As the World Turns: Navigating Benign Paroxysmal Positional Vertigo (BPPV) | E28

Navigating the complex world of inner ear disorders, Dr. Ayla Wolf and Sophia Bouwens discuss the mechanics and causes of Benign Paroxysmal Positional Vertigo (BPPV) and what contributes to re-occurring BPPV.

• Difference between true vertigo and general dizziness 
• How the semicircular canals and otolithic organs in our inner ear detect all head movements
• Infrared goggles essential for accurate BPPV diagnosis 
• Vitamin D, calcium, magnesium and B vitamin deficiencies linked to recurring BPPV
• Thyroid disorders, hormonal fluctuations, and certain antibiotics can trigger vestibular problems
• COVID infections associated with increased vestibular symptoms
• Chinese medicine perspective on "dampness" and its relationship to dizziness

We'd love to hear what specific topics you want to hear more about, and you can do that by clicking the send us a text link that's at the top of the show notes. Video clips from previous episodes are now available on the Life After Impact YouTube channel, which you can find by searching for @LifeAfterImpact.

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Chapters

• 0:00 Welcome to Life After Impact
• 4:35 Understanding Dampness and Dizziness
• 9:05 BPPV: What Is It?
• 15:50 Anatomy of Balance: Semicircular Canals
• 22:00 Diagnosing BPPV With Infrared Goggles
• 28:07 Why BPPV Keeps Coming Back
• 32:47 Surprising Causes: Nutrients to Antibiotics

Transcript

Dr. Ayla Wolf: 0:01

Welcome to Life After Impact the concussion recovery podcast. I'm Dr Ayla Wolf and I will be hosting today's episode, where we help you navigate the often confusing, frustrating and overwhelming journey of concussion and brain injury recovery. This podcast is your go to resource for actionable information, whether you're dealing with a recent concussion, struggling with post concussion syndrome or just feeling stuck in your healing process. In each episode, we dive deep into the symptoms, testing, treatments and neurological insights that can help you move forward with clarity and confidence. We bring you leading experts in the world of brain health, functional neurology and rehabilitation to share their wisdom and strategies. So if you're feeling lost, hopeless or like no one understands what you're going through, know that you are not alone. This podcast can be your guide and partner in recovery, helping you build a better life after impact. All right, sophia, how are you doing today? All right, sophia, how are you doing today?

Sophia Bowens: 1:04

I'm doing really well, Ayla. How are you today?

Dr. Ayla Wolf: 1:08

I am good. It's super hot and humid out, so I'm happy to be recording this podcast in a nice air-conditioned room.

Sophia Bowens: 1:27

You know, what's interesting is this time of the year in Chinese medicine is such a rising energy heat and we're in this transition into like dampness.

Dr. Ayla Wolf: 1:31

And it's interesting because in my experience at the neuroscience center and even in my own life I've been noticing a lot of people are getting more dizzy for our listeners who don't know what dampness means, maybe you could explain what that term means in Chinese medicine and then how that might translate to an increase in dizziness.

Sophia Bowens: 1:53

Oh yes, so that's a great lead. So dampness in Chinese medicine is like the stickiness you know when it's humid or hot and heavy and like kind of damp outside or there's kind of this like griminess sensation of it's not everything's not super clear. It's both like a feeling and also a physiological condition, right, so it can lead to more phlegm, it can lead to more digestive disruption, it can lead to more like sticky skin conditions and it can also lead to this feeling of like fogginess or brain fog. And this condition of just not clear thinking can disrupt our ability to sense the world around us and lead to the sense of like imbalance or dizziness.

Dr. Ayla Wolf: 2:42

And people are also eating way more ice cream, which is super phlegm and damp forming. Yes, exactly so. One of the ways that I look at dampness, this concept of dampness from a Chinese medicine perspective, is a stagnation within the lymphatic system and that can also create a sense of heaviness and swelling and edema.

Dr. Ayla Wolf: 3:10

But within the inner ear we also have endolymph, so we have a very special kind of lymph in the inner ear and the viscosity of that is different from other lymph in the body. And so when we think about dampness causing dizziness, it can also mean that the endolymph itself is actually congested and that the body isn't producing enough new, clear, healthy endolymph. Almost like the blood can become thick, the endo lymph can become thick, and so that can also cause things like dizziness or vertigo or disequilibrium and all these type of inner ear disorders.

