ORIGINAL ARTICLE

DOI: 10.5935/0946-5448.20130003
International Tinnitus Journal. 2013;18(1):16-19.

Benign paroxysmal positional vertigo and tinnitus

Stefania Barozzi1
Marina Socci1
Daniela Ginocchio1
Eliana Filipponi2
Maria Grazia Troja Martinazzoli1
Antonio Cesarani1

Abstract
Introduction: In our clinical experience, some of the patients affected by benign paroxysmal positional vertigo (BPPV)
reported the onset of tinnitus shortly before or in association with the positional vertigo. Objectives: The aim of this
study was to describe the prevalence and the clinical patterns of tinnitus episodes which occurred in association with
BPPV and to suggest possible interpretative hypotheses. Methods: 171 normal hearing patients affected by BPPV
(50 males and 122 females; age range: 25-77 years; mean age 60.3 years 14.9) underwent pure tone audiometry, immittance test and a clinical vestibular evaluation before and after repositioning manoeuvers. Those suffering
from tinnitus were also assessed using visual analogue scales and tinnitus handicap inventory. Results: 19.3% of
the patients reported the appearance of tinnitus concurrently with the onset of the positional vertigo. It was mostly
unilateral, localized on the same ear as the BPPV, slight in intensity and intermittent. Tinnitus disappeared or decreased
in all patients except two, either spontaneously, before performing the therapeutic manoeuvers, or shortly after.
Conclusions: A possible vestibular origin of tinnitus determined by the detachment of macular debris into the ductus
reuniens and cochlear duct is discussed.
Keywords: tinnitus, vertigo, vestibular diseases.

Audiology Unit, Department of Clinical Sciences and Community Health, Universit degli Studi di Milano; Fondazione IRCCS Ca Granda, Ospedale Maggiore
Policlinico. E-mail: [email protected]. E-mail: [email protected]. E-mail: [email protected]. E-mail: [email protected].
E-mail: [email protected]
2
Rehabilitative area, SITRA, Fondazione IRCCS Ca Granda, - Ospedale Maggiore Policlinico. E-mail: [email protected]
Institution: Audiology Unit, Department of Clinical Sciences and Community Health, Universit degli Studi di Milano; Fondazione IRCCS Ca Granda, Ospedale
Maggiore Policlinico, via Sforza, 35 - 20122 Milano, Italy.
Send correspondence to:
Stefania Barozzi.
Audiology Unit, Department of Clinical Sciences and Community Health, Universit degli Studi di Milano; Fondazione IRCCS Ca Granda, Ospedale Maggiore
Policlinico, Via Pace, 9 - 20122 Milano, Italy. E-mail: [email protected]
Paper submitted to the ITJ-SGP (Publishing Management System) on September 9, 2013;
and accepted on January 23, 2014. cod. 140
1

International Tinnitus Journal, Vol. 18, No 1 (2013)

www.tinnitusjournal.com

16

BPPV, 24 (14%) lateral canal BPPV, 9 (5%) multiple canal

BPPV and 2 (1.1%) anterior canal BPPV.
The exclusion criteria were: external or middle ear
diseases, temporomandibular joint dysfunctions, a pure
tone threshold at 0.5, 1.0 and 2.0 kHz (PTA) > 25 dB
HL, BPPV resistant to three repositioning manoeuvers.
The patients were divided into two groups: Group
1 included subjects who did not suffer from tinnitus or
who had been suffering from tinnitus for at least one
month before the onset of BPPV; Group 2 consisted of
subjects whose tinnitus had appeared in association with
BPPV or during the previous month.
All of the patients underwent an audiovestibular
evaluation including:
Detailed history with special attention to tinnitus.
Tinnitus subjects belonging to Group 2 were also
assessed using Visual Analogue Scales (VAS)
from 1 to 10 (in terms of volume and disturbance),
and the Italian version of the Tinnitus Handicap
Inventory (THI)11.
Otoscopic examination in order to exclude possible
external ear and tympanic membrane pathologies.
P u r e - t o n e a u d i o m e t r y p e r f o r m e d i n a
sound-attenuated booth using an Amplaid 309
audiometer (Amplifon, Italy) and calibrated earphones (TDH 49). Pure-tone thresholds were measured in each ear separately at the frequencies
of 0.25-8 kHz for air conduction and 0.25-4 kHz
for bone conduction. Patients with a PTA > 25 dB
were excluded from this study.
Tympanometry and measurement of acoustic
reflex in order to study middle ear function using the
Amplaid A766 Middle Ear Analyzer (Amplifon, Italy)
with a 226-Hz probe. The tympanograms were classified as type A (normal middle ear pressure), type B
(flat curve), type C (negative peak pressure). In patients with type A tympanograms, we determined the
contralateral acoustic reflex using pure-tone signals
at 0.5-4 kHz. Patients with middle ear dysfunctions
defined by tympanograms other than type A and/or
absence of acoustic reflex were excluded.
Clinical vestibular examination, including
Dix-Hallpike manoeuver and supine roll test.
After diagnosing BPPV, all of the patients were
treated with 1-3 repositioning manoeuvers: Semont
or Epley manoeuvers for posterior canal BPPV and
barbecue manoeuver for lateral canal BPPV.
Seven days after each manoeuver, patients were
retested to verify the disappearance of both vertigo and
paroxysmal nystagmus. If the manoeuver had been
successful, Group 1 patients were asked if they had
noticed the appearance of tinnitus and Group 2 patients
were asked if their tinnitus had changed; if the tinnitus
was still present, they repeated VAS and THI.

