# Positional Vertigo: Hula Hoops and Other BPPV Analogies

January 29, 2023

Last week, I told a story about my difficulty in getting a patient to understand the role of meclizine in the treatment of Benign Paroxysmal Positional Vertigo (BPPV). It got me thinking about some of the analogies we use to describe certain concepts about BPPV that may be more relatable to a patient than trying to help them understand things like “free floating otoconia.”

## Describing BPPV – Hula Hoop Analogy

When describing posterior canal BPPV and Canalith Repositioning (CRP), I often use the analogy of a hula hoop (the posterior canal) with some sand (the loose otoconia) inside, only this hula hoop has a plug somewhere (the cupula).

I describe CRP as rotating the hula hoop, using gravity to move the sand away from the plug, towards the opening in the hula hoop (the opening to the vestibule) where the sand somehow got in. If I can get the sand to the opening, the sand will come out and the BPPV will be gone.

Particularly when discussing horizontal canal BPPV, I explain that the sand in the hula hoop may not move very much when it is moved side to side (like shaking the head “NO”). But when you tilt the hula hoop vertically on its side (as when you are supine) gravity is introduced into the equation and the sand shifts every time you roll your head side to side.

## BPPV: Snow Globe Analogy

Another analogy we use frequently is the snow globe. Several concepts regarding BPPV can be explained with this example. When explaining why people get BPPV, we describe otoconia debris (now as snow flakes instead of sand) coming loose from the utricle. If the globe is upright, the snow will settle on the little village, or Santa’a feet, or whatever. If you lay the snow globe on its side, the snow won’t settle on the village, but will go wherever gravity takes it.

In other words, if the otoconia debris comes loose and settles while the person is upright, it will settle in the vestibule, only to be asymptomatically absorbed. But if the otoconia debris comes loose, and the patient lies down, the debris may find its way into a semicircular canal.

We also use this to describe fatigue. If you keep shaking the snow globe, it will keep snowing and the debris won’t settle anywhere.

If any readers have an analogy that they have found to be helpful, please share it with us.