Original Article

International Journal of Audiology 2010; 49: 606612

Stavros Korres1
Maria Riga2
Vasilios Sandris3
Vasilios Danielides2
Aristides Sismanis1
1ENT Department, Hippokration
Hospital, University of Athens, Greece
2ENT Department, University Hospital
of Alexandroupolis, Democritus
University of Thrace, Greece
3ENT Department, General Hospital of
Larissa, Greece

Key Words
Anterior semicircular canal
Canalithiasis
Repositioning manoeuvres

Abbreviations
ASC: Anterior semicircular canal
BPPV: Benign paroxysmal positional
vertigo
D-H: Dix-Hallpike

Canalithiasis of the anterior semicircular

canal (ASC): Treatment options based on the
possible underlying pathogenetic mechanisms
Abstract

Sumario

Benign paroxysmal positional vertigo (BPPV) of the anterior semicircular canal (ASC) is an uncommon disorder currently diagnosed with the Dix-Hallpike (D-H) examination.
According to the literature, nystagmus and vertigo may be
more pronounced when the affected ear is either up or down.
In some patients, both right and left D-H tests can trigger
nystagmus with the same direction. The proposed treatment
options with the addition of a different manoeuvre applied
by the authors of the present study in cases of ASC lithiasis,
seem to present a respective variety regarding the position
of the affected ASC during the procedure of canalith repositioning. The aim of this study is to analyse the mechanisms underlying both the proposed treatment options and
the clinical findings in the D-H examination. The results of
this analysis stimulate further investigation, since they probably imply that repositioning manoeuvres might vary in their
effectiveness when applied to different clinical subgroups of
ASC BPPV.

El vrtigo postural paroxstico benigno (BPPV) del canal

semicircular anterior (ASC) es un desorden poco comn
que actualmente se diagnostica mediante la prueba de DixHallpike (D-H). De acuerdo con la literatura, el nistagmus y el
vrtigo pueden ser ms pronunciados cuando el odo afectado
est tanto arriba como abajo. En algunos pacientes, la maniobra de D-H a la derecha como a la izquierda pueden desencadenar nistagmus con la misma direccin. Las opciones de
tratamiento propuestas con la adicin de una maniobra diferente aplicada por los autores de este estudio en casos de litiasis
del ASC, parece presentar una variedad respectiva de acuerdo
a la posicin del ASC afectado durante el procedimiento de
reposicin canalicular. El propsito de este estudio es analizar
los mecanismos subyacentes tanto de las opciones teraputicas
propuestas como de los hallazgos clnicos de la prueba D-H.
Los resultados de este anlisis estimulan una mayor investigacin puesto que probablemente impliquen que la efectividad
de las maniobras de reposicionamiento puede variar cuando se
aplican a diferentes subgrupos clnicos de ASC BPPV.

Benign paroxysmal positional vertigo (BPPV) of the anterior semicircular canal (ASC) is an uncommon disorder of the vestibular organ (Herdman et al, 1994; Katsarkas, 1999). This is probably due to the fact that
gravity restricts the upward movement of the debris, while facilitating
self-clearance through the posterior arm of the ASC into the common
crus and vestibule (Korres et al, 2002). In addition to being a relatively
rare condition, determining the affected side based on the Dix-Hallpike
(D-H) examination can often be difficult, thus complicating proper diagnosis and treatment (Korres et al, 2008; Bronstein, 2003).
The modified Epley particle repositioning procedure (Jackson
et al, 2007; Lopez-Escamez et al, 2006), as well as the reverse Epley
(Honrubia et al, 1999; Epley, 2001; Seok et al, 2008), have each been
proposed for the treatment of ASC BPPV. A different manoeuvre has
been reported by Rahko (2002). Kim et al (2005) have suggested a
repositioning manoeuvre resembling the D-H test, and Hamid (2001)
has reported the observation that in the cases he had diagnosed, ASC
BPPV had resolved with performing the D-H examination several
times to check for fatigability. Crevits (2004) has proposed a prolonged forced position procedure and Yacovino et al (2009) proposed
a different manoeuvre based on the head-straight neck hyperextension. An additional manoeuvre, roughly resembling also the D-H test,
but with differences in the microforces provoking the movement of
otoconia, is proposed by the authors of this study.
The aim of this study is to review the various treatment options of
ASC canalithiasis and through the understanding of their underlying
mechanisms attempt to identify findings in the D-H examination
which may indicate proposed repositioning manoeuvres. A new
ISSN 1499-2027 print/ISSN 1708-8186 online
DOI: 10.3109/14992021003753490
2010 British Society of Audiology, International
Society of Audiology, and Nordic Audiological Society

