed above.

Physical Therapy for BPPV

Physical therapists are the main providers who perform Canalith Repositioning Maneuvers, so with BPPV, physical therapists are vital to your treatment! If you are pretty sure this is what’s going on, make an appointment with a vestibular PT today. He or she will evaluate you completely, determine the canal and source of your dizziness, and treat you accordingly! You have direct access to a physical therapist in all 50 states (find one here!), so no need to make an appointment with your primary care physician first.

Source:

(1) Fife, T. D. (2017). Dizziness in the Outpatient Care Setting. CONTINUUM: Lifelong Learning in Neurology, 23(2), 359-395. doi:10.1212/con.0000000000000450. https://journals.lww.com/continuum/Fulltext/2017/04000/Dizziness_in_the_Outpatient_Care_Setting.7.aspx

 

Let’s face it, being dizzy can be really scary, and therefore, really anxiety provoking. Anxiety and dizziness go hand-in-hand, when I talk to my patients about this, I compare them to best friends. They love to be around each other, they relate to each other, and when one acts the other reacts. It creates a cycle that goes around and around, usually until the dizziness stops. Vestibular disorders, although invisible to others, cause real physical symptoms of dizziness. These symptoms provoke anxiety and frequently cause anxious behavior, and for patients with vestibular dysfunction this is normal. For those with anxiety surrounding their vestibular disorder, we can work together in physical therapy to treat the root cause.

Symptoms & Diagnosis

Dizziness related to anxiety can be a result of another kind of dizziness or vertigo that then feeds on your anxiety symptoms. Alternatively your dizziness can be a result of an anxiety disorder. However, in most cases I find that my patients have a combination of both happening. The most difficult thing for patients is often breaking your cycle of dizziness and anxiety.

Treatment

Because your dizziness and anxiety cause each other, we need to break the cycle in one or the other. If your dizziness has a root cause, like BPPV or Vestibular Neuritis, we can treat the source of your dizzy symptoms, hopefully relieving some or all of your anxiety. To treat these, we can use exercises for you

Vestibular Ocular Reflex (VOR), an Epley maneuver, or optokinetic stimulation. If anxiety is increasing your symptoms, or is the source of your symptoms, we need to find you a way to stop those feelings. Treatments to help decrease feelings of dizziness and anxiety are meditation, cognitive behavioral therapy, and grounding.

Physical Therapy

Physical therapy is a vital part of your journey toward dizziness relief, your vestibular therapist can help through a variety of treatments. One way to help anxiety through physical therapy is called grounding. There are a few ways you can do grounding, but my favorite is performed in a nice arm chair; if you don’t have an armchair, you can use a chair without arms as well! This kind of grounding is specifically for those with dizziness. Step one (1) sit in a big, sturdy chair, with your feet on the floor and arms on the arms of your chair. Step two (2) place 1 hand on your belly and the other on your chest; breathe diaphragmatically into your stomach. Step three (3) shut your eyes and begin to feel how still your body is. Start at your feet, feel how still the floor is; next feel the back of your legs on your chair and how still you are. Repeat with your arms, back, and maybe even your head! Continue to breathe deeply and evenly into your diaphragm. Continue this for 5-10 minutes until your anxiety and dizziness symptoms decrease.

Your physical therapist may recommend grounding, or may recommend another form of treatment to help with your anxiety. These may include a referral to a therapist or counselor, dietary recommendations and considerations, or vestibular exercises to treat the root of the issue. A discussion of a well-rounded, holistic plan specifically for you is the best way to act on your anxiety and break the cycle.

PS: if you made it to the end of this article and you’re in the holiday challenge, send me a DM for 2 extra points!

Allergy symptoms are usually recognized as a stuffy nose, a familiar congested feeling, sneezing, or itching. However, a less common but significant reaction to allergies is dizziness. Although the dizziness frequently feels like it is in your brain, it’s actually your ears!  In this case, your eustachian tube, the tube that makes your ear “pop” when you climb in elevation, will make you feel dizzy if you’re having severe allergies. Your Eustachian tube gets filled with mucus when you have a reaction to an allergen as a result of histamine buildup. Histamine is produced when the body is having an allergic reaction, usually causing inflammation and congestion. If this response blocks your Eustachian tube, your ear can’t equalize the pressure, and you end up feeling dizzy.

Visual depiction of the Eustachian Tube, Vestibular System/inner ear, and outer ear.

Allergies are also an underlying cause of Secondary Endolymphatic Hydrops (SEH). SEH is a fluid imbalance in the endolymph located inside your vestibular system. Symptoms of SEH include fullness in your ears, tinnitus, and dizziness. Learn more about SEH here!

