What are the symptoms associated with horizontal canal Benign Paroxysmal Positional Vertigo (BPPV)?

From the Guidelines

Horizontal canal benign paroxysmal positional vertigo (HC-BPPV) is characterized by brief episodes of intense vertigo triggered by specific head movements, often accompanied by nausea, vomiting, and direction-changing nystagmus. The symptoms of HC-BPPV can be distinct from other forms of BPPV, with patients experiencing vertigo that is often more intense and may last longer, sometimes up to a minute 1. Some key features of HC-BPPV include:

• Brief episodes of intense vertigo triggered by specific head movements, such as turning the head from side to side while lying down or rolling over in bed
• Nausea and vomiting frequently accompanying these episodes due to the severity of the vertigo
• Direction-changing nystagmus, which changes direction based on head position, typically beating toward the ground in geotropic HC-BPPV or away from the ground in apogeotropic HC-BPPV
• A sense of imbalance between vertigo episodes, with patients possibly adopting behaviors to avoid triggering positions These symptoms occur because free-floating debris (otoconia) in the horizontal semicircular canal of the inner ear move when the head position changes, causing abnormal fluid movement that disrupts the balance system and creates the sensation of spinning 1. The diagnosis of HC-BPPV can be made using the supine roll test, which is the preferred maneuver to diagnose lateral canal BPPV 1. The supine roll test is performed by initially positioning the patient supine with the head in neutral position, followed by quickly rotating the head 90 degrees to one side, with the clinician observing the patient’s eyes for nystagmus. This test can help identify the affected ear and determine the type of HC-BPPV, either geotropic or apogeotropic 1. It is essential to note that the symptoms and diagnosis of HC-BPPV are based on the most recent and highest-quality study available, which provides the best evidence for guiding clinical practice 1.

From the Research

Symptoms of Horizontal Canal BPPV

The symptoms associated with horizontal canal Benign Paroxysmal Positional Vertigo (BPPV) include:

• Recurrent brief episodes of positional vertigo 2
• Paroxysmal bursts of horizontal positional nystagmus 2
• Lack of any other identifiable central nervous system disorder to explain the nystagmus 2
• Horizontal geotropic direction-changing positional nystagmus, observed in 19 of 24 patients in one study 2
• Ageotropic nystagmus, observed in some patients 2
• Symptom description alone is not sufficient to distinguish among canal types of BPPV 2

Diagnosis and Characteristics

The diagnosis of horizontal canal BPPV can be established through:

• Clinical history along with diagnostic maneuvers 3
• Supine roll test for the horizontal canal 3
• Dix-Hallpike positioning and supine lateral head turns to each side 2
• Paroxysmal positional horizontal nystagmus that changes direction with changes in head position strongly suggests the diagnosis 2
• The direction of nystagmus, the type of maneuver that evoked the nystagmus, and the response to canalith repositioning can help distinguish horizontal from posterior canal BPPV 2

Treatment and Outcomes

Treatment options for horizontal canal BPPV include:

• Canalith repositioning maneuvers, such as the Gufoni maneuver and the barbecue 360° maneuver 4
• Cupulolithiasis patients may be asked to sleep in a forced prolonged position 4
• Treatment outcomes vary, with one study reporting a complete resolution of vertigo and nystagmus in 30 patients (81.0%) on the initial visit 4
• Another study found that symptoms subsided immediately in 819 patients (85%) by the first canalith repositioning procedure 5