Received:
April 6, 2009
Accepted:
March 6, 2010

manoeuvre, which has been successfully performed in a limited

number of patients by the authors of this study, is also described
and added to the existing treatment options.

Reported treatment options

The reverse Epley manoeuvre seems to be one of the first particle
repositioning manoeuvres proposed for the treatment of ASC BPPV.
Although this manoeuvre has been recommended by several authors,
detailed data on the number and the history of the patients, as well
as the outcome of this treatment are lacking (Honrubia et al, 1999;
Epley, 2001; Korres et al, 2008; Seok et al, 2008). When applying
the reverse Epley, the ASC is cleared of otoliths by using the same
positioning sequences as for the contralateral posterior canalithiasis
(Epley, 2001; Herdman, 1997; Baloh, 1996) (Figure 1).
Rahko (2002) reviewed the clinical findings and treatment results
of a large population of 57 patients with lithiasis of the ASC, which
in most cases was diagnosed in combination with lithiasis of the horizontal or posterior semicircular canals, or as a result of the previous
Epley and Lempert manoeuvres. He reported that after performing
this manoeuvre, 53 out of 57 patients were free from symptoms at
the follow-up examination. He proposed a different repositioning
manoeuvre which is schematically presented in Figure 2. In order to
perform this manoeuvre the patient first lies on the healthy side (Figure
2A). The head is then tilted downwards 45 for 30 more seconds with
the patient facing the floor (Figure 2B). The next step involves further
tilting of the head for 180 toward the affected side (Figure 2C). After
Maria Riga
35 Leoforos Makris, Nea Chili, 68100, Alexandroupolis, Greece.
E-mail: mariariga@hotmail.com

Figure 1. The reverse Epley manoeuvre for the treatment of left ASC canalithiasis. (A) The procedure begins with the patient sitting with
the head turned 45 to the healthy (right) ear. (B) Then, the patients body is quickly brought back, into a slight head-hanging position,
keeping the head turned to the same side. (C) The head is then slowly rotated toward the affected (left) ear, which is now lowermost. (D)
The patient is then rolled to a side-lying position, with the head turned 45 additionally toward the left ear, and downward to the floor. (E)
Finally, the patient is brought slowly back to the sitting position.
30 seconds the head is turned further upwards 45, so that the patient
faces straight up (Figure 2D). Finally the patient sits up and stays there
well supported for at least three minutes (Figure 2E).
The modified Epley particle repositioning procedure with or without use of vibration is an alternative therapeutic suggestion (Jackson
et al, 2007; Lopez-Escamez et al, 2006). This procedure begins with
the patient sitting with the head turned 45 to the affected ear (Figure 3A). Then, the patients body is quickly brought back, into a
slight head-hanging position, keeping the head turned to the same
side (Figure 3B). The head is then slowly rotated toward the unaffected ear, which is now lowermost (Figure 3C). The patient is then
rolled to a side-lying position, with the head turned 45 additionally
toward the healthy ear, and downward toward the floor (Figure 3D).
Finally, the patient is brought slowly back to the sitting position
(Figure 3E). Jackson et al (2007) reported that the application of this
canal repositioning procedure in a large population of 55 patients
was required 1.32 times in order to resolve ASC BPPV. The same
authors have reported a nearly double the highest incidence of ASC