Sophia Bowens: 3:54

Fascinating. Do you think hydration would affect that?

Dr. Ayla Wolf: 3:58

I think that the electrolyte balance is important, or just the amount of electrolytes, but also balance is important, or just the amount of electrolytes. But also, if you think about this idea that the endolymph is unique and it's in one part of the body, our body is supposed to have the wisdom to be able to have the right concentration of different electrolytes in different parts of the body. And so, obviously, when people have underlying health issues, or even again, like a head trauma that affects the ear or the structures around the ear, that's where you can actually get some of this congestion that happens in that particular part of the body, which makes people more susceptible to things like dizziness.

Sophia Bowens: 4:42

Well, let's dive in. So today we're going to talk about BPPV.

Dr. Ayla Wolf: 4:46

BPPV is Benign Paroxysmal Positional Vertigo, which is such a mouthful that people tend to abbreviate it as BPPV.

Sophia Bowens: 5:00

There's a lot of interesting terminology in this discussion. As we go, the words not only the name is complex, but the words that describe the mechanisms and these weird organs that are in between our ears and have so much effect on our sense of balance in space in the world. They have the strangest names we're not used to hearing. So it's fitting that the title of the condition is kind of complex, but we're going to also work to be making it really really straightforward and understand some of these more complex words that we use to describe this condition.

Dr. Ayla Wolf: 5:36

For sure, and I feel like people that come into my office fall into two camps. The first camp is when I say BPPV, they give me a blank look and they've never heard that term or that abbreviation before ever. And then the other camp is people who have kind of associated all vertigo as BPPV and then I have to explain that while BPPV is often the most common kind of cause of vertigo, not all vertigo is BPPV. So those are kind of the two camps of people that I feel like I see and I figured I'd just like throw that out there that you know it's important to recognize that this is one source or one cause of vertigo, but it's not the only. It's not the only cause.

Sophia Bowens: 6:28

No, and that's really important because oftentimes describing this sensation is really important for the correct diagnosis or even for people to go down the trail of looking for the correct diagnosis. So there's a lot of people confused, dizziness and vertigo. Can you describe or define what each of those are and how they might feel or be described differently by patients?

Dr. Ayla Wolf: 7:09

true vertigo is a sense of rotation or spinning, and so people will either feel like the world is spinning around them or they feel like they are spinning, and so that is what we would consider to be a true vertigo sensation, whereas dizziness is more of a vague sensation of being disconnected from your environment. Some people will describe it as being like oftentimes, when you're dizzy, you are also off balance. So people can be like well, I feel off balance. Or maybe people will say I feel a little lightheaded lightheaded, but often it's like this sense of disorientation where you're just all of a sudden not feeling normal in your own body because of the dizziness.

Sophia Bowens: 7:55

And one marked thing I noticed and I don't think you can correct me if I'm wrong, because you know so much more about this topic than I do. I have had vertigo twice and the second time I had this like extreme feeling of being like pulled to the ground. It felt like I was in like a tilt of world and just like being propelled over and I couldn't. It was kind of awful, kind of terrible and I was like oh my gosh, that that is definitely vertigo of some kind. I got tested and got this. You know everything was treated well and that thank goodness I knew I had the tools to have that done quickly. But I think that this, like strong pulling sensation or forceful sensation, happens sometimes. Does it always happen in vertigo?

Dr. Ayla Wolf: 9:01

It's not always just like oh, I feel like the world is spinning to the right or the world is spinning to the left. Some people will say, you know? They'll say I feel like I'm like doing a backflip, where I'm like going back into the left, or I feel like I'm falling forward into the right, and so people can have all of these diagonal directionalities to their sense of vertigo, which might also feel like you're like being pulled to the floor. But then, when there is vertigo, there can also be an otolithic component where, if there's just hyperactivity happening within the otolithic organs, that can also cause a sense of feeling like you're being pulled to the ground.

Sophia Bowens: 9:46

Okay.