INTRODUCTION
Benign paroxysmal positional vertigo (BPPV)
is the most common vestibular disorder in adults,
affecting between 17% and 42% of patients complaining of vertigo1. BPPV is defined by repeated episodes of
acute, short, paroxysmal vertigo, provoked by changes in
head position relative to gravity. The most common clinical variant is the posterior canal BPPV, which accounts for
approximately 85% to 95% of cases1. Lateral (horizontal)
canal BPPV accounts for between 5% and 15% of cases2.
Other rare forms of BPPV include anterior canal BPPV
and multiple canal PPV. Although debated, the most
widely accepted pathophysiological hypothesis is the
presence of abnormal debris (thought to be fragmented
otolithic particles) upon the cupola (cupololithiasis)3 or
within the semicircular canals (canal lithiasis)4. Diagnosis
is made using Dix Hallpike manoeuver5 for posterior canal
BPPV and the supine roll test6 for the lateral canal BPPV,
both of which provoke vertigo associated with the typical paroxysmal nystagmus. BPPV is treated with particle
repositioning manoeuvers (Semont manoeuver, Epley
manoeuver, barbecue roll manoeuver)7-9 which have the
purpose of moving the particles back into the utricle; in
the vast majority of cases, the patients recovered after
a few sessions.
In our clinical experience, some of the patients
affected by BPPV reported the onset of tinnitus shortly
before or in association with the positional vertigo.
Such tinnitus often decreased or disappeared after the
therapeutic manoeuvers; tinnitus rarely appeared immediately after the manoeuvers. In literature, only one
study performed by Gavalas et al.10 describes tinnitus of
vestibular origin. The authors observed that this tinnitus
disappeared immediately after the Semont and Epley
manoeuvers in some patients and attributed this to a
reduction in autonomic activity.
The aim of this study was to describe the
prevalence and the clinical patterns of tinnitus episodes
which occurred in association with BPPV and to suggest
possible pathophysiological mechanisms.

METHODS
A total of 171 normal hearing patients affected
by BPPV, 50 males and 122 females, of an age ranging
from 25 to 77 years (mean age 60.3 years 14.9) were
enrolled in this study. BPPV had been diagnosed according to the criteria proposed by the American Academy of
Otolaryngology - Head and Neck Surgery (2008) when
the patients reported a history of repeated episodes of
vertigo provoked by changes in head position relative
to gravity and when, upon physical examination, characteristic nystagmus was provoked by the positioning
manoeuvers. 136 patients (79.5%) had posterior canal

International Tinnitus Journal, Vol. 18, No 1 (2013)

