Benign Paroxysmal Positional Vertigo (BPPV)

Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo (spinning sensation) in adults, but uncommon in children. BPPV is characterized by short episodes of vertigo (lasting less than 1 minute) that are triggered by head movement. This might happen with rolling over or getting out of bed. There may be dizziness or lightheadedness, nausea, vomiting, and loss of balance with BPPV. Although the symptoms of BPPV may be bother your child, this condition is not considered serious or life-threatening.

The ability to balance is controlled by the inner ear balance system, vision, and proprioception (muscles and joints sensing the body’s location). Each of these three systems send signals to the brain to help maintain posture and balance. The portion of the balance system (also called the vestibular system) located in the inner ear is comprised of several fluid filled tubes (semicircular canals) and compartments (utricle and saccule) that detect motion and gravity.

Within the utricle there are crystals (otoconia) that help sense gravity. These crystals can dislodge from their normal location due to a variety of factors, and enter into the semicircular canals. When crystals accumulate in the semicircular canals, they interfere with the normal fluid movement and send incorrect signals to the brain that the body is moving. This incorrect signal is mismatched from what the eyes are seeing and muscles are sensing, leading to a sensation of dizziness or vertigo.

Your primary care provider will likely refer your child to a pediatric otolaryngologist (ear, nose and throat or ENT specialist) because diagnosing the cause of vertigo can be challenging. BPPV must be differentiated from other forms of dizziness. A multidisciplinary team of otolaryngologists, audiologists, and physical therapists is best able to perform the comprehensive evaluation and to know when to call on the expertise of other specialists.

The otolaryngology evaluation will include:

• Extensive medical history-taking with questions for both you and your child
• Thorough physical exam, especially of the head and ears

During the course of the evaluation, you will meet with a vestibular trained audiologist for an evaluation and further testing. This evaluation may include:

• Audiologic evaluation (hearing test)
• Rotational chair testing, which involves your child sitting in a computerized rotating chair, safely secured with a seatbelt, and wearing light weight goggles. During this test, your child’s eye movements will be recorded as the chair gently moves.
• Videonystagmography (VNG), which involves your child wearing lightweight goggles that have tiny cameras to record eye movements. During the test, your child will be asked to look at a series of objects and their eye movements will be recorded. In another part of the test, warm and cool air or warm and cool water will be placed in your child’s ear canal and their eye movements will be recorded.
• Vestibular Evoked Myogenic Potential (VEMP), which involves gently placing electrode stickers on your child’s forehead, neck, and eyes. Small earphones will also be placed in their ear. The earphones will send clicking sounds to their ear and your child’s body response to the clicking sound will be measured in the electrode stickers.
• Video head impulse test (vHIT), in which your child will wear lightweight goggles that measure eye movements. During the test the audiologist will quickly turn your child’s head and their eye movements will be recorded.

During the course of the evaluation, you will meet with a vestibular trained physical therapist for an evaluation and they may perform tests such as:

• Evaluation of gross motor skills, such as hopping, skipping and jumping with eyes open and closed.
• Dynamic Visual Acuity, which involves testing your child’s vision while your child is shaking their head.
• Posturography, which involves your child will wearing a safety harness and standing on a moving platform to evaluate balance.

Referrals to other specialist may be considered, as well as:

• Lab (blood) tests
• Imaging tests, such as CT scan or MRI

BPPV will often resolve on its own in several weeks to months. The displaced crystals may dissolve or move to a location where they will no longer cause symptoms. If symptoms persist, exercises to reposition the displaced crystals may be performed in the office by a clinician or home exercises may be recommended.

The Balance and Vestibular Program at Children's Hospital of Philadelphia is a multidisciplinary program that specializes in the evaluation and treatment of children with dizziness and balance disorders. Our program is dedicated to leading the way in the advancement in diagnosis and treatment of pediatric vestibular disorders. Our team is comprised of experts and uses state of the art vestibular testing technology. We work closely with families and referring physicians to better understand a child’s symptoms and create a customized care plan.