Dr. Ayla Wolf: 9:47

And so sometimes, when we talk about vertigo, this is where, like you mentioned, there's all this neuroanatomy that we have to get into, but the thing that causes the spinning is dysfunction within the semicircular canals. So those are part of the vestibular system in the inner ear, and then another part of the vestibular system are the otolithic organs, and so I think it's important to recognize like these are special organs that we have in the inner ear and they have lots of sensory receptors that are picking up every single time our bodies are moving forwards, backwards, side to side or up and down. So you can imagine that if one of these sensors, the one that's telling your brain that we're moving down, if that's firing too much, you're literally going to feel like you're being pulled to the floor.

Sophia Bowens: 10:46

Yep, and that was awful. That's what was happening to me. So there's these. It was. There's these otolithic organs, but there's also these semicircular canals, and can you describe for listeners what those are, what those look like or how they translate information to us?

Dr. Ayla Wolf: 11:08

Yeah, so if we are going to talk about this in terms of shapes, we could say that in the inner ear we have this thing called the vestibule, and we can picture the vestibule as a, as a box, and then inside that box we have the otolithic organs, are two otoliths, and then inside that box we have the otolithic organs, our two otoliths, and then on the outside of the box we've got half circles which represent the three semicircular canals. And so on the right ear we have three semicircular canals and on the left ear we have three semicircular canals, so we've got six in total. We have three semicircular canals, so we've got six in total.

Dr. Ayla Wolf: 12:06

Bowl with a marble in it. Every time you tipped the bowl, the marble would roll right. And so all of these semicircular canals the three on the right and the three on the left they're all working together to tell the brain exactly how the head is tipping and tilting and turning every time you move your head. And so it's like if that bowl was just one big giant sensor. It would be telling the brain exactly where the marble is.

Sophia Bowens: 12:35

Yeah, I like that. And these canals. They work together to provide information to the brain kind of where and how our head is turning. Is that right?

Dr. Ayla Wolf: 12:45

Yeah, and so the problem is, when there's too much activity happening in a canal, it tells the brain that the head is turning in like more, more than it actually is. Or if somebody is perfectly still and that canal is firing, then it's telling the brain that there's that movement is happening when it's not happening.

Sophia Bowens: 13:08

And that can lead to symptoms like vertigo.

Dr. Ayla Wolf: 13:11

Exactly.

Sophia Bowens: 13:13

Okay, so this is complex and there's all these mismatched features of things, but I think that gets really interesting and important when we're looking at really how do we treat this, how do we diagnose it, how do we assess it, how do we figure out what's going on so we can help correct it. What would you say is some of the hallmarks of BPPV, versus just regular dizziness?

Dr. Ayla Wolf: 13:41

I think it's important to point out that when people have BPPV, they can have a pretty long list of symptoms, and so some people like the most common symptom like people will have vertigo. Other people might actually just feel dizzy. Other people could have disequilibrium. Some people can have headaches and nausea and neck tension. So there's a whole long list of possible symptoms that people could experience.

Dr. Ayla Wolf: 14:09

But I think that there's a couple of differentiating features that are helpful in terms of identifying BPPV, and one of them is that when you have a canal lithiasis and this is again another fancy term it's a type of BPPV, saying that there are calcium crystals that have fallen into the canal that are causing the excessive activity that is now tricking your brain into thinking that there's movement happening, and so typically, a classic presentation of BPPV is that somebody tips their head into a specific position and all of a sudden they get vertigo, but then as soon as they get out of that position, it calms back down.

Dr. Ayla Wolf: 15:01

So it's not constantly there all the time, and the thing that my patients often will tell me is when I lay back to go to bed at night, I'll have an episode of vertigo, or when I sit up in the morning I'll have an episode of vertigo. Or when I tilt my head back in the shower to shampoo my hair. All of a sudden I get vertigo hair. All of a sudden I get vertigo, and so people can often identify the position that their head goes into. That then triggers the symptom.

Sophia Bowens: 15:33

And does that help you figure out how to treat it? Or does that give you information which position it is or how the angle that they have to turn to? Does that make a difference?

Dr. Ayla Wolf: 15:44

So that's often the symptom that clues me in to say that sounds like BPPV. Right, but the absolute best way to really diagnose BPPV is to have the patient put infrared goggles on so that the clinician can actually see their eyes, so that the clinician can actually see their eyes, and then the patient is going to be tilted into certain positions that bias one of the semicircular canals. And if nystagmus is observed in the eyes, that then what's nystagmus? So nystagmus is a very specific type of eye movement where the eyes are slowly drifting one direction and then they're rapidly correcting back in the opposite direction.

