Benign Paroxysmal Positional Vertigo (BPPV) is a common inner ear disorder that causes brief episodes of spinning vertigo, typically triggered by changes in head position. This condition occurs when tiny calcium carbonate crystals (otoconia) become dislodged from the utricle and migrate into one of the three semicircular canals. Horizontal Canal BPPV (HC-BPPV) involves the horizontal, or lateral, semicircular canal, which senses head rotation. The resulting vertigo is treated effectively using specialized physical maneuvers designed to move the crystals back into the utricle, where they can be reabsorbed.
Identifying the Cause and Subtype
Accurate identification of the affected ear and the specific variant is necessary before any repositioning maneuver. HC-BPPV manifests in two primary forms based on where the otoconia settle. Geotropic HC-BPPV is the more common variant, where free-floating crystals are in the long arm of the canal. Apogeotropic HC-BPPV occurs when the debris is stuck closer to the cupula, the gelatinous structure at the end of the canal.
Clinicians use the Supine Roll Test (Pagnini-McClure maneuver) to confirm the diagnosis and subtype. During this test, the patient lies supine and is quickly rolled side to side, provoking horizontal eye movement called nystagmus. In the geotropic variant, nystagmus beats toward the ground and is more intense when the affected ear is turned down, indicating free-floating crystals. Conversely, in the apogeotropic variant, nystagmus beats away from the ground, and the affected side produces the weaker nystagmus, suggesting debris near the cupula.
Repositioning Maneuvers for the Geotropic Variant
The goal of treating the geotropic variant is to guide the free-floating otoconia through the semicircular canal and back into the utricle using gravity and head rotation. The most widely used treatment is the Lempert maneuver, also known as the Barbecue Roll. This procedure involves a series of slow, controlled 90-degree body and head rotations.
The maneuver begins with the patient lying supine. The head is first turned 90 degrees toward the affected ear and held for 30 to 60 seconds until vertigo subsides. The patient then slowly rolls onto the unaffected side, turning the body and head an additional 90 degrees in the same direction, pausing again. Next, the patient rolls onto their stomach, tucking the chin toward the chest so the nose points toward the floor, completing the next 90-degree turn.
The final step involves rolling another 90 degrees onto the affected side, with the head facing the ground. After holding this position, the patient slowly returns to a sitting position. An alternative approach is the Forced Prolonged Positioning maneuver, which involves the patient sleeping on the unaffected side for twelve hours to allow gravity to passively shift the particles. The Barbecue Roll often achieves success within one to three repetitions.
Specific Maneuvers for the Apogeotropic Variant
The apogeotropic variant presents a distinct challenge because the debris is positioned near the cupula, requiring maneuvers that pull the particles away. The Gufoni maneuver is a highly effective treatment often favored for this subtype, as it is simpler and less physically demanding than the Barbecue Roll. The procedure starts with the patient sitting, followed by a rapid movement to the side-lying position on the affected ear.
The patient is held in this side-lying position for one to two minutes, or until the vertigo stops. This initial movement can act as a conversion technique, as the rapid shift may dislodge the particles from the cupula, transforming the condition into the easier-to-treat geotropic variant.
The next step involves quickly turning the head 45 degrees upward toward the ceiling while remaining on the affected side. This “nose-up” head turn is held for another one to two minutes, using inertia and gravity to move the particles toward the center of the inner ear. The patient then slowly returns to the sitting position. This maneuver may need to be repeated or followed by a subsequent geotropic maneuver if the otoconia are not fully cleared.
Post-Treatment Guidelines and Recurrence Management
Following a successful repositioning maneuver, patients are advised to avoid movements that could cause the crystals to fall back into the canal. Patients should avoid immediately lying flat and should sleep with their head slightly elevated for the first night after treatment. It is also recommended to avoid extreme head movements, such as looking far up or far down, for at least 48 hours.
A common experience after crystal repositioning is residual dizziness, a persistent feeling of unsteadiness or lightheadedness distinct from spinning vertigo. This feeling is not a sign of treatment failure; rather, it indicates the brain and balance system are adapting to the corrected input. Residual dizziness is reported in 30% to 50% of successfully treated patients and usually resolves spontaneously within a few days to a couple of weeks.
If dizziness or imbalance persists for longer than one to two weeks, Vestibular Rehabilitation Therapy (VRT) may be needed. VRT involves specific exercises designed to retrain the brain to process balance signals correctly, helping resolve persistent unsteadiness. Patients should seek follow-up care if vertigo recurs or if residual symptoms do not improve, as this may signal a need for repeat maneuvers or investigation into other underlying causes.