How is otolith repositioning done based on the affected semicircular canal and direction of vertigo?

Otolith Repositioning Based on Semicircular Canal Involvement

The specific canalith repositioning procedure (CRP) you perform depends entirely on which semicircular canal is affected and the direction of nystagmus observed during diagnostic testing—posterior canal BPPV (85-95% of cases) requires the Epley maneuver directed toward the affected ear identified by the Dix-Hallpike test, while lateral canal BPPV requires either the barbecue roll or Gufoni maneuver based on whether the nystagmus is geotropic or apogeotropic. 1

Diagnostic Algorithm to Determine Canal Involvement

Step 1: Perform Dix-Hallpike Test

• Position the patient upright with head turned 45° toward the ear being tested, then rapidly move to supine with head hanging 20° below horizontal 2, 3
• Positive for Posterior Canal BPPV: Torsional, upbeating nystagmus with brief latency, increasing then resolving within 60 seconds 1, 3
• Horizontal or no nystagmus: Proceed to supine roll test for lateral canal evaluation 1
• The affected ear is whichever side produces the positive response when positioned downward 3

Step 2: If Dix-Hallpike Shows Horizontal Nystagmus, Perform Supine Roll Test

• With patient supine, rapidly turn head 90° to each side 1
• Geotropic nystagmus (beats toward ground): Canalithiasis of lateral canal—more common form 1
• Apogeotropic nystagmus (beats away from ground): Cupulolithiasis or debris in anterior arm of lateral canal 1
• The affected ear is the side producing stronger nystagmus in geotropic variant 4

Treatment Protocols by Canal Type

Posterior Canal BPPV (85-95% of cases): Epley Maneuver

Technique 2, 5:

1. Starting position: Patient seated, head turned 45° toward affected ear
2. Position 1: Rapidly lay patient back to supine with head hanging 20° below horizontal; hold 20-30 seconds
3. Position 2: Turn head 90° toward unaffected side; hold 20 seconds
4. Position 3: Turn head additional 90° in same direction, rolling body to lateral decubitus position; hold 20-30 seconds
5. Return to sitting: Maintain head position while sitting up

Success rates: 80-93% after initial treatment, 90-98% with repeat sessions 2, 6

Critical technical points:

• Movements between positions must be relatively rapid, especially the sitting-to-supine transition 2
• Maintain each position for full 20-30 seconds even if symptoms resolve earlier to allow adequate otoconia migration 2
• Can repeat up to 3 times in same session if needed 2

Lateral Canal BPPV—Geotropic Type (5-15% of cases): Barbecue Roll or Gufoni Maneuver

Barbecue Roll Maneuver (Lempert 360°) 1:

1. Start supine (some recommend starting on involved side)
2. Roll head/body to unaffected side; hold 15-30 seconds
3. Continue rolling until nose-down/prone; hold 15-30 seconds
4. Complete full 360° roll back to supine (or stop at 270° and return to sitting)
5. Return to sitting position

Gufoni Maneuver for Geotropic Lateral Canal BPPV 1:

1. From sitting, rapidly move to side-lying position on unaffected side; hold 30 seconds
2. Turn head 45-60° toward ground (nose down); hold 1-2 minutes
3. Return to sitting with head held toward affected shoulder

Success rates: 81-93% for both maneuvers 1

Lateral Canal BPPV—Apogeotropic Type: Modified Gufoni Maneuver

Technique 1:

1. From sitting, rapidly move to side-lying position on affected side (opposite of geotropic); hold 30 seconds
2. Turn head 45-60° toward ground; hold 1-2 minutes
3. Return to sitting with head held toward opposite shoulder

Key distinction: For apogeotropic variant, lie on the affected side first (opposite of geotropic treatment) 1

Anterior Canal BPPV (Rare, <1% of cases)

• Use reverse Epley maneuver or modified techniques 7
• Success rate approximately 50% 7
• Consider referral to vestibular specialist given rarity and lower success rates

Post-Procedure Management

Do NOT recommend postural restrictions after any CRP for posterior canal BPPV—patients can resume normal activities immediately 1, 2, 5. This is a strong recommendation against restrictions based on randomized controlled trials showing no benefit and potential harm including neck stiffness 1.

When Treatment Fails

Reassess within 1 month 1:

• Repeat Dix-Hallpike or supine roll test to confirm persistent BPPV 2
• Consider canal conversion (6-8% incidence)—otoconia may have moved to different canal during treatment 5, 8
• Most common conversion: posterior canal → lateral canal (4.8% incidence) 8
• If conversion suspected, perform appropriate diagnostic test and switch to corresponding CRP 8

After 2-3 properly performed maneuvers without success 2:

• Evaluate for bilateral or multicanal BPPV 1
• Consider coexisting vestibular disorders requiring different treatment 5
• Refer to vestibular specialist for refractory cases

Common Pitfalls to Avoid

• Inappropriate head movement during CRP: Main risk factor for canal conversion 8
• Performing another Dix-Hallpike immediately after CRP: Can cause otoconia to re-enter canal 8
• Insufficient time in each position: Must hold full 20-30 seconds for adequate particle migration 2
• Wrong maneuver for lateral canal subtype: Geotropic vs apogeotropic require opposite starting positions 1
• Prescribing vestibular suppressants: No evidence of benefit and may interfere with central compensation 1, 2

Contraindications Requiring Modified Approach

Exercise caution or consider referral in patients with 2, 3:

• Severe cervical stenosis or radiculopathy
• Severe rheumatoid arthritis affecting cervical spine
• Significant vascular disease
• Severe kyphoscoliosis
• Morbid obesity