“I have inner ear crystals repositioning?”

Crystal repositioning can happen immediately and can last and do recur. Some people require 2 or 3 treatments a day for a few days before the crystals reposition. Usually, the condition can be controlled. It sounds as if you are being managed correctly.

It would be useful getting testing to see what caused your dizziness

Plain Language Summary: Benign Paroxysmal Positional Vertigo
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Neil Bhattacharyya, MD, Deena B. Hollingsworth, MSN, FNP-BC, Kathryn Mahoney, ...
First Published March 1, 2017 Research Article Find in PubMed
https://doi.org/10.1177/0194599816689671
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Article has an altmetric score of 38 Free Access

Abstract

Objective. This plain language summary serves as an overview in explaining benign paroxysmal positional vertigo, abbreviated BPPV. This summary applies to patients ≥18 years old with a suspected or potential diagnosis of BPPV and is based on the 2017 “Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).” The evidence-based guideline includes research to support more effective diagnosis and treatment of BPPV. The guideline was developed as a quality improvement opportunity for managing BPPV by creating clear recommendations to use in medical practice.
Keywords
benign paroxysmal positional vertigo, vertigo
How Was This Summary Developed?

This plain language summary is based on the American Academy of Otolaryngology—Head and Neck Surgery Foundation’s (AAO-HNSF’s) “Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update),”1 which updates an earlier guideline developed in 2008 by the AAO-HNSF.2 The purpose of the summary is to convey key concepts and recommendations from the guideline in clear, understandable, patient-friendly language. It was developed by consumers, clinicians, and AAO-HNSF staff.

The BPPV guideline was developed with the methods outlined in the third edition of the AAO-HNSF’s guideline development manual.3 A literature search through September 2015 was performed by an information specialist to identify research studies (systematic reviews, clinical practice guidelines, and randomized controlled trials) published since the prior guideline.

The AAO-HNSF assembled a guideline update group representing the disciplines of otolaryngology–head and neck surgery, otology, neurotology, family medicine, audiology, emergency medicine, neurology, physical therapy, advanced practice nursing, and consumer advocacy. The group also included a staff member from the AAO-HNSF. Prior to publication, the guideline underwent extensive peer review, including open public comment.
What Is BPPV?

Benign paroxysmal positional vertigo, abbreviated BPPV, is the most common inner ear problem and cause of vertigo (vertigo is a false sense of spinning). It is more common in older people. Many of us will experience BPPV at some time in our lives.

BPPV is a specific diagnosis, and each word describes the condition:

Benign (pronounce bi-NYN)—it is not life-threatening, even though the symptoms can be very intense and upsetting.

Paroxysmal (pronounced par-ek-SIZZ-muhl)—it comes in sudden, short spells.

Positional (pronounced puh-ZI-shun-uhl—certain head positions or movements can trigger a spell.

Vertigo (pronounced VER-ti-goh)—feeling like you are spinning or the world around you is spinning.4

See Table 1 for a summary of evidence-based statements and recommendations of diagnosis and treatment.
Table


Table 1. Summary of Guideline Key Action Statements.

Table 1. Summary of Guideline Key Action Statements.
View larger version
What Causes BPPV?

Most cases of BPPV happen for no reason. Anyone can have episodes of BPPV, but it happens more often in seniors. It can sometimes be associated with trauma, migraine, other inner ear problems, diabetes, osteoporosis, and lying in bed for long periods of time (preferred sleep side, surgical procedures, illness).

We have crystals of calcium carbonate in our inner ear that help us with our balance and body motion. These tiny rocklike crystals, or “otoconia” (oh-toe-CONE-ee-uh), are settled in the center “pouch” of our inner ear. BPPV is caused by the crystals becoming “unglued” from their normal place. As they float around, they can get stuck on sensors in the wrong part or wrong canal of the inner ear. BPPV symptoms are caused by the crystals being out of position.

The most intense part of BPPV symptoms relate to how long it takes the crystals or sensors to settle down after you move or change your head or body position. As the crystals move and settle in your inner ear, your brain is getting these powerful (false) messages telling you that you are violently spinning when all you may have done is lie down or roll over in bed.
What Are the Common Symptoms of BPPV?