involvement (21.2%). Lopez-Escamez et al (2006) reported a cohort

of 14 patients. ASC canalithiasis was unilateral in nine patients and
bilateral in three patients, while in two patients it was combined
with canalithiasis of the contralateral posterior or lateral semicircular
canal. The ASC was successfully cleared from otoconia in 11 cases
after a single manoeuvre. In two patients a second manoeuvre was
required and in only one patient the down-beating nystagmus did
not resolve despite treatment with several manoeuvres and exercises.
ASC BPPV converted to posterior canal BPPV in one patient.
Hamid (2001) first reported the observation that in the cases that
he had diagnosed ASC BPPV resolved with performing the D-H
examination several times to check for fatigability. The mechanism
underlying this treatment option is presented in Figure 4. A few
years later Kim et al (2005) proposed a repositioning manoeuvre
resembling the D-H test, which yielded good results in a population
of 12 patients with ASC BPPV and 18 patients with both anterior
and posterior semicircular canal BPPV. First the patients head is
turned 45 toward the unaffected side (Figure 5A). Then the patient

Figure 2. The manoeuvre proposed by Rahko (2002) (the black arrows represent the gravitational force on otoconia). The left ASC is
affected. (A) The patient lies on the healthy side for 30 seconds. (B) The head is tilted downwards 45 (facing the floor for 30 seconds
more). (C) Then the head is tilted further 180. Thus, at the end of this phase the patients head is found turned 45 toward the affected side.
The patient remains in this position for 30 seconds more. (D).The head is tilted upwards 45 and for 30 seconds more the patient is facing
straight up. (E) Finally the patient sits up and stays there well supported for at least three minutes.

Korres, Treatment suggestions for the anterior

semicircular canal canalithiasis

Korres/Riga/Sandris/Danielides/Sismanis

607

Figure 3. The modified Epley particle repositioning procedure. The left ASC is affected. (A) This procedure begins with the patient sitting
with the head turned 45 to the affected ear. (B) Then, the patients body is quickly brought back, into a slight head-hanging position, keeping
the head turned to the same side. (C) The head is then slowly rotated toward the unaffected ear, which is now lowermost. (D) The patient
is then rolled to a side-lying position, with the head turned 45 additionally toward the healthy ear, and downward to the floor. (E) Finally,
the patient is brought slowly back to the sitting position.
is lowered to a supine position with the head hanging off 30 at
the end of the bed for two minutes (Figure 5B). Next, the patients
head is elevated in a supine position while the head remains turned
45 for one minute (this step is not included in a D-H examination)
(Figure 5C). Finally, the patient is returned to a sitting position and
his chin is tilted 30 down (Figure 5D). The manoeuvre is based
on the fact that ampullary endings of the ASC are lateral and the
non-ampullary endings are medial (Brantberg & Bergenius, 2002).
This manoeuvre has been reported to resolve the nystagmus and
vertigo in 46.7% of the patients when applied only once, in 80%
of patients when applied twice, and in 93.3% of the patients when
applied three times.
Recently, Yacovino et al (2009) have reported the application of
a different manoeuvre in a small number of eight patients who presented with ASC BPPV and five additional patients who acquired
ASC BPPV following Epleys manoeuvre for the treatment of posterior canal BPPV. According to this manoeuvre, the patient moves

from a head-straight sitting position to a straight head hanging

position and remains in this position for 30 seconds. In the third
step of this manoeuvre the patients head is moved quickly forward chin to chest with the vertex near the vertical axis, while
the patient remains still supine. This position is maintained for
30 more seconds. Finally, the patient is brought into the sitting
position. Eleven patients were reported to respond to a single
manoeuvre, while the remaining two required for the procedure
to be applied twice before they became free from symptoms and
clinical findings.

Description and preliminary results of a new

repositioning manoeuvre

Figure 4. In some cases treatment may simply arise during the

application of the diagnostic D-H examination, especially if in head
hanging position maximal extension of the head is achieved. (A) The
patients head is turned 45 toward the unaffected side, with the head
hanging off 30 at the end of the bed. (B) Otoconia move toward the
top of the canal, because of the gravitational forces achieved through
head extension. (C) When the patient is returned to a sitting position
with his head turned toward the healthy side, angular acceleration
and gravity move otoconia through the common crus and toward
the utricle.

