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Journal of Vestibular Research 22 (2012) 197203


DOI 10.3233/VES-2012-0457
IOS Press

Benign paroxysmal positional vertigo and


head position during sleep
Kohichiro Shigenoa,, Hideaki Ogitab and Kazuo Funabikic
a

Shigeno Otolaryngology Vertigo-Hearing Impairment Clinic, Nagasaki, Japan


Department of Otolaryngology, Kyoto Teishin Hospital, Kyoto, Japan
c
Systems Biology, Osaka Bioscience Institute, Osaka, Japan
b

Received 8 March 2011


Accepted 10 July 2012

Abstract. To determine whether any particular head positions during sleep are associated with BPPV, head position during sleep
was monitored for 3 days in 50 BPPV patients after the disappearance of positional nystagmus and in 25 normal control subjects.
A gravity sensor was attached to the center of the subjects forehead at home. The positional angle of the head was measured at
5-second intervals during sleep. In BPPV, the posterior semicircular canal was involved in 40 patients and the lateral semicircular
canal in 10 patients. Recurrence was found in 22 of 50 BPPV patients. BPPV patients with recurrence were significantly more
likely to sleep in the affected-ear-down 45-degree head position than were patients with no history of recurrence (P < 0.02).
When the head is in the affected-ear-down 45-degree head position, the non-ampullated half of the posterior semicircular canal
and the non-ampullated half of the lateral semicircular canal are nearly in the earth-vertical position, making it easier for detached
otoconia to fall into the posterior or lateral semicircular canal and to agglomerate and attain a certain size in the lowest portion
of each semicircular canal. Our findings showed that the affected-ear-down 45-degree head position during sleep could be an
etiological factor of BPPV, more particularly in patients with recurrent BPPV.
Keywords: Benign paroxysmal positional vertigo, recurrence, head positions, sleep

1. Introduction
Aging, head trauma, and disorders of the inner
ear such as sudden deafness, vestibular neuritis, and
Meni`eres disease are well known etiological factors of
benign paroxysmal positional vertigo (BPPV) [1,9,13].
These factors are thought to cause otoconia to become
detached from the utricular macula. However, in many
cases the cause of BPPV is unknown. Moreover, recurrence of BPPV is common, and BPPV variants such as
posterior canal BPPV and lateral canal BPPV exist, the
reasons for which remain unknown.
Corresponding

author: Kohichiro Shigeno, M.D., Shigeno Otolaryngology Vertigo-Hearing Impairment Clinic, 1-21 Ougi-machi,
Nagasaki 852-8132, Japan. Tel.: +81 95 844 1848; Fax: +81 95 844
1846; E-mail: shigeno@ngs2.cncm.ne.jp.

BPPV sometimes occurs in mothers who have acquired the habit of sleeping in the same position every
night when putting a child to sleep [8]. Its also known
that BPPV often occurs in the morning when the individual is getting out of bed [14]. These clinical facts
suggest that something occurring during sleep may be
a cause of BPPV. A questionnaire study on habitual
head position during sleep has shown that patients suffering from BPPV have a greater tendency to sleep exclusively on one side or the other (right ear down or left
ear down) than do healthy subjects [4,6,8]. However,
there have been no actual studies monitoring the head
position during sleep of BPPV sufferers.
In the present study, gravity sensors were used to
continuously monitor head position during sleep in BPPV sufferers and in normal control subjects with no

ISSN 0957-4271/12/$27.50 2012 IOS Press and the authors. All rights reserved

198

K. Shigeno et al. / Benign paroxysmal positional vertigo and head position during sleep

history of vertigo, to determine whether any particular


head positions were associated with BPPV.

