Diagnosis and treatment

Labyrinthitis or BPPV? The dizziness that comes when you turn your head

Almost everyone calls it labyrinthitis. Most of the time it is something else, with another name, another mechanism and another treatment, and that treatment usually happens during the consultation itself.

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“Doctor, I think I have labyrinthitis”

That is almost always how the conversation starts. The person turned over in bed, the room spun, it passed within a few seconds, and the next day someone said it was labyrinthitis.

Labyrinthitis means, literally, inflammation of the labyrinth, which is the inner ear organ that houses hearing and balance. That condition exists, but it is uncommon. The word has become the generic name for any kind of dizziness, and that is why it almost never describes exactly what the person has.

Most of the time, dizziness that spins, lasts seconds and comes with movement of the head has another name: benign paroxysmal positional vertigo, or BPPV. It is the most common inner ear balance disorder across the life span. And the name, long as it is, says everything: positional because it depends on the position of the head, paroxysmal because it comes in short attacks, benign because it is not a sign of serious disease.

Knowing the right name and the right diagnosis changes what is done, and that is why telling them apart matters. It is not a question of vocabulary. What treats BPPV is not medication, it is a maneuver, performed in the office itself.

What BPPV is: a crystal out of place

Inside the inner ear there are small calcium crystals, the size of specks of dust. Their place is a chamber where they work as a gravity sensor, telling the brain which way is “down”.

Over time, or after a blow to the head, or even with no reason that can be found, some of these crystals come loose and fall into one of the neighboring canals, the semicircular canals. That is not where they belong.

These canals work like a spirit level or like the accelerometer in a phone: they sense the movement of the head through the fluid that shifts inside them. With a loose crystal in there, every time you change the position of your head the crystal rolls, drags the fluid along with it and the canal sends the brain a signal of movement that is not happening. The brain is told that you are spinning while your eyes say that you are still. That mismatch is the vertigo.

Most of the time no cause is found. In some cases, it appears after a head injury.

How it shows up: seconds, and always with movement

The pattern of BPPV is characteristic, and it is the pattern that makes the diagnosis:

It lasts seconds. Usually less than a minute. It is not dizziness that stays with you all day.
It comes with a specific movement. Lying down, turning over in bed, getting out of bed, looking up (hanging up laundry, reaching for something on a high shelf) or bending the head down.
It spins. The patient describes the room turning, not a vague unwell feeling or a sensation of fainting.
It usually comes without hearing loss and without tinnitus. When those two appear, it is a sign that it may be something else.
It can come with nausea. The nausea sometimes lasts longer than the vertigo and leaves the person unwell for hours, which is confusing.

One clue patients often bring on their own: they have already worked out which side they cannot lie on. That information is useful and worth mentioning at the consultation.

When the dizziness does not fit that pattern: what makes me investigate first

Not all dizziness is BPPV, and telling one from the other is the first task of the consultation. There are warning signs if the dizziness comes together with:

hearing loss that appeared along with the dizziness, on one side only
new, persistent tinnitus
a severe headache, different from your usual headaches
double vision, slurred speech, weakness or numbness on one side of the body
difficulty walking or standing that persists after the vertigo has passed
continuous dizziness that does not improve when you keep still, lasting hours or days

These signs do not fit BPPV and call for prompt evaluation. The same goes for anyone who has had a fall because of the dizziness, for anyone who already has difficulty with balance for another reason and for anyone who lives alone: fall risk changes the care, and that is part of the conversation at the consultation.

Labyrinthitis, vestibular neuritis, Ménière’s and vestibular migraine: the other causes

Almost all of these conditions arrive at the office under the same nickname, and it matters to tell them apart, because the treatment of each one is different.

In a British primary care study, among people who saw a doctor because of vertigo, BPPV accounted for 42% of cases, vestibular neuritis for 41% and Ménière’s disease for 10%.

Labyrinthitis and vestibular neuritis. They start suddenly, with severe, continuous dizziness that lasts hours or days on end and does not depend on the position of the head. The difference between the two is in the hearing: when the auditory portion of the inner ear is also affected, hearing loss and tinnitus appear, and it is that involvement that characterizes labyrinthitis; vestibular neuritis tends to spare hearing.

Ménière’s disease. It comes in attacks that last hours, with fluctuating hearing loss, tinnitus and aural fullness on the affected side. It is also not triggered by any position of the head, and the nausea tends to be more prolonged and more disabling.

Vestibular migraine. It is more common than it seems. These are attacks of dizziness lasting from 5 minutes to 72 hours, in people who have or have had migraine, and which in at least half of the attacks come with headache, discomfort with light or with sound, or visual changes.

Hearing is the sign that helps most to separate BPPV from labyrinthitis and from Ménière’s disease: acute hearing loss does not occur in an attack of BPPV. What separates it from vestibular neuritis and from vestibular migraine is the duration and the trigger, not the hearing.