A novel manoeuvre for the repositioning of otoconia in cases of ASC

canalithiasis was successfully applied by the authors of this study
in five patients. The manoeuvre also resembles the D-H test and is
schematically presented in Figure 6. In the head hanging position
and maximal neck extension with torsion of the head 45 to the
affected side, otoconia move slightly toward the top of the canal
(Figure 6A). By turning the patients head 90 toward the healthy
side in head-hanging position, otoconia are expected to move further
toward the utricle (Figure 6B). Both steps of the manoeuvre are
maintained for one minute. When the patient returns quickly to the
sitting position, the synergic action of gravity and angular acceleration is expected to move otoconia to the utricle (Figure 6C). At this
point it should be mentioned that the manoeuvre may be unsuccessful if extension of the head is minimal or absent (Korres et al,
2008). The patient remains in the sitting position well supported for
one to two minutes.
The results for the patients treated by this manoeuvre are presented
in Table 1. All five patients of this study were successfully treated
with this manoeuvre. In two patients a second application of the
manoeuvre one week after the first was necessary before the patient
became free from symptoms and clinical findings. In one patient
the reverse Epley manoeuvre had been performed unsuccessfully in
a previous session. Canal conversion of the vertigo, from otoconia
being transferred to another semi-circular canal as a result of the
manoeuvre, was not noted in any of the patients of this report.

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International Journal of Audiology, Volume 49 Number 8

Figure 6. A novel manoeuvre for the treatment of left ASC BPPV.

(A) In head hanging position and maximal neck extension with
torsion of the head 45 to the affected side otoconia move slightly
toward the top of the canal. (B) By turning the patients head
90 toward the healthy side in head-hanging position, otoconia
are expected to move further toward the utricle. (C) When the
patient returns quickly to the sitting position, the synergic action
of gravity and angular acceleration is expected to move otoconia
to the utricle.

Apogeotropic down-beating nystagmus in the Dix-Hallpike

examination

Figure 5. Kim et al (2005) modification of D-H test for the treatment

of ASC BPPV. (A) First the patients head is turned 45 toward the
unaffected side. (B) Then the patient is lowered to a supine position
with the head hanging off 30 at the end of the bed for two minutes.
(C) Next, the patients head is elevated in a supine position while the
head remains turned 45 for one minute. (D) Finally, the patient is
returned to a sitting position and his chin is tilted 30 down.

Clinical manifestations and respective pathogenic

mechansims
The anterior canal variant of BPPV is typically characterized by a
predominantly down-beating nystagmus with a small torsional component during D-H testing. Torsional nystagmus refers to the fast
phase direction of the top pole of rotation.
The torsional component of the nystagmus beats toward the
affected side and is increased by gaze deviation toward the healthy
semicircular canal. The linear down-beating component is increased
with gaze deviation toward the involved side (Honrubia et al, 1999;
Lopez-Escamez et al, 2006; Aw et al, 2005; Korres & Balatsouras,
2004).
The diagnosis of ASC BPPV is typically based on the Dix-Hallpike
(D-H) manoeuvre. Available reports vary as to whether nystagmus and vertigo is more pronounced when the affected ear is up
(Honrubia et al, 1999; Kim et al, 2005), or down (Bertholon et al,
2002; Crevits, 2004; Brantberg & Bergenius, 2002). In some patients,
nystagmus is triggered by both right and left D-H tests (Bertholon
et al, 2002; Lopez-Escamez et al, 2006).

Korres, Treatment suggestions for the anterior

semicircular canal canalithiasis

In this case the D-H test is performed contralaterally to the lesion and
the uppermost ear is the involved ASC. The torsional component of
the nystagmus is beating toward the involved uppermost ear (apogeotropic), but is increased with gaze deviation toward the healthy
lowermost ear (Korres et al, 2006; Brandt, 2003). By completing
the D-H to the contralateral ear of an affected ASC the pressure
against the cupula and the respective displacement are larger first
because angular acceleration and gravity are both in the direction
of the channel and act synergically to displace otoconia (Bertholon
et al, 2002, Korres et al, 2008).

