Dizziness When Looking Up Or Down

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Dizziness When Looking Up Or Down – Medical Review by Dr. Debra Sullivan, MSN, RN, CNE, COI – By Jennifer Huizen on May 1, 2019

A common cause of dizziness while lying down is abnormal paroxysmal positional vertigo, a condition in which tiny crystals in one part of the ear that help sense gravity mistakenly move to other parts of the ear. Head movement is detected internally.

Dizziness When Looking Up Or Down

Dizziness When Looking Up Or Down

People with atypical paroxysmal positional vertigo (BPPV) experience atypical or nonlife-threatening paroxysmal or sudden, brief periods of vertigo. Vertigo is dizziness, a feeling that the room is spinning.

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In many cases, BPPV appears to develop randomly. However, many conditions can cause or affect BPPV, including:

BPPV usually occurs when calcium carbonate crystals or otoliths located in the gravity-sensitive part of the ear (called the pouch) are released. They then migrate to the highly mobile, motion-sensitive semicircular canals.

If enough otoliths accumulate in any ear canal, it can disrupt the fluid movement the ear canal uses to detect head movement.

Semicircular canals generally do not respond to gravity. However, otoliths move with gravity. So when otolith masses build up in the semicircular canals, they can cause the motors to move when they shouldn’t. This sends the wrong message to the brain that the head is moving.

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When the brain compares the false information from the inner ear with information from other senses and organs, it cannot match them and therefore recognizes it as a spinning sensation.

This illusion results in nystagmus, the uncontrolled movement of the eyes back and forth or up and down, giving the impression that the surrounding environment appears to be spinning.

People with BPPV experience vertigo, a sudden feeling that everything around them is spinning when it isn’t. People who suffer from vertigo due to inner ear problems often also have nystagmus, or uncontrolled eye movement.

Dizziness When Looking Up Or Down

People with BPPV can experience significant dizziness in different ways. They can also experience it differently, depending on the action that triggers the symptoms.

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The dizzy whirling or whirling sensation can be whirling, feeling like you just stepped off a merry-go-round. Vertigo can also cause a feeling that the ground is going up and down, similar to the feeling of being on a boat.

Another description of vertigo is that it can make the person trying to get out of bed feel like they are falling back into bed, and the person who got into bed feel like they are falling out of bed.

In most cases, BPPV only triggers vertigo after certain movements or activities that cause the head to change position relative to gravity, such as:

Most people who wake up with vertigo tend to have BPPV. BPPV vertigo usually lasts 1 minute or less. Some people with BPPV are asymptomatic between dizzy episodes, but others still feel unbalanced all or most of the time.

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Vertigo is the main symptom caused by BPPV. However, the discomfort of vertigo can lead to other symptoms, such as:

BPPV is usually not a serious disease. The biggest risk is injury from a fall or loss of balance.

However, people should consult a doctor about recurrent vertigo after changing head positions. People should also discuss episodes of vertigo that last longer than 1 to 2 minutes with their doctor.

Dizziness When Looking Up Or Down

If a person with vertigo has other symptoms unrelated to BPPV, such as:

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They can then refer people to specialized health professionals, such as an otolaryngologist or a vestibular rehabilitation therapist.

A specialist will have a person move their head in a certain way to see which movements are causing the symptoms.

When someone experiences vertigo, a specialist will watch their nystagmus closely, looking for certain patterns that could diagnose BPPV. This also helps determine which ear and which ear canal the otolith has moved.

In order to properly treat BPPV, a specialist must also determine which type of BPPV someone has. This could be tube stone disease or goblet stone disease.

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Otolithiasis, the most common type of BPPV, involves otoliths that move freely in the ear canal fluid.

Goblet stone disease, which is much rarer than tube stone disease, involves otoliths adhering to nerve bundles that are sensitive to the movement of fluid in the ear canal.

BPPV symptoms lessen over time as the brain adapts to the information from the inner ear. In some cases, BPPV resolves spontaneously after a few days or weeks.

Dizziness When Looking Up Or Down

Once specialists know where the otoliths are loose and whether a person has otolithiasis or calculus, they can use otolith repositioning, or CRM, to treat BPPV.

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CRM is a series of specialized head movements that allow gravity to direct the otoliths to places in the inner ear where they can be reabsorbed.

The Epley maneuver is a technique used to treat ductal stone disease. To perform the Epley maneuver, the doctor or specialist will:

If a person with BPPV does not get relief after the Epley procedure, the doctor or specialist will often repeat until they do.

Goblet stones can develop with free movement. The technique involves moving the head quickly within the plane of the affected ear canal in an attempt to shake out the displaced otolith.

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Once the otoliths are mobilized, the procedure uses another CRM method to guide them out of the ear canal and back into their proper chambers.

Fully resolving BPPV using CRM techniques may take several sessions, but most people make a full recovery. According to some estimates, up to 90% of BPPV cases resolve after one to three CRM sessions.

But cases associated with goblet stones may take longer to be successfully treated. Likewise, if a person has otoliths in more than one canal, the doctor or therapist must correct each canal individually, prolonging the recovery process.

Dizziness When Looking Up Or Down

Even after the vertigo itself wears off, many people who recover from BPPV remain sensitive to movement and instability. A doctor or therapist will usually perform exercises at home to help reduce these residual feelings quickly.

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BPPV cases can be resolved randomly, and specialists can also perform CRM techniques on people with BPPV, which can cause dizziness when lying down.

However, up to 50% of people will experience a recurrence of symptoms within 5 years. The earlier and more thorough treatment of BPPV, the more successful the long-term outlook.

If someone has repeated episodes of the same type of BPPV in the same canal, a doctor or therapist can teach the person how to perform CRM at home.

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It was the first procedure of its kind and was published in the early 90s by the late American physician John Epley. Since then, many healthcare providers and vertigo researchers around the world have developed a whole catalog of “horror reset movements.”

In this blog, I discuss five main reasons why the Epley maneuver may not be effective in treating BPPV.

The Epley maneuver, Modified Epley, and all particle repositioning maneuvers of BPPV require very precise, technically correct performance to be effective. Providers may perform Epley operations incorrectly if they have not investigated techniques to reproduce accuracy and precision.

Dizziness When Looking Up Or Down

In teaching this movement and other particle reset treatments to other providers, I have found that beginners make some predictable mistakes. These errors can reduce the effectiveness of the treatment.

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The options are Right, Left, or Both. This can be diagnosed with a BPPV test by a skilled provider.

It amazes me how many times I have come across patients who describe previous treatments for their “undeveloped ear” that apparently didn’t help at all and actually made them feel worse.

If free BPPV crystals are floating in or before the horizontal tube, the Epley maneuver may not solve the problem.

These other inner auditory canals require different treatments that were developed after the first publication of Epley’s operation.

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The Epley procedure assumes that BPPV crystals are floating freely in the posterior auditory canal of the treated ear. However, BPPV crystals or debris may adhere to the sensory mechanism inside the semicircular inner ear canal called the “pinna.”

This is a type of BPPV called “cupulolithiasis,” as opposed to the more common “canalithiasis” that has free-floating crystals.

Cup stones are very rare. In my experience treating thousands of BPPV patients, I have only found

Dizziness When Looking Up Or Down

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