And one observation that explains much of the confusion: BPPV can occur together with any of these conditions, or as a consequence of them. Having one does not rule out the other, and that is why a well-done evaluation is essential in order to understand exactly the cause of each of these forms of dizziness.

How I confirm the diagnosis: the Dix-Hallpike maneuver, during the consultation itself

The diagnosis of BPPV is clinical, made in the office chair, and it has a name: the Dix-Hallpike maneuver.

It works like this. I sit the patient on the examination table, turn the head 45 degrees to one side and lay the patient back quickly, with the head slightly hanging. If there is a loose crystal in the canal on that side, the vertigo appears within a few seconds, and along with it an involuntary eye movement called nystagmus, with a characteristic direction that I watch closely.

It is that eye movement that confirms the diagnosis. It tells three things at once: that it is BPPV, which side and which canal. If the test produces a different movement, or none at all, I perform a second test, lying down, that assesses another canal.

And here is a warning: the maneuver provokes the vertigo on purpose. It is uncomfortable for a few seconds and then it passes. It is that brief discomfort that spares you tests, weeks of waiting and treatment in the dark.

Why, in the typical presentation, complex tests are not necessary

This is the part that most surprises people who come to the office expecting a test.

When the presentation is typical and the maneuver confirms the diagnosis, imaging and balance testing add nothing. The American BPPV guideline, which is the international reference on the subject, recommends against ordering imaging and against ordering vestibular testing in that situation. It is not a matter of saving money: it is that the test does not show the loose crystal, does not confirm or rule out the diagnosis, and delays a treatment that could have been done the same day. What identifies the affected canal is the maneuver in the office.

The condition is in the recommendation itself, and I follow it: this applies to the typical presentation, with none of the discordant signs from the previous section. When there is a sign that does not fit, testing comes in, and it comes in for a clear reason.

The treatment: the repositioning maneuver, in the same consultation

If the diagnosis is confirmed, I treat right there, in the same consultation.

The treatment is a second sequence of head movements, the canalith repositioning maneuver, better known by the name of the person who described it: the Epley maneuver. The logic is direct: if the problem is a crystal in the wrong place, the maneuver takes that crystal back to the chamber where it causes no symptoms. It is a few positions of the head, each held for about 20 to 30 seconds, in the right order for the canal the test identified.

That is why the diagnosis matters so much: the maneuver is specific to the side and to the canal. Performed on the wrong canal, it does not work.

The American guideline classifies repositioning as a strong recommendation, which is the highest grade it uses, based on systematic reviews of randomized trials. In the Cochrane review it cites, the maneuver was more effective than the sham procedure both for resolution of symptoms and for turning the diagnostic test negative. One of the trials included in that review compared the repositioning maneuver with a week of Brandt-Daroff exercises, done at home three times a day: by day 7, the diagnostic test was negative in 80.5% of those who had the maneuver and in 25% of those who did the exercises.

Sometimes one maneuver settles it. Sometimes it has to be repeated, on the same day or at the follow-up visit. I reassess within one month to confirm that the condition has in fact resolved, which is what the guideline recommends, and to look for another cause if the symptom persists.

“And the medication I already take for dizziness?”

Many people come to the office already taking something, prescribed by another professional or suggested at the pharmacy, and the question is a common one.

The simple answer is that this kind of medication acts on the symptom, not on the cause. It can reduce the spinning sensation and the nausea, and it has no way of putting a crystal back in place. That is why the American guideline recommends against using these medications (vestibular suppressants) as routine treatment for BPPV. There are three reasons. They do not treat what is happening. In older people they can interfere with balance and increase the risk of falls, which is exactly what we want to avoid. And, something almost no one knows, they can obscure the diagnostic test, making the Dix-Hallpike maneuver less clear on the very day it would be performed.

That does not mean medication never has a place, and the guideline itself provides for exceptions, for a small group of patients: very severe symptoms while definitive treatment has not yet happened, and use immediately before or immediately after the maneuver. What to do about what you already take is a decision made at the consultation, and in some situations I keep it. What does not make sense is treating BPPV with medication alone and never performing the maneuver, because then the crystal stays where it is.

After the maneuver: you do not need to sleep sitting up

For years, people who had the maneuver were told to sleep sitting up, not to lie on the treated side and to avoid bending the head down for a few days.

The current guideline recommends against these restrictions, and also at maximum strength: the trials showed that they do not improve the result of the maneuver. So, after repositioning, the guidance is to go back to normal life.

What I do ask for is care in the first few hours, for a practical reason: a sense of unsteadiness or light-headedness can linger for a while, and that matters when driving and when climbing stairs. It is not a postural restriction, it is common sense.

When vestibular rehabilitation comes in

Vestibular rehabilitation is a course of exercises led by a physical therapist or a speech-language pathologist with training in the field.