Dr. Ayla Wolf: 16:33

The thing that we have to appreciate is the fact that our vestibular system, these semicircular canals they are hardwired into the nuclei that then control the six eye muscles, and so when a canal is overfiring, it's going to cause the eyes to move in a very specific direction.

Dr. Ayla Wolf: 16:55

So, for example, if the left posterior canal is overfiring, the eyes are going to be pushed down into the right and then they're going to correct back up into the left, and there's also going to be a torsional aspect to this as well, meaning the eyes are going to roll and so you're going to see a nystagmus that is in a very specific direction and there might also be a torsional component to it. And there might also be a torsional component to it, whereas if you have a high firing left horizontal canal, the eyes are going to be pushed to the right and then have a fast correction these infrared goggles on. And there was a study that I thought was really important, because the study said that if you are only relying on just tilting somebody's head in different positions to see if it triggers dizziness or vertigo, and you're not using infrared goggles and you're not actually seeing nystagmus, that you're going to get your diagnosis wrong 50% of the time.

Sophia Bowens: 18:10

Basically, Wow, that's not good. So you don't just go based on, like what they're feeling. You have to. This eye movement component is really important for this diagnosis to be accurate. Is that what I'm hearing you say?

Dr. Ayla Wolf: 18:25

Yep, that's exactly it.

Dr. Ayla Wolf: 18:27

So being able to observe the nystagmus is really key if we want to have an accurate diagnosis.

Dr. Ayla Wolf: 18:34

And then to add even more complexity, sometimes, these calcium crystals that we think are in some cases causing the BPPV, there's again, there's very smart people who still aren't quite sure if this calcium crystal theory is like the end-all, be-all of all causes of BPPV. But to make matters more complex, these calcium crystals, they can adhere to the wall of the canal, and so if they've adhered to the wall of the canal, you might not see the nystagmus during your testing. And so one of the things that can help is to just take a tuning fork and place it on the mastoid, which causes a really gentle vibration, but it can shake those crystals loose off of the canal wall. And so then, if there really truly are free floating crystals in the canal that's causing the vertigo, well, now you've kind of loosened them up so that, a, you can get an accurate diagnosis and then, b, the head repositioning maneuvers are probably going to be more effective, because you've actually gotten the crystals to shake loose and then they can more freely fall back into the vestibule where they belong.

Sophia Bowens: 19:51

So complex. So I know that we've already dove into this topic so much, but I want to just backtrack for a second because I want to be clear on how someone might describe dizziness or a feeling of imbalance in a way that might tune you in to think it might be BPPV versus other types of dizziness.

Dr. Ayla Wolf: 20:10

You don't want to diagnose BPPV based on somebody's symptoms. However, when someone describes vertigo that comes on suddenly and usually calms back down within about 30 seconds to a minute and seems to be responsive to an adjustment of position, that's always my kind of cue to say this sounds like BPPV.

Sophia Bowens: 20:37

Versus another type of dizziness, because there are other drivers of dizziness or vertigo. Bppv is just the most common, is that right?

Dr. Ayla Wolf: 20:46

Yeah, I mean there's a million causes of dizziness. That's a whole nother conversation. When people say they're dizzy, that could mean anything.

Sophia Bowens: 20:56

That definitely needs a lot more diagnostic workup and it's not kind of constant all the time. It's definitely positional and there are these eye movement components that are present to help us understand what is kind of going on and how we might assess or treat it. And then you talked about this like crystal component of these crystals are floating around in these canals that are providing feedback into our system, but some schools of thought and some really intelligent people challenge this crystal theory. That's really interesting to me because for as long as I've learned about BPPV or this vestibular component, it's always this like dynamic between these little cilia here on the inside of these canals and these crystals floating around. Can you talk more about this idea that maybe that's not the endovial, maybe there's different types or maybe there's other things driving this?

Dr. Ayla Wolf: 21:57

I think a lot of it is observation, because once you start seeing lots and lots of patients that have vertigo, you start to feel like not everybody falls into a textbook. Cat, you know, category of BPPV, and that's the thing is is like we, you know, we all go to school we learn these textbook presentations and then we get out into the real world and all these people come in and they are they don't fit the textbook right, they're not textbook.