www.tinnitusjournal.com

17

Gavalas et al.10 observed that, in some patients, tinnitus associated with recent vestibular symptomatology,
was reduced after Semont and Epley exercises. How it is
possible to explain the presence of tinnitus in BVPP and/
or its disappearance through rehabilitative procedures?
There are three possible pathophysiological hypotheses.
The existence of anatomical connections between
the vestibular and cochlear systems could justify the
involvement of the auditory pathways secondary to a
labyrinth stimulus and the occurrence of tinnitus in BPPV
patients. Nervous connections between the two systems
have been described in the internal auditory canal, at
the nuclear level and also in the auditory cortex12-14. The
existence of these neural fibre connections explains the
persistence of tinnitus after cochlear neurectomy performed for intractable tinnitus or the modification of some
kind of tinnitus through caloric vestibular stimulation. It
is unlikely, however, that this could justify the tinnitus of
patients in which it does not coincide in time with the
positioning manoeuvers.
According to the model of Jastreboff, tinnitus may
be caused by the interaction between the vestibular and
the limbic systems. In fact, the vertiginous symptoms
can be so acute and intense as to induce emotional
responses such as fear and terror of provoking the vertigo through the movements. The disappearance of the
tinnitus could be due to the relief they experience when
symptoms resolve. According to Gavalas et al.10, it is
exactly this reduction in autonomic activity that could
mediate the decrease of tinnitus after repositioning
manoeuvers. However, this theory does not explain the
appearance of tinnitus before the onset of positional
vertigo as experienced by some of our patients.
The third hypothesis considers changes in the
hydrodynamics of the inner ear fluids. There are two main
theories concerning the secretion and absorption of endolymph in the membranous labyrinth. In the longitudinal
flow theory14, the endolymph of the cochlea is produced
in the scala media and normally flows through the ductus
reuniens, the saccule and the endolymphatic duct where it
is reabsorbed; in the vestibular system, on the other hand,
there is a flow of endolymph from the utricle and semicircular canals towards the endolymphatic sac. According
to the theory of radial flow, the endolymph is produced
and absorbed locally in the scala media and utricle (there

RESULTS
Of the 171 BPPV patients, 138 (80.7%) belonged
to Group 1 and 33 (19.3%) to Group 2.
For each group, age and gender of the patients,
type (semicircular canal involved) and side of BPPV are
reported in Table 1.
Group 2 patients described tinnitus as: ringing/
ticking (9 patients), buzzing (6), hissing (5), creaking (5),
blowing (3), like the sea (3) and pounding (2). Tinnitus
was intermittent in 25 (75.8%) patients, with a duration of
few seconds/minutes and continuous in 8 (24.2%). Tinnitus was unilateral and localized in the same ear as BPPV
in 75.8% (25) of the patients, and in the contralateral ear
in 18.2% (6). Two patients complained of bilateral tinnitus.
Tinnitus was modified by changes of head position in
30.3% (10) of the patients.
The intensity of tinnitus, as shown by the VAS scale
was < 5 in 28 (84.8%) patients and > 5 in 5 (15.2%)
patients. The mean THI score was: 25.2 7.2.
In 24.2% (8) of the patients, the tinnitus, which
had originated in association with BPPV, had already
disappeared spontaneously before the therapeutic
manoeuvers were performed. At the control visit, after
a successful manoeuver, tinnitus had disappeared in
another 48.5% (24) of the patients. In 18.2% (6) it had
decreased in intensity and duration; only in 2 patients
did it remain unchanged.
In 2 patients belonging to Group 1, a transitory
tinnitus appeared after the repositioning manoeuvers,
but resolved spontaneously in a few days.

DISCUSSION
As far as we know, this is one of the few studies
dealing with tinnitus in BPPV.
In our experience, 19.3% of the patients affected by BPPV reported the appearance of tinnitus in
association with the onset of positional vertigo. It was
mostly unilateral and localized in the same ear as the
BPPV, slight in intensity and intermittent. In about one
third of the subjects it was modified by changes of
head position. Tinnitus disappeared or decreased in
all patients except two, either spontaneously, before
performing the therapeutic manoeuvers, or immediately
after them. Conversely, the manoeuvers provoked temporary tinnitus in 2 patients.

Table 1. Descriptive statistics for Group 1 and Group 2 patients. Age, gender, type (semicircular canal involved) and side of BPPV
are reported.
N.

Age (years)
(Min/Max/Med)

Gender
(males/females)

Semicircular Canal
Post/Lat/Ant/Multi

Side
(right/left/bilat.)

Group 1

138 (80,7%)

25 77 59.3

43 95

113 18 0 7

68 63 7

Group 2

33 (19.3%)

39 77 59.9

7 26

23 6 2 2

17 14 2

Inclusion criteria required that all of the patients had normal hearing sensitivity.

International Tinnitus Journal, Vol. 18, No 1 (2013)

www.tinnitusjournal.com

18

are no secretory cells - dark cells - in the saccule)15 In both

cases, it seems unlikely that debris upon the cupola or
within the semicircular canals in BPPV can cause an acute
modification of the cochlear endolymphatic pressure. It is
possible, however, according to the theory of radial flow,
that otoliths or saccular macular debris may slide through
the ductus reuniens into the cochlear canal. Gussen16
reported that the atrophy of the saccular macula in humans
causes an accumulation of otolith debris within the ductus
reuniens and cochlear duct. According to this theory, just
as the detachment of debris from the utricle into the semicircular canals determines vertiginous episodes in BPPV,
the detachment of macular debris from the saccule into the
ductus reuniens and cochlear duct might result in tinnitus.
This theory would also explain why some kind of tinnitus
in patients affected by recurrent BPPV can disappear with
liberatory manoeuvers also during periods of remission
from vertiginous symptoms.
In our study, the ear affected by tinnitus corresponds
in most cases to the side of BPPV; this could be helpful
to the physician before performing repositioning manoeuvers when the side of BPPV is uncertain, as in some
cases of lateral canal BPPV.