Geotropic down-beating nystagmus in the Dix-Hallpike

examination
In some cases of ASC BPPV, the D-H test may be positive when
performed ipsilaterally to the lesion (Bertholon et al, 2002;
Crevits, 2004; Brantberg & Bergenius, 2002). In this case the
lowermost ASC is affected and the induced nystagmus presents
a geotropic torsional component (beating toward the involved
lowermost ear). During the examination, the ASC ampullary segment of the lowermost ear also points downwards at an angle of
37 from vertical (Bertholon et al, 2002) and displacement of
canaliths is provoked, due to this downward slope of the canal,
by gravitational forces. The patients head rotates orthogonally
to the plane of the affected ASC and the component of the force
perpendicular to the channel exerts no pressure against the cupula
(Korres et al, 2008; House & Honrubia, 2003; Bertholon et al,
2002; Lopez-Escamez et al, 2006). Moreover, the transcupular
pressure is diminished for particles located away from the canal
centerline (Squires et al, 2004). Thus, when the D-H test is performed and the affected ear is lowermost, the provoked pressure
against the cupula and the corresponding symptoms are expected
to be less pronounced.

Korres/Riga/Sandris/Danielides/Sismanis

609

Table 1. History and therapeutic outcome in the population of this study after the application of the manoeuvre proposed by the authors.
Previous manoeuvres manoeuvres that had already been performed unsuccessfully in another medical center. Canal conversion otoconia
being transferred in another semi-circular canal as a result of the proposed repositioning manoeuvre. (-): patient free from symptoms and
clinical findings.
Duration of
symptoms

Previous
manoeuvres

1
2
3

1 week
1 month
1 month

None
Reverse Epley
None

1 month

None

4 months

None

Patients

1st follow-up visit

(-)
(-)
2nd application of the
manoeuvre
2nd application of the
manoeuvre
(-)

Down-beating nystagmus triggered by head hyper-extension

2nd follow-up visit

Canal conversion

(-)

No
No
No

(-)

No
No

In ASC canalithiasis, the nystagmus may be present or more pronounced when the patient is placed (1) with the affected ear uppermost in the D-H examination, (2) with the affected ear lowermost
in the D-H examination, or (3) with head-straight neck hyperextension. The variable laterality of clinical findings in the D-H
examination and head hanging position may represent slight differences in the diameter of the common crus, the position of any obstructions within the membranous duct (Bertholon et al, 2002; Crevits,
2004; Schratzenstaller et al, 2005), or the anatomical positions of
the semicircular canals (Schratzenstaller et al, 2005; Korres et al,
2008). Interestingly, the ASC canalithiasis seems to resolve by the
use of an analogous variety of repositioning manoeuvres, where
the patient may be placed with the affected ear uppermost, lowermost or at neck hyper-extension. After an analysis of the different
combinations of the gravitational forces components amplified in
each manoeuvre, the use of the clinical findings for the selection