Sophia Bowens: 22:28

Right A little bit of this a little bit of that, no.

Dr. Ayla Wolf: 22:33

Yeah. And so I think that when you've got a lot of practitioners who see people that always that maybe don't fit into these textbook descriptions of BPPV, they start to think like, well, what else is going on? And it also seems like if you, if you go on the internet, there's a new vestibular repositioning technique that shows up every year. And so now we have all these different repositioning maneuvers and it's like, okay, well, are they actually dealing with calcium crystals, or are these repositioning maneuvers somehow maybe recalibrating the vestibular system in a way that is actually helping the patient to not be so dizzy or have vertigo? And so I think that when very intelligent people are saying I'm not sure this calcium crystal theory is the end-all, be-all of explaining every single case of BPPV, I think this is where they're coming from.

Sophia Bowens: 24:46

And I wonder too if this challenge comes from a reoccurrence of BPPV, Like if it's just these crystals that get dislodged, a what causes them to be dislodged and what about when those crystals get put back into place. And it continues to be an issue for some patients and not for others.

Dr. Ayla Wolf: 25:04

When people do get BPPV. Some people end up in the camp where they then start to get it. I don't necessarily it doesn't always have to be frequently, but some patients will say, oh my gosh, I get it every three months. Some people will say I get it once a year. Some people will say I get it once a year. Some people will say I had it years ago and now I have it again. So can reoccur at very different frequencies for different people. But there I think has been more interest in trying to understand why does this keep coming back? And so we can break it up into kind of a couple different categories. So what they have found is that some people have nutrient deficiencies that can contribute to it. So simple things like a vitamin D deficiency seems to cause reoccurring BPPV. So for some people it's as simple as hey, you need to get your vitamin D status back up to a healthy level.

Sophia Bowens: 26:03

Vitamin D is considered like a yang tonic or a yang vitamin in Chinese medicine and yang helps transform phlegm or this dampness. It comes from the sunshine, which helps dry dampness. So if we're thinking of this through the Chinese medicine lens, for me that's kind of where my head goes, like oh yeah, this young thing that really helps clear dampness and dry up and clear phlegm. I love Chinese medicine and how it ties into these wisdoms. Sometimes when you see the dots, you can't help but connect them. So vitamin D deficiency can be a contributing factor to reoccurring BPPT a contributing factor to reoccurring BPPT.

Dr. Ayla Wolf: 26:43

Yeah, and I think that's hilarious that you were able to bring this full circle from when we started talking about dampness to then talking about vitamin D and sunlight drying dampness. So there you go.

Sophia Bowens: 26:52

Are there other things that I mean not just vitamin D, though, right, there's like a lot more.

Dr. Ayla Wolf: 26:58

Yeah, so I mean as far as the nutrients, calcium and magnesium deficiencies can be problematic as well as B vitamin deficiencies. So there's research to show that B vitamin deficiencies can contribute to reoccurring BPPV. So those are kind of the big ones as far as nutrients go. And then when people have thyroid dysfunction or parathyroid disorders that can affect calcium metabolism, and so whenever you're throwing off calcium metabolism, obviously those are the people that then also might be dealing with osteoporosis or osteopenia, and so those particular individuals can have reoccurring BPPV.

Sophia Bowens: 27:41

They're more prone to it. And what stands out to me about all those things those nutrients calcium, magnesium, b vitamins is they're really important for nerve function and maintaining that cellular balance. This system is really sensitive to those even small disruptions in the cellular functioning.

Dr. Ayla Wolf: 28:04

Yeah, absolutely. And then I don't know if you saw this, but during COVID, especially when the Omicron variant was going around, lots of my patients were coming in with vestibular disorders and with reoccurring BPPV, and so infections and anything affecting the inner ear can definitely cause that. And I think one of the most frustrating thing for those patients is that they were all saying the exact same thing, which was I went to my ENT, they looked in my ears, they told me I was fine and they sent me home and they're like but I am still dizzy and I have vertigo and I can't walk straight and I have all these vestibular symptoms, and so in that case I think again, when you're talking about the inner ear, it is very sensitive to infections, it's very sensitive to inflammation and, as we mentioned before, that idea that if the endolymph is getting congested and it's throwing off the viscosity of the endolymph, all of that can cause vestibular symptoms it's amazing that we don't all have a lot more vestibular symptoms.

