VARIANT MANEUVERS FOR LATERAL CANAL BPPV

Timothy C. Hain, MD
Page last modified: January 2, 2022

The main Lateral Canal BPPV page is here. Gufoni maneuver (for geotropic).Li maneuver (for geotropic).Gufoni maneuver (for ageotropic).Log Roll for either

All variant maneuvers are modifications of the log-roll. As of early 2022, the Gufani is the gold standard for the geotrophic lateral canal BPPV, while the log-roll or Zuma variants is the gold standard for ageotrophic. Fortunately, there is now a BPPV viewer (see resources at the end) and you can check on the illustrations yourself.

Vannucchi maneuver, also called "forced prolonged positioning" : incomplete

This is a maneuver invented in Italy. Simply sleeping with the "affected" ear up has been reported to cure about 75% of patients (see Vannucchi et al, 1997).  This is the second to last step of the log-roll (position 3 above).

Considering the mechanics of the situation, one would expect that bad-ear up would work only for case where the debris is close to coming out already -- i.e. the geotrophic variant of BPPV. It would not be expected to work for the ageotropic variant of lateral canal BPPV. The biophysical rationale for this maneuver is puzzling. Debris probably does not take all night to sediment. 10 minutes, in theory, is plenty.

Another Vannucchi maneuver:

Another Vannucchi maneuver is the "Vannucchi-Asprella" maneuver (2005). In this maneuver, while supine, the head is rapidly rotated away from the "bad" ear, then moved into sitting, then slowly aligned with the body, and then returned to supine. This maneuver attempts to use inertial force to displace otoconia. In our opinion, inertial force is not likely to move debris as intertial force is less than gravitational force, but perhaps it "breaks loose" otoconia adherent to the canal wall.

 

Gufoni maneuvers •Gufoni maneuver (for geotropic).Gufoni maneuver (for ageotropic).

For those of you in a hurry, the geotropic Gufoni is the one to choose, but pick either the log-roll or the Zuma variant for ageotropic.

For these maneuvers, one must both know if the nystagmus is geotrophic/ageotrophic as well as know the side of debris (which is not always the clearest). Because the usual assumption is that the "affected" side is the one with stronger nystagmus in geotrophic, and the affected side is the side with weaker nystagmus in ageotrophic, in either case, one starts on the side with weaker nystagmus.  If the nystagmus is geotrophic, one after 2 minutes, then one proceeds towards nose down. If it is ageotrophic, then nose up.   We suuggest for the ageotrophic, continuing on with either the "geotrophic" Gufoni or just the rest of the logroll. Nausea or vomiting are obvious potential issues with these maneuvers that require one to spend 4 minutes in positions that induce severe vertigo.

Of course if you are just not sure which side is affected, you could end up mistaken as to the maneuver and end up doing nothing at all.

The main advantage of these abbreviated procedures is that they may be quicker as they cut out some of the useless steps of the Log-roll. We agree with the logic that the full log-roll is not always necessary for geotrophic BPPV. We do not agree with the logic that the "ageotrophic Gufoni" is a complete treatment. We think a log-roll is the logical treatment for ageotrophic.

Zuma maneuver for ageotropic.

The Zuma maneuver is a log-roll variant with rapid head movements. It is a reasonable maneuver for ageotropic lateral canal. For geotropic, the Gufani is quicker.

Li Maneuver for geotrophic lateral canal BPPV.

Li Maneuver

The Li maneuver is discussed here. We don't think it is a good idea.

Rapid head movement (about the yaw axis) as a treatment for lateral canal BPPV

Another variant is to move the head briskly towards the good ear during each step, which might add an inertial acceleration component to the repositioning process (Lempert and Tiel-Wielck, 1994). However, theory suggests that inertia contributes little to the movement of otoconia (Hain et al, 2005). Still this is part of some maneuvers (e.g. see the Zuma variant).

Brisk turns adds risk to the maneuver as it could hurt the treated person's neck as well as, in theory at least, dissect a vertebral or carotid in the same way that forceful chiropractic manipulations can sometimes induce stroke. Actually, we encountered one patient who dissected their vertebral from swimming, and another who dissected their carotid artery from VEMP testing with head turning (not the method we favor). . Brisk head movements may also increase risk of retinal detachment. Vibration might be a little safer -- but no studies so far. In spite of all of these thoughts about risk, practically we have never encountered anyone with a dissection or a retinal detachment related to a physical therapy maneuver of this nature.

Head-shaking as a treatment for lateral canal BPPV.

Several authors have suggested that rapid horizontal head-shaking can resolve lateral canal BPPV (Oh et al, 2009; Vanucchi et al, 1997; Kim et al, 2012). This is somewhat plausible considering that the lateral canal is normally tilted so that debris would tend to roll out of it, and by shaking things up, this might be encouraged. 

Kim et al (2012) described the maneuver as follows: " For head-shaking maneuver,15 patients were brought into a sitting position. After pitching the head forward by approximately 30°, we moved the head sideways in a sinusoidal fashion at an approximate rate of 3 Hz for 15 seconds". They do not mention the head excursion (presumably small -- for convenience lets choose 57.2958 degrees = 1 radian). They reported similar rates of response to head-shaking (63%) to the Gufoni (73.1%), both of which were much better than the sham maneuver (34.7%).

In theory, the tangential acceleration of the ear (r=6cm) at 3 hz is r*w (w=angular velocity), which is only about a tenth of a gravity. The problem is the small radius, r. The radial acceleration, which is r*w**2, is higher because it depends on the angular velocity term squared.

There are some interesting issues brought up here -- in our clinic, we routinely use head-shaking as a diagnostic maneuver, prior to positional testing, and prior to any physical treatments. We also use the HIT test, which incoporates a high acceleration head movement. Could we be treating patients by accident ?

See also the comments above about the dangers of brisk head shaking.

 

Resources for BPPV maneuvers

  1. BPPV viewer (downloadable model of BPPV geometry)

References about lateral canal BPPV: See this link