Everyone will experience BPPV differently, but there are common symptoms:

Distinct triggered spells of vertigo or spinning sensations

Nausea (sometimes vomiting)

Severe feeling of disorientation in space or instability

These symptoms will be intense for seconds to minutes. You can have lasting feelings of dizziness and instability but at a lesser level, once the episode has passed. In some people, especially seniors, BPPV can seem more like an isolated feeling of instability that happens when changing body or head position. Sitting up, looking up, bending over, and reaching can trigger this feeling. BPPV does not cause constant severe dizziness and is usually triggered by movement. BPPV does not affect your hearing or cause you to faint. The dizziness episodes related to BPPV can increase your risk of falling.
How Is BPPV Diagnosed?

Health care providers diagnose BPPV through a physical examination and review of your medical history. Normal medical imaging, such as scans and x-rays, or medical laboratory testing cannot confirm BPPV. Your health care provider or examiner will complete simple bedside testing to help to confirm your diagnosis. The bedside testing requires the examiner to move your head into a position that makes the crystals move, and it will make you dizzy. The testing may include hanging your head a little off the edge of the bed or rolling your head left and right while lying in bed. The examiner will be watching you for a certain eye movement to confirm your diagnosis. The most common tests are called the Dix-Hallpike test and supine roll test.
What Treatments Are Available?

Medications may be used for the relief of immediate distress, such as nausea, but not for BPPV itself. Most BPPV cases can be corrected with repositioning procedures that will be performed bedside by your provider. These treatments usually take only a few minutes to complete. They have high success rates (around 80%), although sometimes the treatment needs to be repeated a few times. Examples of these treatments are the Epley maneuver (Figure 1) and the Lempert 360° roll maneuver (Figure 2).
figure

Figure 1. Depiction of the canalith repositioning maneuver (Epley maneuver) for right ear posterior semicircular canal benign paroxysmal positional vertigo. Adapted and reproduced with permission from Fife et al.5 © 2008 Barrow Neurological Institute, Phoenix, Arizona.
figure

Figure 2. The Lempert 360° roll maneuver (sometimes referred to as the barbecue roll maneuver) for the treatment of right lateral semicircular canal benign paroxysmal positional vertigo—geotropic type. Adapted and reproduced with permission from Fife et al.5 © 2008 Barrow Neurological Institute, Phoenix, Arizona.

These repositioning treatments (referred to as “maneuvers”) are designed to guide the crystals back to their original location in your inner ear. You may be treated during the same office visit when the diagnosis testing is performed. You might be sent to a health professional (medical provider, audiologist, or physical therapist) who can perform these maneuvers, especially if any of the following apply:

You have severe disabling symptoms.

You are a senior with history of past falls or fear of falling.

You have difficulty moving around, such as joint stiffness (especially in your neck and back) and/or weakness.

You can also be taught to perform these maneuvers by yourself with supervision, which is called “self-repositioning.” Discuss learning these maneuvers with your health care provider.
Does BPPV Go Away on Its Own?

There is evidence that if BPPV is left untreated, it can go away within weeks. The natural course of BPPV is to become less severe over time. People will often report that their very first BPPV spinning episode was the worst and the following episodes were not as bad. However, remember that while the crystal is out of place, in addition to feeling sick and sensitive to motion, your unsteadiness can increase your risk for falling. You will need to take precautions not to fall. You are at a higher risk for injury if you are a senior or have another balance issue. Seniors are encouraged to seek professional help quickly to resolve symptoms.
How Long Will It Take before I Feel Better?

During the BPPV treatment, you may experience brief distress from vertigo, nausea, and feelings of disorientation. After treatment, some people report that their symptoms start to clear right away. Others report that they have continuing motion sickness–type symptoms and mild instability. You can still feel a little bit sensitive to movement even after successful treatments for BPPV. These symptoms can take a few days to a few weeks to slowly go away. Once your symptoms are slowly going away, it is important to return to normal activities that you can do safely. Exposure to motion and movement will help to speed your healing. You should discuss these activities with your provider. Seniors with a history of falls or fear of falling may need further exercises or balance therapy to clear BPPV completely.
Can BPPV Come Back? Can I Prevent It?