of the correlative repositioning manoeuvre seems to be a logical

clinical approach.
In cases where the nystagmus elicited by the Dix-Hallpike examination is more pronounced with the affected ear uppermost and
according to the underlying mechanisms described previously, three
manoeuvres seem to take the best advantage of the forces which
seem to conduct otoconia toward the vestibule. The reverse Epley,
the manoeuvre described by Rahko (2002) and the manoeuvre proposed by Kim et al (2005), all start with the patient lying on the
healthy side (the affected ear is uppermost) (Figures 1, 2, 5). Among
them the reverse Epley manoeuvre seems to be the procedure recommended by most authors. Kims manoeuvre (2005), however,
also seems to have attributed very good results in a considerable
number of patients (n 30). An important detail which may differentiate Rahkos manoeuvre (2002) from the other two is that in
this procedure steps B and C involve bending of the head instead
of head-extension (Figures 2B, 2C). In this way larger angles with
earth horizontal may be achieved and the movement of the debris is
further facilitated by the gravitational forces, since the head is much
more flexible toward bending rather than extending. The latter is
particularly true and important for elderly patients or patients with
dysfunction of the cervical spine.
In cases where the nystagmus elicited by the Dix-Hallpike examination is more pronounced with the affected ear lowermost, two
manoeuvres seem to take the best advantage of the forces which
seem to conduct otoconia toward the vestibule, according to the
underlying mechanisms described previously. Contrary to the previous three manoeuvres, the modified Epley and the manoeuvre proposed by the authors of this study begin with the affected ear down,
since the patient first lies on the affected side (Figures 3, 6) (Jackson et al, 2007; Lopez-Escamez et al, 2006). By using this particle
repositioning procedure Jackson et al (2007) and Lopez-Escamez
et al (2006) have reported very good results in 55 and nine patients
respectively. The authors have used the proposed manoeuvre in a
small number of five patients with excellent results. ASC was the
only canal affected in all five patients of this study. BPPV was not
a result of canal conversion following another manoeuvre in any of
the reported patients. In such patients, particle repositioning through
a manoeuvre is of absolute importance, since there is an established
long-term failure of the ASC to self clear.
Although both the manoeuvres described by the authors of this
study and by Kim et al (2005) may be roughly described as modifications of the D-H examination, they present significant differences.

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International Journal of Audiology, Volume 49 Number 8

Head extension is of particular importance as far as ASC BPPV

is concerned. The angle of the head extension, which may vary
according to the examiners technique or the patients neck flexibility, may influence the clinical findings as well as the outcome of
the therapeutical manoeuvres. It is characteristic that in some cases
of ASC BPPV, nystagmus cannot be triggered unless large angles
of the ASC relative to the earth-horizontal are achieved. Bertholon
et al (2002) report that in two patients with a typical history of
positional vertigo but negative D-H manoeuvres, the straight head
hanging manoeuvre was performed and found positive for downbeating nystagmus with a small torsional component. In this case, it
is assumed that gravitational forces, suitably amplified by a larger
head extension, may have provoked the movement of the displaced
otoconia within the ASC, or may have reinforced this movement so
as to reach the threshold necessary to stimulate the vestibule-ocular
pathway. The head is more extended during the straight head hanging position than during the D-H test, since in the latter the head is
also rotated 4045. Consequently, the angle of the ASC relative to
the earth-horizontal is approximately 20 larger during the straight
head hanging position than during the D-H test. This additional angle
may be responsible for triggering nystagmus in patients with lithiasis of the ASC and negative D-H tests (Korres et al, 2008; LopezEscamez et al, 2006).

Discussion

First, the manoeuvre of Kim et al (2005) begins with the affected

ASC uppermost, since the patient first lies on the healthy side (Figure
5), while the manoeuvre proposed by the authors of this study begins
with the affected ear down, since the patient first lies on the ipsilateral to the lesion side (Figure 6). Second, the manoeuvre of Kim
et al aims at moving the otoconia from the top of the canal further
toward the utricle by nullifying head extension (Figures 5 B, C). In
the manoeuvre proposed by the authors of this study, otoconia are
moved from the top of the canal further toward the utricle by turning
the head toward the side of the lesion, while hyper-extension of the
head is preserved (Figure 6B).
Assuming that gravity is the force which slides the otoliths, the
slope of the canal wall may be important in order to achieve the
movement of otoconia. In theory, the slope of the ASC canal wall
is larger during the movement in Figure 6B, than in Figures 5 B,C.
The vice versa seems to apply to the first step of the manoeuvres,
since the gravitational component is larger in Figure 5A than in
Figure 6A. Therefore, Kims manoeuvre (2005) seems to be more
effective when the nystagmus elicited by the Dix-Hallpike examination is more pronounced with the affected ear uppermost, whereas
the manoeuvre proposed by the authors seems to be more effective
when the nystagmus provoked by the Dix-Hallpike examination is
more intense with the affected ear lowermost.
For those cases where the nystagmus cannot be triggered unless
large angles of the ASC to the earth-horizontal are achieved, the
procedure proposed by Yacovino et al (2009) seems to provide the
largest neck hyperextension. Unlike all the aforementioned particle
repositioning manoeuvres, this procedure uses the head-straight
neck hyper-extension in order to clear otoconia away from the ASC.
The horizontal angle of the ASC relative to the earth-horizontal is
approximately 20 larger during the straight head hanging position
than during the D-H test, in which the head was rotated 4045. The
movement of otoconia away from the ampullary end and toward the
mid part of the ASC is attained solely by the additional gravitational
forces that develop in both ASCs when the neck is hyper-extended.
Diagnosis of the affected ASC is not a prerequisite for the application of this procedure, since the patients head is straight in the
middle in all steps of this procedure. This may prove very helpful
in cases where the torsional component of the nystagmus is very
weak and its direction can not be easily defined (Korres et al, 2008;
Bertholon et al, 2002).
A final comment emerging from the review of the relevant literature is that, regardless of the underlying pathogenetic mechanism,
the orientation of the ASC seems to favour good clinical results
through a variety of therapeutical procedures. Once the otoliths reach
the top of the canal, gravity may easily facilitate their movement
toward the utricle. However, further research with double blind control studies may be the ideal way to investigate which repositioning
manoeuvre is the most effective for each one of the three clinical
subgroups of ASC BPPV. Since this variant of BPPV is rare and difficult to diagnose, statistically significant results in large populations
may require several years or multicentre studies.

