Ending Vertigo Today

After successful maneuvers, one of our readers wondered about the fate of the removed crystals.  Do they go back to their original position in the gravity sensor, get washed away from the inner ear, or dissolve?  If so, can they regenerate?

Read more: What happens to BPPV crystals after maneuvers remove them? 

The otoconia are the crystals of calcium carbonate in the inner ear that are used to sense gravity.  They are already forming in the fetus as early as two months of gestation.  Calcium builds up on a collagen matrix to form each otoconium.  They are embedded in a similar sticky protein matrix that holds them to the gravity sensors loosely enough that they and the membrane can shift as the head moves.  This movement as you tilt your head allows you to sense gravity.  They are designed to be permanent and to last throughout life.

Unfortunately, they do not always remain healthy.  Calcium can erode from the crystals in some disorders, leaving a moth-eaten appearance.   Older people often show cracks and furrows on the surface of the crystals, and pieces of broken crystals can be seen.  Head trauma, lack of bloodflow, calcium disorders such as osteoporosis, and genetic defects in otoconia formation can all contribute to degeneration.  Some antibiotics (aminoglycosides) can dissolve calcium from the crystals in addition to other serious effects on the inner ear. 

When successful maneuvers are done for BPPV, the crystals are removed from the semicircular canals where they don’t belong, and return to the sac containing the utricle, a gravity sensor.  However, they don’t necessarily re-attach.  They may just settle down in the sac, waiting for an opportunity to go back into the canal and cause BPPV again.  They always remain within the inner ear.  If they do undergo slow degeneration, the calcium leaves but the collagen matrix may remain. 

Unless you have been exposed to aminoglycoside antibiotics or have serious defects of the inner ear, there are dense piles of otoconia on the utricle that are still attached even when you have had BPPV.  This means that the utricle continues to function, but with aging it will become a bit less effective.  The damaged or wandering crystals do not get replaced once they are detached from the utricle, and no new ones form. 

In experimental animals, otoconia can be removed from the utricle by centrifuging (spinning the animals at high acceleration).  This is very similar to the movements in some spinning “G-force” amusement park rides.   These rides are not a good idea if you want to keep your otoconia in place as long as possible. 

A reader whose BPPV resolved with maneuvers wonders whether there is any benefit or downside to doing other vestibular exercises after BPPV is over, like turning the head left and right while walking or moving the head rapidly up- and downward or diagonally.

Read more: Should you do vestibular exercises after BPPV?

There are many different vestibular exercises that are used for an assortment of balance disorders. The best treatment for BPPV is to remove the particles from the semicircular canals by doing maneuvers.  If this results in a complete resolution of symptoms, then no other exercises are needed.  Moving your head when walking or sitting upright after BPPV is gone will not have any effect on whether positional vertigo will recur.  The only movement to avoid after BPPV is treated is lying flat on your back or placing your head below the horizontal, since this can move particles back into the semicircular canals. 

The head movements our reader described are designed to treat two slightly different conditions.  People who have lost balance function in one or both ears have difficulty stabilizing vision while making head turns, so their vision tends to blur momentarily.  This can be improved by moving the head rhythmically and at varying speeds and angles to gradually train the balance system to predict exactly how far to move the eyes to prevent this blurring.  If you do not have any damage to the inner ears, then these exercises will not really help anything, but will not hurt you either. 

The other situation where these exercises are used is in people who have BPPV that cannot resolve their symptoms with maneuvers.  In general, if you can make yourself dizzy by moving your head, you can also adapt to this dizziness by practicing that movement.  For example, before we had maneuvers to treat BPPV, people were told to sit on the edge of a bed and fall back repeatedly to set off the dizziness.  This worked very gradually to reduce the spells (Cawthorne exercises).  Most of this effect was due to ocasionally shaking some of the particles out of the canals, so it was simply a poor form of today’s maneuvers.  However, if you have consistent dizzy spells brought on by a particular movement that is not due to BPPV or cannot be resolved by maneuvers, you can become accustomed to the dizziness and greatly improve it by repeating the movements that provoke it.  The brain can gradually learn how to use vision to overcome some of this chronic dizziness. 

In general, moving your head while walking can help you relearn balance if you have any ongoing dizziness disorder affecting the ears and is usually included in vestibular therapy. This type of balance treatment is highly effective.