What is the treatment for lateral canal Benign Paroxysmal Positional Vertigo (BPPV)?

Treatment of Lateral Canal Benign Paroxysmal Positional Vertigo (BPPV)

For lateral canal BPPV, the Gufoni maneuver is the most effective treatment with success rates up to 93% for geotropic variants and 71% for apogeotropic variants. 1, 2

Diagnosis and Classification

Before treatment, proper diagnosis and classification are essential:

1. Confirm lateral canal BPPV using the supine roll test (head turned 90° to each side while supine)
2. Determine the variant:
   • Geotropic variant: Stronger nystagmus when affected ear is down
   • Apogeotropic variant: Stronger nystagmus when unaffected ear is down

Treatment Algorithm by Variant Type

For Geotropic Lateral Canal BPPV:

1. First-line treatment: Gufoni maneuver (93% success rate) 1

   • Step 1: Patient sits upright, then quickly lies on the unaffected side for 30 seconds
   • Step 2: Head is quickly turned 45°-60° toward the ground, held for 1-2 minutes
   • Step 3: Patient sits up with head tilted toward the unaffected shoulder until fully upright

2. Alternative: Barbecue Roll/Lempert Maneuver (81% success rate) 1, 2

   • Step 1: Start from supine position (some recommend starting on the affected side)
   • Step 2: Roll head (or full body) to the unaffected side
   • Step 3: Continue rolling until head is completely prone (nose down)
   • Step 4: Complete the roll to return to starting position
   • Each position is held for 15-30 seconds or until nystagmus stops

For Apogeotropic Lateral Canal BPPV:

1. First-line treatment: Gufoni-Appiani maneuver (71.4% success rate) 1, 2

   • Step 1: Patient sits upright, then quickly lies on the affected side for 30 seconds
   • Step 2: Head is quickly turned 45°-60° toward the ground, held for 1-2 minutes
   • Step 3: Patient sits up with head tilted toward the unaffected shoulder until fully upright

2. Alternative approaches (if Gufoni is unsuccessful):

   • Barbecue roll (33.3% success rate) 2
   • Forced prolonged positioning: Lying in bed for at least 12 hours with head turned toward the unaffected ear 1

Treatment Considerations

• Multiple maneuvers may be needed: Success rates increase from 47.9% after one maneuver to 75% after multiple maneuvers in a single visit, and 93.8% after one week of follow-up 2

• Factors associated with persistent symptoms:

  • Older age
  • Left-sided involvement
  • Apogeotropic variant
  • Longer latency and duration of diagnostic nystagmus 2

• Canal conversion: About 14.6% of lateral canal BPPV cases may convert to posterior canal BPPV during treatment, requiring Epley or Semont maneuvers 3

• No postprocedural restrictions are necessary after repositioning maneuvers 1

Clinical Pearls

• Lateral canal BPPV may spontaneously remit more quickly than other forms of BPPV 1
• The Gufoni maneuver is generally easier to perform than the barbecue roll as it requires fewer movements and more comfortable positions for patients 3
• For treatment-resistant cases, consider repeating maneuvers or trying alternative approaches before considering referral to a specialist
• Identifying the correct side and variant type (geotropic vs. apogeotropic) is crucial for successful treatment 1, 4