If you feel like your dizziness fluctuates as allergy season ebbs and flows, this may be the cause of your dizziness. Luckily, you have options for treatment!

Symptoms & Diagnosis

Allergies can be distinguished by multiple different feelings, most of which we are familiar with. These include:

Additionally, a symptom of allergies can be dizziness. Dizziness has multiple definitions, but most commonly with allergies they include:

These two kinds of dizziness, lightheadedness and spinning, are common symptoms of many inner ear disorders, so differentiating them from another cause of vertigo or vestibular disorder is important. Typically, when you have allergy-related-dizziness, your symptoms will be related to the environment, seasons, or foods. You might start to notice that every time you are around a certain kind of tree, or when it is “allergy season” you start to feel dizzy. I also find people telling me that they’ve never had allergies, but moved to a new city and aren’t sure why they developed them all of the sudden (1).  Keeping track of your symptoms with a journal or log to find triggers can be an important step in finding what it is you’re allergic to in order to seek treatment. Despite this feeling being very disruptive and frustrating, it is usually treatable!

Treatment

Treatment for allergy-induced-dizziness is treated a lot like other allergies. A physical therapist is not the practitioner most qualified to treat your allergies, if allergies are the only cause of your dizziness, you should seek help from an allergist or your primary care provider. When you find out what is causing your allergies, there are a few ways to treat the symptoms.

Diet
Often we are allergic to something in our diets when we don’t realize it. Even in adulthood and as we age, we can develop allergies, so something that you may have been eating your whole life can suddenly cause an allergic reaction. The most common culprits are  nuts, corn, soy, dairy, citrus fruits, nightshade vegetables, wheat, foods containing gluten, pork, eggs and seafood (2). If you suspect your dizziness is related to your diet, you can try an elimination diet. To do this, first determine which food or foods you suspect may be causing your symptoms. Next remove those foods from your diet for 2-3 weeks. If your symptoms decrease, you may be allergic to one or multiple of them. Then, reintroduce the foods one at a time. If your symptoms increase, you are now aware of what is causing your dizziness and can eliminate it for good. Don’t forget to always consult your qualified healthcare provider prior to changing your diet!

Allergy Shots
For more severe allergies, an allergist, or other qualified healthcare provider, can provide allergy shots to slowly desensitize your body to the allergen causing your symptoms. You may have a multiple-injection course of treatment. Gradually, your body will build a defense to the allergen, treating the root cause, therefore reducing your dizziness. There are usually two phases to receiving allergy shots. Phase 1 is the build-up phase, where you receive shots one to three times a week, gradually increasing the dosage at each appointment. Then, when you enter Phase 2, you will receive monthly shots for three to five years depending on your specific case (3).

Allergy Medications
There are many brands and forms of allergy medications, but they are all focused on treating the same factor — histamine (4). Allergy medications, or antihistamines, treat allergy symptoms by reducing the reaction to histamine. Many antihistamines cause drowsiness, so be careful about operating or driving machinery after taking the medication, always pay close attention to the directions, and be sure to contact your doctor before taking a new or different medication. Ultimately, when taking an antihistamine, you are looking to treat the allergies to reduce the symptoms of dizziness.

Physical Therapy

If allergies are the underlying cause of your dizziness, a physician will help you treat these symptoms, but if you have continual dizziness and imbalance, physical therapy is likely right for you. Physical therapy for SEH is in the form of vestibular rehabilitation. Your therapist will help you with your balance, mobility, activity tolerance, and energy levels. Your PT should also be able to assist you with dietary recommendations for SEH and other ways to manage your symptoms!

Sources:
(1) Jewell, T. (2020, March 30). Can You Develop Allergies in Adulthood? What Science Says. Retrieved August 20, 2020, from https://www.healthline.com/health/allergies/can-you-develop-allergies

(2) Raman, R. (2017, July 2). How to Do an Elimination Diet and Why. Retrieved August 20, 2020, from https://www.healthline.com/nutrition/elimination-diet

(3) Mayo Clinic Staff. (2020, February 08). Allergy shots. Retrieved August 20, 2020, from https://www.mayoclinic.org/tests-procedures/allergy-shots/about/pac-2039287

(4) Cafasso, J. (2020, June 30). Allergies and Dizziness. Retrieved August 20, 2020, from https://www.healthline.com/health/allergies/dizziness

An acoustic neuroma is a slow growing, benign tumor that typically develops on your vestibular nerve. Your vestibular nerve carries signals from your inner ear and vestibular system to your brain, controlling balance and dizziness. Sometimes acoustic neuromas grow on your cochlear nerve, which transmits information about sound from your inner ear to your brain. An acoustic neuroma grows from Schwann cells, which is the cell that creates myelin, a material that protects and insulates nerves throughout your body. Most typically, acoustic neuromas occur in women aged 30-60, and arise from unknown cause.