2. Methods
2.1. Diagnosis, treatment and follow-up observations
Patients visiting the clinic of the first author with a
chief complaint of vertigo were examined and BPPV
was diagnosed based on the history of positional vertigo and results of testing for positional nystagmus using
an infrared CCD camera (SN IR-1 Nagashima medical instruments. Co.Ltd.). Examinations for positional nystagmus were performed using the Dix-Hallpike
maneuver [11], as well as by the supine head rolling
procedure, in which the patients head is moved from
the supine right-ear-down position to the supine leftear-down position and vice versa. Patients exhibiting
upbeating-torsional nystagmus with the torsional component beating towards the lowermost ear in the DixHallpike position were diagnosed with posterior canal
BPPV. Patients experiencing transient horizontal nystagmus to the right ear in the supine right-ear-down
position, or to the left ear in the supine left-ear-down
position, were diagnosed as lateral canal BPPV. In patients with posterior canal BPPV, the side exhibiting
upbeating-torsional nystagmus with the torsional component beating towards the lowermost ear in the DixHallpike position was considered to be the affected
side, and in patients with lateral canal BPPV, the side
showing the strongest geotropic horizontal nystagmus
and vertigo was regarded as the affected side.
On the day of examination, patients diagnosed with
posterior canal BPPV or lateral canal BPPV were treated by means of the Epley [7] or Semont [2], or Lempert
maneuvers [16], respectively, in order to reposition the
particles causing the disturbance. Each maneuver was
performed only once on any given day. The Semont
maneuver was performed only after the Epley maneuver had been found to be ineffective, under a diagnosis
of posterior canal BPPV. As for postmaneuver restrictions, in cases of posterior canal BPPV, subjects were
advised to remain in a sitting position until they went to
bed on the day of the maneuver. Subjects with lateral
canal BPPV were advised to remain in a sitting position
until they went to bed, and were also advised to sleep
with the affected ear up [12] on the day of the maneuver. No postmaneuver restrictions were implemented
on the day following the procedure, or thereafter.

Positional nystagmus was examined the following


day, and then again every two or three days until vertigo and nystagmus had disappeared. If it persisted, the
repositioning maneuver was repeated.
BPPV patients in this study were surveyed by means
of return postcard questionnaires every 4 months for
a period of one year to check for recurrence of positional vertigo. Whenever recurrence was reported, the
patients were then encouraged to come in for retesting.
At the re-examination, the patients were asked about
the circumstances of the recurrence, the positional test
described above was administered, the presence or absence of BPPV was confirmed, and the affected side
was verified.
The diagnosis, treatment and follow-up observations
were carried out at the clinic of the first author by the
first author himself.
2.2. Subjects
2.2.1. BPPV patients
Between July 2007 and December 2008, a total of
122 patients (30 men and 92 women; average age:
64 years; age range: 2886 years) were treated for BPPV at the clinic of the first author. Of these, 50 patients
(8 men and 42 women; mean age: 63.5 years) living in
the local area were eligible for inclusion in the study.
On the day that vertigo and nystagmus disappeared,
the author explained the significance of our proposed
measurement of head position during sleep, the safety
of the procedure, and the method to be employed. All
50 participants gave written informed consent.
The age and sex distribution of these 50 subjects were
as follows: 2029 years (no males, 2 females); 30
39 years (no males, 3 females); 4049 years (1 male,
3 females); 5059 years (3 males, 2 females); 60
69 years (3 males, 11 females); 7079 years (1 male,
17 females); 8089 years (no males, 4 females).
With regard to underlying disease in BPPV, one subject had experienced head trauma (2 years prior to onset), and two suffered from Meni`eres disease, but none
had experienced sudden deafness or vestibular neuritis.
Of the 50 subjects, 31 (62%) reported that they tended to sleep with their head facing in the same direction
every night (right-ear-down, 20; left-ear down, 11).
The BPPV variants, the affected sides and sex distribution among the 50 subjects were as follows: 40 patients had posterior canal BPPV (right side, 24; left
side, 16; 6 males and 34 females) and 10 patients had
lateral canal BPPV (right side, 8; left side, 2; 2 males
and 8 females).

K. Shigeno et al. / Benign paroxysmal positional vertigo and head position during sleep

Twenty-two of the 50 subjects experienced recurrences either before or within one year after the measurement of their head position during sleep. Fourteen
patients had one recurrence, 5 had two recurrences,
1 had four recurrences, and 2 had five recurrences. Recurrence was defined as the occurrence of BPPV at least
one month after the positional vertigo and nystagmus
of the previous BPPV had disappeared. Of the 22 cases
that experienced recurrence, 13 patients had a previous
history of BPPV (mean: 18 months; range: 6 months
3 years and 10 months), and 12 patients experienced a
recurrence within one year after measurement of head
position during sleep. On the other hand, recurrence
was not observed in 15 subjects who had no previous
history of positional vertigo and who did not experience
positional vertigo within one year after measurement
of head position during sleep. Thirteen subjects were
excluded from the present analysis. Seven patients had
a previous history of positional vertigo without confirmed BPPV nystagmus. Three patients experienced
positional vertigo within one year after measurement
of head position during sleep, but without confirmed
BPPV nystagmus. Three patients could not be followed
until one year after measurement of head position during sleep.
Of these 22 cases that experienced recurrence, canal
transition between posterior canal BPPV and lateral
canal BPPV was observed in 6 cases (27%). The affected side at recurrence was unchanged in 22 subjects.
However, of the cases of suspected BPPV recurrence,
there were three cases in which the affected ear was
clearly different from that of the original BPPV. These
3 cases were not included among the 22 cases we identify as having experienced a recurrence.
The average age and sex distribution were 3 men
and 19 women, average age 53.6 years in the 22 cases
of recurrence, and 3 men and 12 women, average age
62.9 years in the 15 cases with no recurrence.
2.2.2. Healthy control subjects without a history of
vertigo
We measured head position during sleep between
January and August 2010 in 25 sex- and age-matched
healthy controls (4 men, 21 women; mean age: 62.5)
from the local area, who had no history of vertigo. We
explained the objective of our proposed measurement
of head position during sleep, the safety of the procedure, and the method to be employed. All 25 participants gave written informed consent. The age and
sex distribution among these 25 controls were as follows: 2029 years (no men, 1 woman); 3039 years