Unfortunately, BPPV is a condition that can sometimes return. Your risk for BPPV returning can shift from low risk (few experiences in your lifetime) to a higher risk, which is often caused by some other factor, such as trauma (physical injury), other inner ear or medical conditions, or aging. Medical research has not found any way to stop BPPV from coming back, but it can be treated with a high rate of success. It is very important to follow-up with your health care provider if you continue to have symptoms. You may be sent for further testing to confirm your diagnosis and/or discuss other treatment options.
Where Can I Get More Information?

Health care providers should discuss all treatment options and find the best approach for you. There is a printable patient handout of frequently asked questions (Figure 3) and other resources that further explain BPPV and can help with decisions about care options. For more information on BPPV, go to http://www.entnet.org/BPPVCPG . Additional information can be found by visiting the Vestibular Disorders Association, at http://vestibular.org/.
figure

Figure 3. Patient information: “Frequently Asked Questions: Benign Paroxysmal Positional Vertigo (BPPV).”
About the AAO-HNS

The American Academy of Otolaryngology—Head and Neck Surgery (www.entnet.org), one of the oldest medical associations in the nation, represents about 12,000 physicians and allied health professionals who specialize in the diagnosis and treatment of disorders of the ears, nose, throat, and related structures of the head and neck. The Academy serves its members by facilitating the advancement of the science and art of medicine related to otolaryngology and by representing the specialty in governmental and socioeconomic issues. The AAO-HNS Foundation works to advance the art, science, and ethical practice of otolaryngology–head and neck surgery through education, research, and lifelong learning. The organization’s vision: “Empowering otolaryngologist–head and neck surgeons to deliver the best patient care.”
Author Contributions

Neil Bhattacharyya, writer, chair; Deena B. Hollingsworth, writer, panel member; Kathryn Mahoney, writer, panel member; Sarah O’Connor, writer, AAO-HNSF staff.
Disclosures

Competing interests: Neil Bhattacharyya, Intersect ENT, Entellus, Sanofi—consultant; Sarah O’Connor, salaried employee of American Academy of Otolaryngology—Head and Neck Surgery Foundation.

Sponsorships: American Academy of Otolaryngology—Head and Neck Surgery Foundation.

Funding source: American Academy of Otolaryngology—Head and Neck Surgery Foundation.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
References
1. Bhattacharyya, N, Gubbels, SP, Schwartz, SR. Clinical practice guideline: benign paroxysmal positional vertigo (update). Otolaryngol Head Neck Surg. 2017;156(3_Suppl):S1-S47.
Google Scholar | SAGE Journals | ISI
2. Bhattacharyya, N, Baugh, RF, Orvidas, L. Clinical practice guideline: benign paroxysmal positional vertigo. Otol Head Neck Surg. 2008;129:S47-S81.
Google Scholar | SAGE Journals | ISI
3. Rosenfeld, RM, Shiffman, RN, Robertson, P. Clinical practice guideline development manual, 3rd edition: a quality-driven approach for translating evidence into action. Otolaryngol Head Neck Surg. 2013;148(suppl 1):S1-S55.
Google Scholar | SAGE Journals | ISI
4. Woodhouse, S. Benign paroxysmal positional vertigo (BPPV). https://vestibular.org/understanding-vestibular-disorders/types-vestibular-disorders/benign-paroxysmal-positional-vertigo. Accessed January 2017.
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5. Fife, TD, Iverson, DJ, Lempert, T. Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2008;70:2067-2074.
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View Abstract
Article available in:
Vol 156, Issue 3, 2017
Guidelines and Quality Improvement

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Some of these ‘precautions’ are old school thinking and modern research suggests they aren’t required. Nonetheless, I would say 48 hours

You can certainly perform these maneuvers yourself at home. Google "Epley Maneuver" and if you feel spining vertigo lasting only seconds with certain head positions, then try the epley maneuver on yourself. If it doesnt work then seek help from your ENT.