Symptoms & Diagnosis

Because of the slow growing nature of an acoustic neuroma, it can often be difficult to diagnose. Symptoms often build up slowly and begin with hearing loss and dizziness. If it grows large enough, it may press on other nerves or your brainstem and worsen symptoms. These are also difficult to diagnose because the typical symptoms are common in other types of vestibular disorders. Symptoms include some, or all, of the following:

Any, or all, of these symptoms can occur with an acoustic neuroma as well as other vestibular or central nervous system disorders. It is important that you and your healthcare provider rule out all other diagnoses before getting to acoustic neuroma. The first tests that will likely be done are a hearing test and an ear exam. Then, if an acoustic neuroma is still suspected you will receive an MRI and/or a CT scan.

For an MRI, you will likely be injected with contrast dye prior to your scan. This will help show your physician a 3D image of the soft tissues in your brain, and help the tumor be differentiated from the rest of your brain tissue.

The CT scan will provide a 3D image of your brain as well, and is used if you have metal in your body, or any other reason you can’t have an MRI. You may be given an injection of contrast dye to help enhance the image as well. If you have a positive CT or MRI scan, your healthcare provider will provide you with a few treatment options depending on your specific needs.

Treatment
There are a few ways your healthcare team may choose to handle your acoustic neuroma once you receive your diagnosis. The best choice is always the one that you make with the assistance of your treatment team. You and your team should always make sure to consider all options before coming to a decision. The three most common forms of treatment are observation, surgical removal, or radiation. These three choices are incredibly different, so let’s break them down together to help with your decision

Observation
Observation is usually the choice best suited for people who have very small or slow growing tumors, or those without symptoms. Acoustic neuromas do not always require immediate treatment, so if your providers make this recommendation don’t be worried that you aren’t taking a more significant action — you’re likely making the best decision for yourself!
You may need surgery or radiation therapy in the future if the tumor grows or you develop symptoms, but in this case that can be reserved for the future!

Surgical Removal
Surgical removal of an acoustic neuroma is a procedure done under a microscope, a microsurgery, for partial or full removal of the mass. You and your surgeon can decide on if a partial or total removal of the neuroma is right for you. A partial removal indicates only removing a portion of the tumor in order to decrease the complication rate and decrease risk of facial paralysis or hearing loss. However, with a partial removal you may have to undergo another surgery in the future if the tumor returns. The other option is a total removal of the tumor. In a total removal, your surgeon will remove the entire neuroma while also trying to preserve hearing and avoid facial paralysis.

Radiation Therapy
The final option, radiation therapy, has increased in accuracy and dependency with recent technology. People can now use radiation therapy to reduce the size of the neuroma and slow or even stop growth. Depending on your case, it can take one or many treatments before results are seen, but this treatment can be done in an out-patient setting like a regular trip to the doctor. The concept is the direct radiation specifically at the tumor, sparing the tissue around it, to stop growth and decrease the tumor’s size.

Physical Therapy
Physical therapy is a vital part of your treatment once you are diagnosed with an acoustic neuroma. Your physical therapist should have a background and understanding of vestibular care, and will help treat your symptoms! You can start before, during, or after your other medical treatments depending on what you decide with  your healthcare team. Vestibular Rehabilitation Therapy will help to increase your balance, decrease dizziness, and improve your overall vestibular function. In patients who underwent surgery, those who received direct instruction to improve their vestibular system post-operation had significantly improved balance compared to the group who received general instruction about vestibular rehabilitation (2).  Your physical therapist should understand your personal goals, and work with you to determine the best course of treatment with you!

Sources:
(1) National Organization for Rare Disorders (NORD). (2016). Acoustic Neuroma. Retrieved August 18, 2020, from https://rarediseases.org/rare-diseases/acoustic-neuroma. 
(2) Vereeck L, Wuyts FL, Truijen S, De Valck C, Van de Heyning PH. The effect of early customized vestibular rehabilitation on balance after acoustic neuroma resection. Clin Rehabil. 2008;22(8):698-713. doi:10.1177/0269215508089066. https://pubmed.ncbi.nlm.nih.gov/18678570/.