BPPV Complications: Seven Examples

BPPV complications can and sometimes do occur during BPPV treatment. The possibility of BPPV complications is the main reason why I do not recommend that people to attempt to treat themselves for BPPV.

If anyone experiences a BPPV complication, I think it is best for a professional to be there to reassess and adjust the BPPV treatment plan as needed on the spot. The symptoms might change in a different way than expected. The nystagmus might even switch directions in the middle of a BPPV treatment session.

In this article, I will cover seven examples of BPPV complications.

Bilateral BPPV

Patients can have BPPV in the right ear or the left ear – or both ears. BPPV on both sides is called bilateral.

Bilateral BPPV can cause a complication because even successful treatment can cause severe spinning and vomiting, during or afterward.

Patients with bilateral BPPV typically feel worse after treatment, even if the treatment was successful. They usually don’t start feeling better until at least one side is all the way cleared.

This BPPV complication can be confusing to people who are trying to treat themselves or novice clinicians.

Multi-Canal BPPV

Within each ear, there are three semi-circular canals (SCCs) that can have BPPV crystals in them. When the BPPV crystals are in more than one semi-circular canal (SCC) within the ear, that is called multi-canal BPPV.

This BPPV variant occurs most often after head trauma but does not require head trauma to occur. Multi-canal BPPV can present a BPPV complication because clinical judgment needs to dictate which canal to treat first.

If the canals are treated in an order that is not therapeutic, the patient can get very sick and feel miserable. The proper sequence of BPPV maneuvers may be difficult for novice clinicians to figure out and would certainly be very difficult for patients to determine.

In some very difficult cases, patients can have multi-canal BPPV bilaterally. That is a very complex BPPV complication.

Canal Switch

Within the semi-circular canals, there are multiple locations where BPPV crystals can be found. The different locations within the canal can present with different symptoms and different eye movements (nystagmus).

Sometimes the crystals switch locations within the semi-circular canal during BPPV testing or treatment. This is called a canal switch or an “ipsicanal switch.”

This presents a BPPV complication because the symptoms and nystagmus may change mid-treatment. When a canal switch occurs, it can confuse novice clinicians and patients who are trying to treat themselves.

I think it’s ideal for vestibular professionals to be present to assess any canal switch and continue with proper treatment.

Canal Conversion

The goal of BPPV treatment is to get the BPPV crystals to move from the semi-circular canal, wherever they are, into the utricle.

The utricle is the vestibular end organ where the BPPV crystals actually belong.

However, the crystals can sometimes switch canals in the middle of a treatment or immediately after a BPPV treatment.

This BPPV complication is called a canal conversion. I will give you a few brief examples of canal conversions.

Examples of Canal Conversions

One example of a canal conversion is when the BPPV crystals move from the anterior canal into the posterior canal during or after BPPV treatment.

Another example of a canal conversion is when the BPPV crystals move from the posterior canal into the anterior canal. This can happen during normal daily life if the patient flips their head upside down or during a half-somersault maneuver that the patient found online. I do not recommend that patients attempt the half-somersault maneuver, even though it is gaining popularity online.

If the patient attempts a self Epley, but they do not do the maneuver correctly, then the crystals can predictably convert from the posterior canal to the horizontal canal. I do not recommend attempting a self-Epley maneuver unless you have been properly trained by a professional.

Within the posterior canal, there are a few locations where crystals can be found. One location is called the long arm and another possible location is called the short arm. These both respond to different BPPV treatments.

During or after a BPPV treatment for the long arm of the posterior canal, the crystals can convert into the short arm. That occurs if they fall past the utricle and settle in the short arm during or after treatment.

During or after a BPPV treatment for the short arm of the posterior canal, the crystals can convert into the long arm. This is still being studied by researchers, so stay tuned for more information on how this occurs.

The bottom line is that a canal conversion may require a different BPPV treatment than it originally appeared, for a full resolution of vertigo.

That is one explanation for why the Epley maneuver does not always work.

Single Canal BPPV Conversion to Multi-Canal BPPV

Sometimes a canal conversion does not transfer all the crystals from one canal to another canal. Therefore, some canal conversions result in multi-canal BPPV. In this case, the crystals spread out between two canals during or after treatment.

In that case, some BPPV crystals may remain in the original semi-circular canal and now some BPPV crystals converted into a second semi-circular canal within the same ear. That results in multi-canal BPPV, which is a BPPV complication we already discussed.

Type of BPPV Conversion

There are two types of BPPV: canalithiasis and cupulolithiasis.

1. Canalithiasis is when the crystals are free-floating like fake snow inside a snow globe.
2. Cupulolithiasis is when the crystals are adhered to the cupula structure inside the semi-circular canal, like a lollipop stuck on a kitchen counter.

BPPV can convert from one type of BPPV to another type of BPPV in the middle of a treatment session. It typically converts from cupulolithiasis type to canalithiasis type.

I included this as a BPPV complication because the symptoms and nystagmus pattern can change when the crystals convert from being stuck to free-floating. Novice clinicians or patients who are attempting self-treatment may be especially rattled by the sudden change in symptoms or nystagmus after the type of BPPV converts to the other type of BPPV.

The conversion of cupulolithiaisis type BPPV to canalithiasis type BPPV is ultimately helpful to the patient’s overall recovery!

However, a different treatment may be needed to resolve the BPPV after it converts to a different type of BPPV.

Canal Jam

Although canal jams are rare, they can happen. In this case, the patient will experience continuous unrelenting vertigo and eye-bouncing nystagmus after sitting up from a BPPV treatment.

In my entire career treating thousands of patients with BPPV, this has only happened twice but I can assure you that the patients were glad I was there to help.

This BPPV complication occurs when the crystals clog the canal, like a stopped-up drain. When this BPPV complication occurs, it is ideal to have a professional to assess and help relieve the canal jam.

The key point is that it is best to be assessed by a professional rather than trying to treat yourself for vertigo.