Benign Paroxysmal Positional Vertigo (BPPV) is a common inner ear disorder that causes brief, intense spinning sensations, or vertigo, triggered by specific head movements. This condition occurs when tiny calcium carbonate crystals (otoconia) become dislodged from their normal location and migrate into one of the three semicircular canals. Horizontal Canal BPPV (HC-BPPV) is a less frequent variant where these crystals enter the horizontal canal. Treatment focuses on physical maneuvers that use gravity to guide the misplaced crystals out of the canal and back into the utricle, where they will no longer cause symptoms.
Identifying Horizontal Canal BPPV
Accurate diagnosis is necessary because HC-BPPV requires different treatment maneuvers than the more common posterior canal type. Patients typically experience brief, intense episodes of vertigo when turning their head from side to side while lying down, such as when rolling over in bed. Symptoms are often more severe and may last up to a full minute.
The diagnostic test used to confirm HC-BPPV is the Supine Roll Test (Pagnini-McClure test). The patient lies on their back with their head slightly elevated, and the head is quickly turned 90 degrees to each side. This movement provokes a horizontal involuntary eye movement, called nystagmus, which is observed by the clinician.
The direction and intensity of the nystagmus reveal the affected ear and the specific type of HC-BPPV. In the most common form, geotropic nystagmus, the eye movement beats toward the ground, and the affected ear is the side producing the stronger nystagmus. In the less common apogeotropic nystagmus, the eye movement beats away from the ground, and the affected ear is the side producing the weaker movement. This precise identification determines the correct therapeutic maneuver.
Step-by-Step Repositioning Maneuvers
Treatment for HC-BPPV involves specific movements to roll the crystals out of the horizontal canal. These canalith repositioning maneuvers should be performed under the guidance of a trained healthcare professional, such as a physical therapist or doctor, to ensure correct positioning. Two primary maneuvers are used depending on the nystagmus type observed during diagnosis.
The Log Roll (or BBQ Roll) Maneuver
The Log Roll maneuver (also known as the Lempert maneuver) is commonly used to treat the geotropic form of HC-BPPV. The patient begins lying flat on their back. The head is quickly turned 90 degrees toward the affected side and held until vertigo subsides, plus an additional 30 to 60 seconds.
The head is then rotated back to the center position, held, and then turned 90 degrees toward the unaffected side, holding again. The final step involves the patient rolling onto their stomach, with the nose pointing down toward the floor, maintaining this position for 30 to 60 seconds. This sequence rolls the patient 270 degrees, using gravity to move the crystals along the canal and into the utricle.
The Gufoni Maneuver (or Forced Lateral Position)
The Gufoni maneuver is a simpler, quicker alternative, often used when the Log Roll maneuver is difficult or when treating the apogeotropic variant. For the geotropic type, the patient starts seated and is quickly moved to a side-lying position with the unaffected ear facing downward. The head is kept level until the vertigo stops, plus an additional minute.
The head is then rapidly turned 45 degrees toward the floor, and this position is held for one to two minutes. For the apogeotropic type, the maneuver is performed similarly, but the patient is initially laid down on the affected side, followed by the head turn toward the ground.
Managing Recovery and Recurrence
Immediately following a successful repositioning maneuver, patients commonly experience lightheadedness, residual dizziness, or a sensation of imbalance. These symptoms are generally short-lived and should gradually resolve over the next few hours or days as the inner ear system stabilizes. This residual dizziness is a normal adjustment as the brain adapts to the corrected signal from the inner ear.
While strict, long-term restrictions are not necessary, practical advice for the first 24 to 48 hours can help the inner ear settle. Patients are typically advised to avoid extreme head movements, such as looking far up or far down, and to sleep with their head slightly elevated on two pillows. Current research suggests that post-maneuver restrictions may not significantly impact the long-term success rate.
HC-BPPV has a known recurrence rate, meaning the crystals can become dislodged again over time. The Gufoni and Log Roll maneuvers are highly effective, with success rates often exceeding 90 percent after one to three sessions. If symptoms persist or return, the patient should seek follow-up treatment with a specialist, as a repeat diagnostic test and maneuver may be necessary to fully resolve the condition.