Conclusions
ASC BPPV presents with a variety of clinical manifestations during the D-H examination, which may be attributed to a respective diversity in the orientation of the obstructions within the duct,
the anatomy of the semicircular canals, or even the differences in

Korres, Treatment suggestions for the anterior

semicircular canal canalithiasis

the degree of head extension during testing. The canalith repositioning manoeuvres proposed for the treatment of ASC BPPV are
the reverse Epley, the modified Epley, the manoeuvre proposed
by Rahko (2002), by Kim et al (2005), by Yacovino et al (2009),
and a novel manoeuvre described by the authors of the present
study. Similarly to the variety of clinical findings, the repositioning
manoeuvres also seem to use respectively different routes in order
to achieve the movement of otoconia toward the utricle. Although
the orientation of the ASC strongly facilitates the whole procedure
in all cases, this correspondence could possibly indicate that the
clinical findings may be used as guidance for the selection of the
most effective therapeutical manoeuvre. However, further studies
are required before establishing any clinical significance for the
choice of the repositioning manoeuvres according to the clinical
findings of the D-H examination.

Acknowledgements
The authors thank Mrs Athanasia Cheli for the drawings used in the
upper frames of the figures.
Declaration of interest: The authors report no conflicts of interest.
The authors alone are responsible for the content and writing of the
paper.

References
Aw S.T., Todd M.J., Aw G.E., McGarvie L.A. & Halmagyi G.M. 2005.
Benign positional nystagmus. A study of its three dimensional spatiotemporal characterisitics. Neurology, 64, 18971995.
Baloh R.W. 1996. Benign positional vertigo. In: R.W. Baloh & G.M.
Halmagyi (eds.) Disorders of the Vestibular System. New York: Oxford
University Press, pp. 328339.
Bertholon P., Bronstein A.M., Davies R.A., Rudge P. & Thilo K.V. 2002.
Positional down beating nystagmus in 50 patients: Cerebellar disorders
and possible anterior semicircular canalithiasis. J Neurol Neurosurg
Psychiatry, 72, 366372.
Brandt T. 2003. Benign paroxysmal positional vertigo. In: T. Brandt (ed). Vertigo:
Its Multisensory Syndromes, 2nd edn. London: Springer, pp. 25183.
Brantberg K. & Bergenius J. 2002. Treatment of anterior benign paroxysmal
positional vertigo by canal plugging: A case report. Acta Otolaryngol,
122, 2830.
Bronstein A.M. 2003. Vestibular reflexes and positional manoeuvres. J Neurol
Neurosurg Psychiatry, 74, 289293.
Crevits L. 2004. Treatment of anterior canal benign paroxysmal positional
vertigo by a prolonged forced position procedure. J Neurol Neurosurg
Psychiatry, 75, 779781.
Epley J.M. 2001. Human experience with canaliths repositioning manoeuvres. Ann N Y Ac Sci, 942, 179191.
Hamid M. 2001. The manoeuvres for benign positional vertigo. Operative
Techniques in Otolaryngol Head Neck Surg, 12, 148150.
Herdman S.J., Tusa R.J. & Clendaniel R.A. 1994. Eye movement signs in
vertical canal benign paroxysmal positional vertigo. In: A.F Fuchs, T.
Brandt, U. Buttner & D. Zee (eds.). Contemporary Occular Motor and
Vestibular Research: A tribute to David A. Robinson. Stuttgart: Georg
Thieme Verlag. pp. 385387.
Herdman S.J. 1997. Advances in the treatment of vestibular disorders. Phys
Ther, 77, 602618.
Honrubia V., Baloh R., Harris M. & Jacobson K. 1999. Paroxysmal positional
vertigo syndrome. Am J Otol, 20 (4), 465470.
House M.G. & Honrubia V. 2003. Theoretical models for the mechanisms of
benign paroxysmal positional vertigo. Audiol & Neurotol, 8, 9199.