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(no men, 2 women); 4049 years (no men, 2 women);


5059 years (2 men, 1 woman); 6069 years (2 men,
5 women); 7079 years (no men, 9 women); and 80
89 years (no men, 1 woman).
Eleven (44%) of the 25 control subjects reported that
they tended to sleep with their head facing in the same
direction every night (right-ear-down: 8, left-ear-down:
3).
2.3. Measurement of head position during sleep
(Fig. 1)
A measurement device equipped with a linear acceleration sensor (KXM52 Kionix, INC, Ithaca, NY)
was fitted to the subjects to enable measurement of
gravitational force along the X (forward/backward), Y
(left/right) and Z (up/down) axes. The positional angle
of the head was measured based on the value of the
gravitational force in three axial directions. The positional angle of the head was measured at 5-second intervals during sleep. These measurements were performed
at the subjects homes in both the BPPV group and
in the healthy controls. A gravity sensor was attached
to the center of the subjects forehead using doublesided tape, and the measurement device was placed
near the pillow. The subject turned the device on (start
measurement) when going to bed, and turned it off
(end measurement) upon getting up. Measurements
were conducted on three different days, according to a
schedule convenient to the subject. The first measurement was made on average one week (mean 6.8 days
10.5 days) after confirmation of the disappearance of
positional vertigo and nystagmus, while the final measurement was made on average two weeks after that
time (mean 13.8 days 15.6 days). If the subject got
up during the night, measurement ceased at that point.
Data for each day were collected, and the device was
checked to ensure that it was functioning properly.
Among BPPV patients, data were successfully acquired on only one day in 9 subjects, on two days
in 7 subjects, and on all three days in 34 subjects.
The average length of measurement period per day
was 5.6 hours, and the total measurement period over
the three days averaged 13.9 hours (range: 1.4 hours
25.7 hours).
Among the healthy subjects with no history of vertigo, measurements were obtained on only 2 days in
2 subjects, but on all 3 days in the remaining 23 subjects. Over the entire 3 days, the average length of measurement period per day was 5.2 hours, and total measurement time in the healthy volunteer group averaged
15.0 hours (range: 8.5 hours23.8 hours).

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K. Shigeno et al. / Benign paroxysmal positional vertigo and head position during sleep

Fig. 1. Measurement device and measurement of head position during sleep. (a) Tri-Axis accelerometer (KXM52 Kionix, INC, Ithaca, NY) is
attached to the foreheads of subjects. The measurement range of the tri-axis accelerometer is 2 g. (b) PIC-Data logger (Akizuki Denshi, Tokyo,
Japan) stores voltage data in ten bits (01023). Data are stored every 5 seconds with time data. In this study we stored tri-axis data (X, Y and Z).
This PIC-Data logger can store 131072 data, so it can store data for 60.7 hours (131072 5 / 3 seconds). (c) The value when the accelerometer
is neutral is 511. When the accelerometer is turned to the right, the value of C6 increases. And when it is turned to the left, the value of C6
decreases. PIC-Data logger is connected to Windows PC and data are transferred to the PC. Data are analyzed with Excel Macro.

2.4. Analysis of head position data


We focused our analysis particularly on movement
of head position during sleep around the Z (up/down)
axis. The head positions were divided into 15 degree
increments with the face-up supine position assigned
the value of zero (0 degree = 7.5 degrees7.5 degrees,
15 degree = 7.5 degrees22.5 degrees, and so on).
Head positions held for 5 seconds were included in the
frequency count for that position. Frequency distributions for each day of measurement were calculated for
these head positions. Finally, we calculated the relative
frequencies of each head position for all measurement
days taken together (day 1day 3). The measurement
devices and software for data analysis were constructed
by one of the authors (Ogita). Final evaluation of the
analysis was performed by Ogita, Shigeno and Funabiki.
The Mann-Whitney test (Statmate III, ATMS Co.
Ltd.) was used to calculate the significance of differences in the frequencies of various head positions.
Differences of 5% or more were considered significant.
3. Results
We focused on the affected-ear-down 45-degree
(37.5 degrees52.5 degrees) and healthy-ear-down 45degree (37.5 degrees52.5 degrees) head positions.

