What is the indication for the Canalith (Benign Paroxysmal Positional Vertigo, BPPV) repositioning procedure?

Indications for Canalith Repositioning Procedure

The canalith repositioning procedure (CRP) is indicated for patients diagnosed with benign paroxysmal positional vertigo (BPPV) confirmed by a positive Dix-Hallpike test or supine roll test, depending on the canal involved. 1

Diagnostic Criteria for BPPV Requiring CRP

• Posterior canal BPPV (85-95% of cases):

  • Positive Dix-Hallpike test showing characteristic nystagmus
  • Brief episodes of vertigo triggered by changes in head position relative to gravity
  • Symptoms typically last less than one minute

• Lateral (horizontal) canal BPPV (5-15% of cases):

  • Positive supine roll test
  • Characteristic direction-changing nystagmus during head rotation

Patient Selection for CRP

CRP should be performed in patients with:

1. Clinical history consistent with BPPV (brief episodes of positional vertigo)
2. Positive provocative maneuver (Dix-Hallpike or supine roll test)
3. No contraindications to head positioning maneuvers

Specific CRP Selection Based on Canal Involvement

• Posterior canal BPPV: Epley maneuver (standard CRP)
• Lateral canal BPPV: Barbeque roll maneuver or other lateral canal repositioning techniques
• Anterior canal BPPV: Modified Epley maneuver

Effectiveness and Expected Outcomes

CRP is highly effective with:

• 85% success rate after a single procedure 2
• Up to 90-98% success rate with repeated procedures 1
• Significant improvement in quality of life compared to no treatment 1

When to Repeat CRP

• If symptoms persist after initial treatment
• If Dix-Hallpike test remains positive on follow-up
• For recurrent episodes of BPPV

Special Considerations

• Persistent BPPV: Consider repeated CRPs before exploring other diagnoses
• Treatment failures: Reevaluate for:
  • Incorrect canal identification
  • Canal conversion (one canal BPPV converting to another canal)
  • Multicanal involvement
  • Underlying vestibular pathology
  • CNS disorders masquerading as BPPV (rare, ~3% of treatment failures) 1

Common Pitfalls to Avoid

1. Misdiagnosis: Ensure proper diagnosis with appropriate provocative testing before performing CRP
2. Incorrect canal identification: Carefully observe nystagmus pattern to identify the affected canal
3. Inadequate follow-up: Reassess patients to confirm resolution or need for additional treatment
4. Missing comorbid conditions: Consider comprehensive vestibular testing in patients with atypical presentations or failed response to repeated CRPs

CRP is a simple, effective, non-invasive procedure that can be performed in various healthcare settings without specialized equipment, making it the first-line treatment for properly diagnosed BPPV.