What is Horizontal Canal BPPV?

Benign Paroxysmal Positional Vertigo (BPPV) is a common vestibular disorder that causes brief episodes of vertigo, typically triggered by changes in head position. While most cases of BPPV affect the posterior semicircular canal, about 5-20% of cases involve the horizontal (or lateral) canal, leading to Horizontal Canal Paroxysmal Positional Vertigo (HC-BPPV).

This condition occurs when otoconia, tiny calcium carbonate crystals, dislodge from the utricle and migrate into the horizontal canal, disrupting the normal flow of fluid and causing abnormal signals to the brain that result in dizziness or vertigo.

Diagnosing Horizontal Canal BPPV

Patients with HC-BPPV typically experience brief, intense episodes of vertigo triggered by specific head movements, such as turning the head to the side or rolling over in bed.

Unlike posterior canal BPPV, where vertigo occurs when looking up or down, HC-BPPV vertigo is often elicited by horizontal head movements. Nystagmus, a rapid involuntary eye movement, is a key diagnostic sign. In HC-BPPV, the nystagmus is horizontal and can be either geotropic (toward the ground) or apogeotropic (away from the ground), depending on the position of the affected ear.

The Roll Maneuver

Horizontal canal BPPV can be diagnosed using the roll maneuver. In this maneuver, the lateral canal is positioned in the vertical plane by placing the patient in a supine position with their head tilted forward by 30 degrees. The head is then quickly turned toward the right ear.

If the patient has horizontal canal BPPV in the right ear, this movement will produce horizontal nystagmus when the head is turned to the right and the left, with the fast phase of the eye movements beating toward the ear closest to the ground. The direction of the head turn that results in the stronger nystagmus response will be toward the affected ear.

In the case of apogeotropic nystagmus, the head turn will also result in nystagmus when the head is turned in both directions. The affected ear is on the side which results in weaker nystagmus.

The use of Videonystagmography (VNG) goggles can be a valuable tool in diagnosing HC-BPPV. These goggles record eye movements in response to positional changes, allowing clinicians to observe the direction and nature of nystagmus, which helps pinpoint the affected canal and determine the appropriate treatment.

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Treatment Options for Horizontal Canal BPPV

Treating HC-BPPV typically involves canalith repositioning maneuvers designed to move the dislodged otoconia out of the horizontal canal and back into the utricle. The most common maneuvers include the BBQ Roll (or Lempert maneuver) and the Gufoni maneuver.

The BBQ Roll Maneuver

To perform the BBQ Roll, the patient begins by lying down flat on their back (supine position) with their head tilted slightly upward, about 30 degrees. The head is then turned 90 degrees toward the affected side (e.g., right ear down). The patient holds this position for about 15-30 seconds or until any dizziness subsides.

Next, the patient continues to turn their head another 90 degrees, so they are now facing upward, looking directly at the ceiling. After holding this position, they turn their head another 90 degrees to the opposite side (e.g., left ear down). This series of movements allows the otoconia to progress through the horizontal canal.

Finally, the patient turns their head and body another 90 degrees in the same direction, bringing them into a prone position (face down) with their head turned slightly downward. After holding this position for 30 to 60 seconds, the patient can carefully return to an upright sitting position. The BBQ Roll helps guide the dislodged otoconia back into the utricle, where they can no longer cause vertigo.

The Gufoni Maneuver

The Gufoni maneuver is a targeted treatment for Horizontal Canal BPPV and can be particularly effective depending on the type of nystagmus observed. To perform the Gufoni maneuver, follow these steps:

1. The patient begins in an upright sitting position on the examination table or bed.
2. The patient is quickly moved to a side-lying position. The direction of the observed nystagmus during the Roll test determines which side the patient should lay on first. If the nystagmus is geotropic, the "good ear" (unaffected side) should face downward, followed by turning the head toward the ground. An easy way to remember this is "G-G-G" (geotropic, good ear, ground). If the nystagmus is apogeotropic, the "affected ear" should face downward, and the head should be turned away from the ground—remember it as "A-A-A" (apogeotropic, affected ear, away).
3. If geotropic nystagmus (nystagmus that beats toward the ground) is observed, the patient’s head is turned 45 degrees upward (toward the ceiling). This position is held for 1-2 minutes.
4. If apogeotropic nystagmus (nystagmus that beats away from the ground) is observed, the patient’s head is turned 45 degrees downward (toward the floor). This position is also held for 1-2 minutes.
5. After holding the head turn for the appropriate duration, the patient is slowly returned to the upright sitting position.
   

This sequence of movements helps to relocate the dislodged otoconia from the horizontal canal back into the utricle, alleviating the symptoms of vertigo. The choice of maneuver, whether it’s the Gufoni or another, depends on the specific characteristics of the patient’s nystagmus, as identified during the diagnostic process.

Treating Horizontal Canal BPPV with the TRV Chair

The Interacoustics TRV Chair allows for the effective treatment of all types of BPPV with its 360° movement in all semicircular canal planes. It’s especially beneficial for patients with limited mobility or frailty, offering a safer alternative to traditional bedside treatments. The TRV Chair enables precise head positioning for accurate diagnosis of Horizontal Canal BPPV and facilitates controlled repositioning techniques like the Barbecue maneuver, improving both diagnosis and treatment outcomes.

Interacoustics TRV Chair

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Horizontal Canal BPPV, though less common than its posterior counterpart, requires careful diagnosis and targeted treatment. Understanding the symptoms and utilizing tools like VNG goggles are essential for accurate diagnosis, while specific repositioning maneuvers can effectively alleviate symptoms. With proper care, patients with HC-BPPV can achieve significant relief from vertigo and return to their daily activities.

Are you considering adding vestibular services and need advice? Reach out to your local office today.

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Need balance equipment? e3 Diagnostics offers top-notch vestibular and rehabilitation solutions from leading manufacturers like Micromedical by Interacoustics and Virtualis.

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Other Good Reads: BPPV Treatment: The TRV Advantage

Resources: TRV chair: How to perform a dynamic BBQ maneuver

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