The Medical Consumer's Advocate

Ear crystals? A discussion of BPPV, benign paroxysmal positional vertigo

This letter originally appeared in Dr. Hoffman's column on allHealth.com.

Q: My husband has been previously been diagnosed with "ear crystals." He will suffer severe cases of vertigo and aches. The symptoms come and go with no warning. We have found no allergies and the doctors cannot give any more information. Please help us.

A: "Ear crystals" can only mean benign paroxysmal positional vertigo, or BPPV. I have never heard BPPV referred to as "ear crystals," and "benign paroxysmal positional vertigo" is a far more descriptive name for this condition, as you will understand in a moment.

First, we should make sure that you and I are talking about the same thing. Patients with BPPV experience a severe spinning sensation (vertigo) in response to particular changes in head position. The most common complaint is vertigo after rolling over in bed. Quite often, the patient will have problems only when they roll to one particular direction. People with BPPV are often intolerant of other head movements, such as looking upwards or looking over one’s shoulder.

Vertigo in BPPV lasts only for several seconds – never more than one minute, although a sense of dysequilibrium may persist throughout the day. A person may have several attacks in a short interval (days, weeks, even months), followed by a remission period that may last for months or years.

Usually, an ear, nose, and throat (ENT) doctor can make this diagnosis based solely upon the patient’s description of his symptoms. There are, however, a few key observations from the physical examination which will support the diagnosis. The ENT puts patient through particular positional changes to provoke the vertigo; when this is done, observation of the patient’s eyes can be quite informative. Coincident with the symptom of vertigo, the patient’s eyes will bob up and down (vertical nystagmus) or more often twist in a characteristic manner (torsional, or rotational nystagmus). There is usually a two or three second delay between assumption of the position and initiation of the nystagmus; this is known as latency. When the ENT repeats the positional maneuver, the patient is often surprised to discover that his symptoms are much decreased. This is known as fatigability. When an ENT can demonstrate vertical/rotational nystagmus, latency, and fatigability on positioning maneuvers, he can be nearly certain of the diagnosis of BPPV.

BPPV is benign in that it does not signify anything life-threatening to the patient (such as a brain tumor). Paroxysmal refers to the fact that the episodes are brief and self-limited – "paroxysm" means "attack." The positional vertigo aspect of BPPV should be evident from the description above.

So ... what on earth are "ear crystals"? The medical term for "ear crystal" is otolith (also known as otoconia). Everyone has otoliths. They are found in two inner ear organs, the utricle and the saccule, collectively known as the otolithic organs. These organs are responsible for our ability to sense a gravitational field. In other words, even if you are in a pitch dark room, floating in a swimming pool (thus deprived of visual cues and musculoskeletal cues), you will still know which way is up, thanks to your otolithic organs.

The nerve endings in the otolithic organs are embedded in a gelatinous goo known as the otolithic membrane. Embedded in this gelatinous membrane, like grapes in fruit jello, are the otoconia. They are tiny calcium carbonate/calcite crystals. Their whole purpose in life is to make that jello as heavy as possible. That way, when you tilt your head in a gravitational field, the otolithic membrane moves accordingly, thus stimulating the nerve endings underneath.

Now we leave the realm of hard scientific fact and embark into the great fantastical beyond. Current dogma states that otoliths may become liberated from the otolithic membranes, and are then free to float through the inner ear fluid. These free agents are capable of stimulating other parts of the inner ear. In particular, with regard to BPPV, they are thought to most commonly stimulate a structure known as the posterior semicircular canal. The semicircular canals are responsible for our sense of rotational motion. If a semicircular canal is stimulated by errant otoliths, the result is a sense of rotational vertigo.

While I have facetiously implied that this is a fantasy, it is certainly true that this theory explains all of the symptoms and physical findings associated with BPPV. Also, there have been reports from various ear surgeons that they have seen (intraoperatively) particulate matter in the posterior semicircular canals of BPPV patients.

Fortunately, there is a very simple and virtually risk-free treatment for BPPV. A positional maneuver (known as the Epley maneuver, for the doctor who developed it; also known as the otolith or canalith repositioning maneuver) allows the otoliths to "settle out" in a region of the inner ear where they will not cause problems. Patients can be taught this maneuver and can practice it at home. If, in fact, your husband’s diagnosis of "ear crystals" corresponds to BPPV, then he needs to ask his ENT about the Epley maneuver.