3.1. Is there any difference in head position during


sleep between BPPV patients and healthy
controls without vertigo?
We compared the relative frequencies of each head
position during sleep between right-sided BPPV and
healthy controls, and left-sided BPPV and healthy controls. We focused particularly on the right-ear-down 45degree and left-ear-down 45-degree head positions, but
observed no significant difference between the BPPV
group and healthy controls. Neither were any significant differences observed among any other head positions during sleep.
3.2. Do BPPV patients tend to sleep on their affected
side, or on their healthy side?
We compared the relative frequencies of sleeping
on the affected versus the healthy side in the posterior
canal BPPV and lateral canal BPPV groups. There was
no significant difference in the relative frequencies of
affected- and healthy-ear-down head position in the
posterior canal BPPV and lateral canal BPPV groups.
However, in the posterior canal BPPV group, patients
were more likely to sleep in the healthy-ear-down 45degree position than in the affected-ear-down 45-degree
position, although the difference was not significant

K. Shigeno et al. / Benign paroxysmal positional vertigo and head position during sleep

Fig. 2. Head position during sleep in BPPV with or without recurrence. The relative frequencies of the healthy-ear-down 45-degree
head position and affected-ear-down 45-degree head position during
sleep in BPPV patients with or without recurrence are shown. The
top of each box indicates the 75th percentile, the horizontal band inside the box is the median value, and the bottom of the box indicates
the 25th percentile. The ends of the whiskers indicate minima and
maxima. Open cycles represent the mild outlier.

(P = 0.051). No significant differences were observed


among any other head positions during sleep.
3.3. Is there any difference in head position during
sleep between BPPV with recurrence as opposed
to BPPV without recurrence?
We compared the relative frequencies of different
head positions during sleep between BPPV patients
with or without recurrence. Our results showed that
BPPV patients with recurrence were significantly more
likely to sleep in the affected-ear-down 45-degree position than were patients with no history of recurrence
(P < 0.02). There was no significant difference between BPPV patients with and those without recurrence in the relative frequency of the healthy-ear-down
45-degree position (Fig. 2). No significant differences
were observed among any other head positions.
4. Discussion
Head position during sleep is associated with BPPV,
particularly recurrent BPPV.
BPPV is thought to occur as the result of otoconia becoming detached from the utricular macula and moving
from the non-ampullated end of the semicircular canal

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into the semicircular canal. Otoconia moving freely in


the canal are thought to cause canalolithiasis, while
those that attach to the cupula are considered to cause
cupulolithiasis.
The diagram in Fig. 3, adapted from the 3D model of Wang et al. [5], illustrates the relationship between the utricular macula, the common crus, the nonampullated half of the lateral semicircular canal, the
non-ampullated half of the posterior semicircular canal,
and head position during sleep (right-ear-down 45degree head position, face-up supine head position,leftear-down 45-degree head position), in cases where the
right ear is affected.
In the healthy-ear-down (a) or face-up supine head
position (b), detached otoconia are expected to be located on the side opposite the ampulla of the lateral
semicircular canal, in the lateral portion of the utricle.
When the head is in the affected-ear-down 45-degree
head position (c), (d), the non-ampullated half of the
posterior semicircular canal and the non-ampullated
half of the lateral semicircular canal are nearly in the
earth-vertical position, making it easier for detached
otoconia to fall into the posterior or lateral semicircular
canal and to agglomerate and attain a certain size in the
lowest portion of each semicircular canal [10]. Otoconia detached from the nearly vertical utricular macula
pass the common crus and, following along the posterior canal wall, they are easily able to enter the posterior semicircular canal (solid arrows). This may explain
why posterior canal BPPV is the most common type
of BPPV. If the head is elevated, it may become easier for the detached otoconia to enter the lateral semicircular canal (dashed arrows). When using the Epley
maneuver in cases of posterior canal BPPV to shift the
otoconial particles from the semicircular canal back to
the utricle, healthy-ear-down 135 degrees is the key
head position, and this is 180 degrees opposite of the
affected-ear-down 45-degree head position.
On the other hand, when shifting from the affectedear-down 45-degree head position to the face-up supine
head position (d), (b), (a), and then to the healthyear-down 45-degree head position, the angle of incline
of the non-ampullated half of the posterior and lateral semicircular canals is reduced, and in the healthyear-down 45-degree head position, the non-ampullated
half of the posterior and lateral semicircular canals are
in a horizontal orientation, making it difficult for the
detached otoconia to enter the semicircular canal.
BPPV is reported to recur in around 50% of cases,
and most recurrences are within one year after initial
onset [15]. The affected-ear-down 45-degree head po-

