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Benign Peroxismal Positional Vertigo or BPPV is a benign condition of the inner ear that causes momentary dizziness in the form of vertigo. Vertigo is a sensation of spinning. This sensation is almost always related to a disorder of the inner ear. The typical scenario of an attack of BPPV is as follows: Just a few seconds after lying down in bed and rolling over to one side one experiences a feeling that everything is spinning around them. This sensation lasts for a few seconds. It may seem like a lot longer time in retrospect; but if timed, it would really end up being only about 15 seconds or so. BPPV is not usually associated with nausea and vomiting as some of the more involved inner ear disorders are. If one were to continue lying on that side the spinning would stop in less than a minute. Upon arising there is usually a brief spin again. This sensation can also be triggered by looking up and over one's shoulder as in looking up into a cabinet or looking up at an airplane. With BPPV spontaneous dizziness does not occur. It is always correlated with some change of head position. It is not accompanied by any change in hearing, numbness, paralysis, or slurred speech.

BPPV is caused by some loose calcium particles in the inner ear. The utricle is one of the five organs of balance in the inner ear. The little nerve endings of the utricle are embedded into a calcium matrix. Occasionally, some of this matrix breaks loose. These particles can migrate into one of the three balance canals. When the head is turned a certain way, the calcium particles hit the nerve endings of the balance canal and send an irregular signal to the brain. This is interpreted by the brain as an unusual spin. The signal also causes a relay to the eye resulting in a rotation of the eyes. This is easily demonstrated in the patient.

There are four reasonable treatments for BPPV. The first treatment is observation. Most people will get better on their on. Time is helpful. 

The second reasonable treatment is the institution of special exercises that train the brain to ignore the irregular signals that it is getting. These are known as Cawthorne exercises, after the man that devised them. These exercises basically consist of repeating the same motion that caused the dizziness. You will soon find that after repeating that maneuver three or four times, that maneuver won't cause you to be dizzy. The Cawthorne exercises are easy to do. If they do not stop the dizziness you should go back to see your doctor. The instructions for these exercises are listed at the end of this document. 

If you are one of the 5% of people for which these exercises fail to control the dizziness of BPPV, then you may benefit from a particle repositioning maneuver. This consist of a brief head manipulation by your doctor to try and rotate the labyrinth, or inner ear, to get the calcium particles out of the balance canal and back into the vestibule, or that portion of the inner ear where the particles came from. This is not a painful maneuver and only takes a few minutes. Sometimes a vibrator is placed over the mastoid or ear bone to facilitate migration of the calcium particles through the inner ear. After the repositioning maneuver is accomplished one needs to follow the following instructions:
  1. Do not lie flat on your back for 48 hours.
    At night, sleep in a recliner, but do not recline more than 45 degrees.
  2. Do not bend forward all the way over or put your head way back for 48 hours. (Be careful putting on shoes, looking in bottom or top cabinets; bend at the knees instead)
  3. After the 48 hours is up:
    Do not lie on your affected side for 5 days.

At night, sleep on the couch on your unaffected side, with your back to the back of the sofa to prevent you from rolling over. Remember, you must not lie on your affected side for those 5 nights.

There are very few people for whom the above options are ineffective. However, for the rare person in whom these measures don't work, there is one more option in the form of surgery. The surgery requires a general anesthetic. In this surgery, the balance canal is blocked up and rendered mute. This surgery is not to be done unless the problem is really bothersome because of the risks involved. This surgery can result in deafness and/or some constant unsteadiness. Rarely is BPPV bothersome enough to warrant the risks involved with this surgery. Nevertheless, it is a good option to have for those with severe problems unresponsive to the more conservative therapies. 

Cawthorne Exercises
These excercises involve attempts to stimulate the various nerve endings of the three balance canals in each inner ear. As you stimulate these balance canals they will send messages to the computer part of your brain to let the brain know if you are spinning. By repeating these excercises you will retrain your brain to know that you are not moving as fast as it may be indicating due to a damaged inner ear.
There are five different positions that you assume to stimulate the balance canals. The same routine is employed for each position. First you assume the indicated position and stay in that position until the dizziness caused by assuming that position resolves. Then you sit and wait two minutes. Repeat that same maneuver, maintaining that position until the dizziness resolves and then sit up for two minutes. Keep repeating this until you don't get dizzy with that maneuver. Usually it takes about 3 to 4 times until that maneuver causes no dizziness. 
After you reach a point in which that exercise causes no dizziness, you go to the next exercise. Repeat theses five exercises 3 times a day for two weeks. If followed regularly this will greatly diminish your problems due to inner ear dizziness.

The five positions all start by sitting on the edge of the bed. They are as follows:

  1. Recline straight back looking up at the ceiling.
  2. Recline straight back and quickly turn your head to the right. 
  3. Recline straight back and quickly turn your head to the left.
  4. Lie down on your right side.
  5. Lie down on your left side.


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