It is not the first step in BPPV, and the guideline treats it as an option rather than as initial treatment, because repositioning resolves most cases more directly. But it does have a place: when imbalance remains after the vertigo has passed, when there is unsteadiness on walking, when the patient has had a fall or when there is another balance problem alongside it. In those cases I refer, and I go on following the patient.

Can BPPV come back?

It can, and it is important to know that beforehand, not afterwards.

Studies with longer follow-up show recurrence of between 5% and 13.5% at six months and between 10% and 18% at one year, and it may reach as high as 36% over time. People who had BPPV after a head injury tend to have it again more often.

That does not mean the treatment failed. It means the crystal can come loose again and that, if it does, the path is known and short: repeat the test and repeat the maneuver. Patients who have been through it usually recognize the pattern straight away, and that recognition shortens everything.

Who this evaluation is for, and what it does not solve

This consultation makes sense for anyone with dizziness that spins, lasts seconds and appears on lying down, turning over in bed or looking up, and also for anyone who has been treated for “labyrinthitis” without improvement and has never had a diagnostic maneuver.

It is not the route for anyone with continuous dizziness of unclear cause, imbalance without vertigo, fainting or falls without dizziness. Those conditions have other causes, some of them outside otolaryngology, and they start with a different investigation. At the consultation I see which of the two groups your case belongs to, and I say clearly when assessment by another specialist, such as a neurologist, is needed.

BPPV is usually simple to resolve once it has been identified. The hard part is reaching the diagnosis, and it is harder than it should be because almost everyone starts from the wrong name.

Frequently asked questions

Is BPPV serious?

No. The name carries the word benign for exactly that reason: it is not a sign of brain disease and it does not turn into one. The real risk it carries is indirect and should not be underestimated: an attack while standing, on a staircase or in the street, can cause a fall, and a fall in an older person is a serious problem. That is the reason to treat it, and to treat it soon.

How do I know whether it is BPPV or labyrinthitis?

By the duration and by the trigger. BPPV lasts seconds and always appears linked to a movement of the head, almost always without hearing loss and without tinnitus. The other conditions that get the same nickname are described in the section above. Hearing is the sign that helps most to separate BPPV from labyrinthitis and from Ménière’s disease, because acute hearing loss does not occur in an attack of BPPV; what separates it from vestibular neuritis and from vestibular migraine is the duration and the trigger. The separation is made at the consultation, with the diagnostic maneuver, and not by the name the dizziness was given earlier.

Can BPPV go away on its own?

It can, and some cases resolve without treatment. The problem is time: it can take weeks, and those are weeks of attacks, of being afraid to lie down and of fall risk. The American guideline accepts observation with follow-up as an option, noting that people who choose to wait tend to stay symptomatic for longer than those who have the maneuver.

What should I avoid if I have BPPV?

After the maneuver, no postural restrictions: the guideline recommends against them, and sleeping sitting up does not improve the result. Before treatment, the care is about safety: avoid climbing ladders or stools, get out of bed slowly, and do not drive during an attack.

How do I know whether the dizziness is “from the crystals”?

“Ear crystals” is the popular nickname for BPPV, and it is closer to the mark than “labyrinthitis”, because it describes the mechanism. Confirmation does not come from the history or from imaging: it comes from the Dix-Hallpike maneuver, which provokes the vertigo and shows the eye movement that identifies the affected canal.

Do I need to bring any test results to the consultation?

There is no need to have tests done beforehand. If you already have test results, bring them and I will look at them. What helps most is your own observation: in which position the dizziness appears, how long it lasts, which side you have already worked out you cannot lie on, whether there is hearing loss or tinnitus, and which medications you are taking.

How long does the consultation take?

It is an ordinary consultation, and it has room for the examination, the diagnostic test and, if the diagnosis is confirmed, the treatment maneuver. There is no need to book a second appointment in order to be treated.

References

1. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017;156(3_suppl):S1-S47. DOI 10.1177/0194599816689667. PMID 28248609.

2. von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007;78(7):710-715. DOI 10.1136/jnnp.2006.100420. PMID 17135456.

3. Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014;(12):CD003162. DOI 10.1002/14651858.CD003162.pub3.

4. Hanley K, O’Dowd T. Symptoms of vertigo in general practice: a prospective study of diagnosis. Br J Gen Pract. 2002;52(481):809-812.

If your dizziness spins, lasts seconds and appears when you lie down or turn your head, the step that solves it is not starting a medication, it is having the test that identifies the affected canal. At the office of Dr. José Eduardo Marcondes, the diagnostic maneuver is performed during the consultation itself and, when the diagnosis is confirmed, treatment is done on the same day. Care is provided on a private (out-of-pocket) basis, at the Morumbi, Itaim Bibi and Alphaville offices.

Dr. José Eduardo Marcondes, physician, otolaryngologist (ENT). CRM-SP 107.711 (Brazilian medical license) | RQE 43.840 (specialist registration). This content is informational, does not replace a medical consultation, and does not supersede the plan of care defined by your own physician.