Dr. Ayla Wolf: 29:12

Yeah and a lot of this stuff. With the reoccurring bppv, it requires again more like investigative lab work to try to figure out does somebody have a nutrient deficiency? Do they maybe have a thyroid disorder? Because autoimmune thyroid issues Hashimoto's is very common and autoimmune disorders are on the rise and especially as people age it actually becomes more common. And so again, I think, in elderly individuals a lot of times doctors aren't, they're not searching for an autoimmune disorder, they're not looking for you know, they're not immediately thinking let's test the thyroid for Hashimoto's with this person who's in their 60s, for example.

Sophia Bowens: 29:57

Do you see this being sensitive to blood sugar regulation or people with diabetes?

Dr. Ayla Wolf: 30:02

Absolutely so. That can be another source of why people might have reoccurring BPPV, because when people have diabetes and unmanaged high blood sugar, that actually causes nerve damage and in some cases that causes nerve damage to the inner ear, and so that can be a problem. And then there's also antibiotics that are actually ototoxic, so they're toxic to the inner ear and can cause inner ear damage, and so it's important to recognize, I think, for people, if they've already dealt with BPPV, to be very careful about antibiotic use and which ones they need to avoid.

Sophia Bowens: 30:44

That's super fascinating that even things like antibiotics, which could be used to treat things like ear infections or strep or other infections, can have this risk of being ototoxic. Do you know which antibiotics in particular present this highest risk for this ototoxicity?

Dr. Ayla Wolf: 31:04

Yeah, they say definitely when people have intravenous antibiotics in certain classes that I think that becomes like one of the higher risk factors. So the aminoglycosides are one example, Streptomycin is one of those, and then vancomycin has a higher risk. And the macrolides that category of antibiotics which include azithromycin and erythromycin, all are known. I think that's important for people that do have kind of a background in vestibular disorders. If they're ever given an antibiotic, I think it would be important that they talk to their doctor and read the potential side effects to make sure that they might not be taking something that's ototoxic if they already have different vestibular issues going on. So that's an important thing to keep in mind.

Sophia Bowens: 31:58

All these things we haven't really thought about but can make such a difference for this really sensitive apparatus.

Dr. Ayla Wolf: 32:04

Yeah, even different issues with hormones. So I have a friend who I work out with at the gym and she was having BPPV and basically finally figured out that it was hormonal and so it was happening at a very specific time in her cycle every month and once she dealt with her hormonal and so it was happening like at a very specific time in her cycle every month and once she dealt with her hormonal imbalances, then the vertigo went away.

Sophia Bowens: 32:26

So for women who are menstruating, it could be like that this comes on a certain time of the month when that gets higher. What about do you see this happening more or less in like menopausal, paramenopausal?

Dr. Ayla Wolf: 32:37

women. For sure, like with menopause, those hormone changes can affect the difference between estrogen playing a role in our bone density and our calcium metabolism. So as estrogen levels fall, then all of a sudden that gets thrown out of balance. So that can also be a trigger.

Sophia Bowens: 32:57

Fascinating so much. Well, this is an interesting topic and I think we scratched the surface of it. I think a follow up episode we should do is like the complexities of, like the visual system, how it plays into this vestibular system, and maybe how things like proprioception or joint position can play into this too. In your book you do such a nice job of breaking down all these things in relation to BPD.

Dr. Ayla Wolf: 33:21

Oh, well, thank you so much, and we'll definitely have to do another deep dive into the world of vestibular symptoms here soon. And for you listening, we'd love to hear what specific topics you want to hear more about, and you can do that by clicking the send us a text link that's at the top of the show notes. I also want to mention there are now video clips from previous episodes on the Life After Impact YouTube channel, which you can find by searching for at Life After Impact Medical disclaimer. This video or podcast is for general informational purposes only and does not constitute the practice of medicine or other professional health care services, including the giving of medical advice. No doctor patient relationship is formed. The use of this information and materials included is at the user's own risk. The content of this video or podcast is not intended to be a substitute for medical advice, diagnosis or treatment, and consumers of this information should seek the advice of a medical professional for any and all health-related issues. A link to our full medical disclaimer is available in the notes.