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K. Shigeno et al. / Benign paroxysmal positional vertigo and head position during sleep
(a)

(b)

Healthy-ear-down
45-degree
Head Position U

Face-up
Supine
Head Position

L
P

P
Right-sided BPPV

(c)
Affected-ear-down
45-degree
Head Position

(d)

Affected-ear-down
45-degree
Head Position

C
P

(view from
the right side)

(view from
above the head)

Fig. 3. Characteristics of the affected-ear-down 45-degree head position, face-up supine head position, healthy-ear-down 45-degree head position
(Right-sided BPPV). Schematic illustration, adopted from the 3D model of Wang et al. [5], showing the relationship between head position, the
utriclular macula (U), the common crus (C), the non-ampullated half of the lateral semicircular canal (L) and the non-ampullated half of the
posterior semicircular canals (P). The anterior semicircular canal is not shown. Schematic illustrations (c) and (d) show two perpendicular views
of the affected-ear-down 45-degree head position, one from the right side, and the other from directly above the top of the head.

sition allows otoconial particles to freely fall into the


posterior or lateral semicircular canal and to agglomerate and attain a certain size in the lowest portion of
each semicircular canal, and our findings showed that
patients with recurrent BPPV tended to habitually sleep
in that position.
However, in the posterior canal BPPV group, patients were more likely to sleep in the healthy-ear-down
45-degree head position than in the affected-ear-down
45-degree head position, although the difference was
not significant. Most of the measurements of head position during sleep in the present study took place at a
relatively early stage (on average 2 weeks) after the disappearance of positional nystagmus or vertigo. Head
position during sleep may well be easily influenced by
psychological or physiological factors. It is possible
that patients who have recovered from posterior canal
BPPV may have either consciously or unconsciously
avoided the affected-ear-down 45-degree head position,
and may have chosen instead to sleep in the healthyear-down 45-degree head position. Patients with posterior canal BPPV subjectively noted that vertigo occurred when they slept in the affected ear down position, so they may have avoided sleeping with the affected ear down. In contrast, patients with lateral canal
BPPV experienced vertigo when turning over in their
sleep regardless of which ear had been down, so there

may be no difference between the affected and healthy


side in these patients.
Our results indicated a relation between recurrent
BPPV and head position during sleep, although no relation was observed between head position during sleep
and all BPPV. It appears, however, that the affectedear-down 45-degree head position during sleep could
be an etiological factor of BPPV. We cannot deny the
possibility that all BPPV patients, not only recurrent
patients, had slept in the affected ear-down 45-degree
head position prior to onset of BPPV. In patients with
recurrent BPPV, if we adjust sleep times to a 7-hour period, the actual time spent in the affected-ear-down 45degree head position was only 30 minutes each night
(median value; range: 2 1/2 hours1 minute). Just as a
single Epley maneuver can cause BPPV to resolve, it is
also possible that simply rolling over onto the affectedear-down 45-degree head position even once during
sleep could precipitate BPPV.
To prevent recurrence of BPPV, is it necessary to
avoid sleeping with the affected ear down for an extended period? The effectiveness of postmaneuver restrictions in BPPV is controversial. In an effort to maintain the effect produced by the repositioning maneuver,
postmaneuver restrictions such as the use of a neck collar, or instructions to avoid sleeping with the affected
ear down for a period of 7 days, have been tried, but no
clear results were obtained [3]. For practical purposes,

K. Shigeno et al. / Benign paroxysmal positional vertigo and head position during sleep

it is considered impossible to force BPPV patients to


avoid sleeping with the affected ear down every day.
The question of what type of head position during sleep
or at the end of sleep is most useful in preventing recurrence on BPPV requires further study.
We did not find any relation between the posterior
canal and lateral canal BPPV variants and head position
during sleep. Recurrence of BPPV often involves a
transition to a different variant (27%). This suggests
that transition to a different variant could be caused by
a very slight difference in sleeping head angle in the
affected-ear-down 45-degree head position.
Acknowledgments
We would like to thank Prof. Haruo Takahashi (Department of Otorhinolaryngology,Nagasaki University,
Nagasaki, Japan) for his scientific comments and Prof.
Sumihisa Honda, Ph.D., statistician (Graduate School
of International Health Development, Nagasaki University, Nagasaki, Japan) for his help in performing the
statistical analysis.
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