3. Schuknecht HF. Cupulolithiasis. Arch Otolaryngol. 1969;90(6):76578. DOI: http://dx.doi.org/10.1001/archotol.1969.00770030767020

4. Parnes LS, McClure JA. Free-floating endolymph particles: a new
operative finding during posterior semicircular canal occlusion.
Laryngoscope. 1992;102(9):988-92. PMID: 1518363
5. Dix MR, Hallpike CS. The pathology symptomatology and diagnosis
of certain common disorders of the vestibular system. Proc R Soc
Med. 1952;45(6):341-54. PMID: 14941845
6. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003;169(7):68193. PMID: 14517129
7. Semont A, Freyss G, Vitte E. Curing the BPPV with a liberatory
maneuver. Adv Otorhinolaryngol. 1988;42:290-3. PMID: 3213745
8. Epley JM. The canalith repositioning procedure: for treatment of
benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg.
1992;107(3):399-404. PMID: 1408225
9. Lempert T, Tiel-Wilck K. A positional maneuver for treatment
of horizontal-canal benign positional vertigo. Laryngoscope. 1996;106(4):476-8. PMID: 8614224 DOI: http://dx.doi.
org/10.1097/00005537-199604000-00015
10. Gavalas GJ, Passou EM, Vathilakis JM. Tinnitus of vestibular
origin. Scand Audiol Suppl. 2001;(52):185-6. DOI: http://dx.doi.
org/10.1080/010503901300007470
11. Monzani D, Genovese E, Marrara A, Gherpelli C, Pingani L, Forghieri
M, et al. Validity of the Italian adaptation of the Tinnitus Handicap
Inventory; focus on quality of life and psychological distress in
tinnitus-sufferers. Acta Otorhinolaryngol Ital. 2008;28(3):126-34.
12. Ozdomu O, Sezen O, Kubilay U, Saka E, Duman U, San T, et
al. Connections between the facial, vestibular and cochlear nerve
bundles within the internal auditory canal. J Anat. 2004;205(1):6575. DOI: http://dx.doi.org/10.1111/j.0021-8782.2004.00313.x
13. Fredrickson JM, Scheid P, Figge U, Kornhuber HH. Vestibular nerve
projection to the cerebral cortex of the rhesus monkey. Exp Brain
Res. 1966;2(4):318-27. DOI: http://dx.doi.org/10.1007/BF00234777
14. Odkvist LM, Rubin AM, Schwarz DW, Fredrickson JM. Vestibular
and auditory cortical projection in the guinea pig (Cavia porcellus).
Exp Brain Res. 1973;18(3):279-86. DOI: http://dx.doi.org/10.1007/
BF00234598
15. Kimura RS. Distribution, structure, and function of dark cells in the
vestibular labyrinth. Ann Otol Rhinol Laryngol. 1969;78(3):542-61.
16. Gussen R. Saccule otoconia displacement into cochlea in cochleosaccular degeneration. Arch Otolaryngol.
1980;106(3):161-6. PMID: 7356437 DOI: http://dx.doi.org/10.1001/
archotol.1980.00790270025006

CONCLUSIONS
In some patients with BPPV, a characteristic tinnitus may appear, mostly slight, intermittent and localized
in the same ear affected by BPPV; it often regresses
either spontaneously or after repositioning manoeuvers.

REFERENCES
1. Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass
S, et al.; American Academy of Otolaryngology-Head and Neck
Surgery Foundation. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008;139(5
Suppl 4):S47-81. PMID: 18973840 DOI: http://dx.doi.org/10.1016/j.
otohns.2008.08.022
2. Cakir BO, Ercan I, Cakir ZA, Civelek S, Sayin I, Turgut S.
What is the true incidence of horizontal semicircular canal benign paroxysmal positional vertigo? Otolaryngol Head Neck
Surg. 2006;134(3):451-4. PMID: 16500443 DOI: http://dx.doi.
org/10.1016/j.otohns.2005.07.045

International Tinnitus Journal, Vol. 18, No 1 (2013)

www.tinnitusjournal.com

19