Korres/Riga/Sandris/Danielides/Sismanis

611

Jackson L.E., Morgan B., Fletcher J.C. Jr. & Krueger W.W. 2007. Anterior
canal benign paroxysmal positional vertigo: An underappreciated entity.
Otol Neurotol, 28(2), 21822.
Katsarkas A. 1999. Benign paroxysmal positional vertigo (BPPV): Idiopathic
versus post-traumatic. Acta Otolaryngol, 119 (7), 7459.
Kim Y.K., Shin J.E. & Chung J.W. 2005. The effect of canalith repositioning
for anterior semicircular canal canalithiasis. ORL, 67, 5660.
Korres S., Balatsouras D.G., Kaberos A., Economou C., Kandiloros D. et al.
2002. Occurrence of semicircular canal involvement in benign paroxysmal positional vertigo. Otol Neurotol, 23 (6), 92632.
Korres S. & Balatsouras D. 2004. Diagnostic, pathophysiologic and therapeutic aspects of benign paroxysmal positional vertigo. Otolaryngol Head
Neck Surg, 131, 438444.
Korres S., Balatsouras D. & Ferekidis E. 2006. Prognosis of patients with benign paroxysmal positional vertigo treated with repositioning manoeuvres. JLO, 120, 528533.
Korres S., Riga M., Balatsouras D. & Sandris V. 2008. Benign paroxysmal
positional vertigo of the anterior semicircular canal: Atypical clinical findings and possible underlying mechanisms. Int J Audiol, 47(5), 27682.

Lopez-Escamez J., Molina M. & Gamiz M. 2006. Anterior semicircular canal

benign paroxysmal positional vertigo and positional down-beating nystagmus. Am J Otolaryngol, 27, 173178.
Rahko T. 2002. The test and treatment methods of benign paroxysmal
positional vertigo and an addition to the management of vertigo due to
the superior vestibular canal (BPPV-SC). Clin Otolaryngol & Allied Sci,
27(5), 392397.
Schratzenstaller B., Wagner-Manslau C., Strasser G. & Arnold W. 2005.
Canalolithiasis of the superior semicircular canal: An anomaly in benign
paroxysmal vertigo. Acta Otolaryngol, 125, 10551062.
Seok J.I., Lee H.M., Yoo J.H. & Lee D.K. 2008. Residual dizziness after
successful repositioning treatment in patients with benign paroxysmal
positional vertigo. J Clin Neurol, 4, 107110.
Squires T.M., Weidman M.S., Hain T.C. & Stone H.A. 2004. A mathematical
model for top-shelf vertigo: The role of sedimenting otoconia in BPPV.
J Biomech, 37, 11371146.
Yacovino D.A., Hain T.C. & Gualtieri F. 2009. New therapeutic manoeuvre
for anterior canal benign paroxysmal positional vertigo. J Neurol, 256,
18515.

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