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

Treatment of Lateral Canal BPPV

For lateral canal BPPV, perform either the Gufoni maneuver (93% success rate) or the Barbecue Roll maneuver (50-100% success rate), with the specific technique depending on whether the variant is geotropic or apogeotropic. 1, 2

Critical First Step: Identify the Variant

Before treating, you must determine two things using the supine roll test:

• Which ear is affected (the side with stronger nystagmus indicates the affected ear) 3
• Which variant you're dealing with: geotropic (nystagmus beats toward the ground) or apogeotropic (nystagmus beats away from the ground) 1, 4

This determination is paramount—treating the wrong side or using the wrong variant technique will fail. 4

Treatment for Geotropic Lateral Canal BPPV (Most Common)

Option 1: Gufoni Maneuver (Preferred - 93% Success Rate)

The Gufoni maneuver is more effective than the barbecue roll (93% vs 81% success) and is easier to perform. 1, 4

Technique for geotropic variant:

1. Start with patient sitting upright 1, 4
2. Rapidly move patient to straight side-lying position on the unaffected side (the ear WITHOUT BPPV) for 30 seconds 1, 4
3. Quickly turn the patient's head toward the ground 45°-60° and hold for 1-2 minutes 1, 4
4. Return patient to sitting with head held toward the left shoulder until fully upright 1

Option 2: Barbecue Roll (Lempert 360° Roll) Maneuver

This achieves 50-100% success rates but requires more complex movements. 1, 2

Technique:

1. Start from supine position 1
2. Roll head (or full body) to the unaffected side 1
3. Continue rolling in same direction until nose-down/prone position 1
4. Some recommend stopping at 270° and returning to sit, as debris is anatomically repositioned 1
5. Originally described as completing full 360° roll and returning to sitting 1
6. Hold each position for 15-30 seconds or until nystagmus stops 1

Treatment for Apogeotropic Lateral Canal BPPV (Less Common)

Modified Gufoni Maneuver

The key difference: patient lies on the AFFECTED side (opposite of geotropic variant). 1, 4

Technique:

1. Start with patient sitting upright 4
2. Rapidly move patient to straight side-lying position on the affected side (the ear WITH BPPV) for 30 seconds 1, 4
3. Quickly turn patient's head toward the ground 45°-60° and hold for 1-2 minutes 1, 4
4. Return to sitting with head held toward opposite shoulder until fully upright 4

Evidence for apogeotropic treatment is weaker, with only a single RCT providing insufficient evidence for a preferred technique. 1

Alternative Treatment: Forced Prolonged Positioning

This involves lying for an entire night on the uninvolved side (for geotropic) or involved side (for apogeotropic), with effectiveness of 75-90% based on case series. 1

This can be performed alone or combined with other maneuvers, though it's less convenient than office-based repositioning. 1

Critical Post-Treatment Instructions

Do NOT impose postprocedural restrictions—patients can resume normal activities immediately. 2, 4 There is strong evidence that restrictions provide no benefit and may cause unnecessary complications. 2

What NOT to Do

Never prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment for lateral canal BPPV. 2 These have no evidence of effectiveness, interfere with central compensation mechanisms, and cause adverse effects including drowsiness, falls (especially in elderly), and cognitive deficits. 2

Medications may only be considered for short-term management of severe nausea/vomiting in severely symptomatic patients. 2

Common Pitfalls to Avoid

• Canal conversion occurs in 6-7% of cases during treatment—patient may convert from lateral to posterior canal BPPV and require Epley or Semont maneuver. 5, 6
• Failing to correctly identify the affected side before treatment will result in ineffective therapy. 4
• Not distinguishing geotropic from apogeotropic variants leads to using the wrong technique (lying on wrong side). 1, 4
• Lateral canal BPPV may spontaneously remit more quickly than posterior canal BPPV, so some cases may resolve without treatment. 1

When Treatment Fails

If symptoms persist after initial treatment: 2

• Repeat the supine roll test to confirm persistent lateral canal BPPV 2
• Check for canal conversion to posterior canal BPPV 2
• Evaluate for multiple canal involvement or bilateral BPPV 2
• Consider coexisting vestibular pathology if symptoms occur with general head movements 2
• Rule out central causes if atypical features present 2

Repeat repositioning maneuvers can achieve 90-98% success rates in persistent cases. 2

Self-Treatment Option

Self-administered repositioning can be taught to motivated patients after at least one properly performed in-office treatment, with 64% improvement rates. 2 This is significantly more effective than Brandt-Daroff exercises (23% improvement). 2

Special Populations

Assess all patients before treatment for: 2

• Impaired mobility or balance
• CNS disorders
• Lack of home support
• Increased fall risk (especially elderly patients)

For patients with severe cervical stenosis, rheumatoid arthritis, cervical radiculopathies, or spinal issues, consider Brandt-Daroff exercises instead or refer to specialists experienced in modified techniques. 3, 2

Follow-Up

Reassess within 1 month after initial treatment to document resolution or persistence of symptoms. 3, 2