Original Paper
Audiology
Audiol Neurotol 2013;18:83–88
Neurotology
DOI: 10.1159/000343579
Canalith Repositioning Procedures
among 965 Patients with Benign
Paroxysmal Positional Vertigo
E. Prokopakis a I.M. Vlastos a M. Tsagournisakis b P. Christodoulou a
H. Kawauchi c G. Velegrakis a
Departments of a Otorhinolaryngology and b Neurology, University of Crete School of Medicine, Heraklion, Greece;
c
Department of Otorhinolaryngology, Faculty of Medicine, Shimane University, Izumo, Japan
Key Words
Benign paroxysmal positional vertigo ⴢ Canalith
repositioning procedure ⴢ Short- and long-term results ⴢ
Vertigo ⴢ Epley maneuvers
Abstract
Background: Canalith repositioning procedure (CRP) has in-
creasingly been utilized for the last 15 years for the treatment
of benign paroxysmal positional vertigo (BPPV). We assess
the short- and long-term efficacy of CRP on the treatment of
patients with BPPV. Methods: Nine hundred sixty-five pa-
tients (481 men and 484 women, from 18 to 87 years of age)
were enrolled in this prospective study during 1995–2010.
Inclusion criteria were a patient history compatible with
BPPV and a positive provocative maneuver (either Dix-Hall-
pike or Roll test). Reported duration of symptoms at the time
of their first examination varied from 1 day to 18 months.
Variants of the Epley and Barbeque maneuver were used for
posterior and anterior canal involvement, and horizontal ca-
nal involvement, respectively. Short-term follow-up was ob-
tained 48 h and 7 days after initial treatment, whereas long-
term follow-up was obtained at repeated 6-month intervals.
Results: Symptoms subsided immediately in 819 patients
(85%) by the first CRP. Only 19 patients (2%) required CRP
more than 3 times. Patients’ mean follow-up was 74 months;
© 2012 S. Karger AG, Basel
1420–3030/13/0182–0083$38.00/0
Fax +41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com www.karger.com/aud
Received: May 23, 2012
Accepted after revision: September 17, 2012
Published online: November 6, 2012
symptom recurrence was noted in 139 patients. A statisti-
cally significantly higher recurrence rate was noted in elder-
ly people or those with head trauma or a history of vestibular
neuropathy (p ! 0.001). Conclusions: This study provides
class IV evidence that CRP remains an efficient and long-last-
ing noninvasive treatment for BPPV, especially for younger
patients without a history of head trauma or vestibular neu-
ropathy. Elderly people have a significantly higher recur-
rence rate requiring additional education to minimize po-
tential morbidity of their falls.
Copyright © 2012 S. Karger AG, Basel
Introduction
Benign paroxysmal positional vertigo (BPPV) is the
most common form of peripheral vertigo with an esti-
mated incidence of 107 cases per 100000 population per
year [Froehling et al., 1991; Lee and Kim, 2010]. Patients
usually report that their symptoms are triggered by a cer-
tain change in head position, such as lying down, rolling
over in bed, bending over, or looking up [Prokopakis et
al., 2005]. Since 1952, when Dix and Hallpike described
their classical provocative maneuver [Dix and Hallpike,
1952], several theories have been proposed in order to ex-
plain the torsional vertical nystagmus that is provoked by
Emmanuel Prokopakis, MD, PhD
Department of Otorhinolarygology, University Hospital of Crete
Building A, 3rd Floor, University Avenue
GR–71110 Heraklion, Crete (Greece)
E-Mail emmanuel @ prokopakis.gr
Table 1. Diagnosis of canal involvement with the Dix-Hallpike test
Canal Right Dix-Hallpike
Right posterior Upbeat, counterclockwise torsional nystagmus
Right anterior Downbeat, counterclockwise torsional nystagmus
Left anterior Downbeat, clockwise torsional nystagmus
a specific ear-down position with a latency of several sec-
onds. Nystagmus typically lasts only for a limited time,
its direction reverses on resuming the upright position
and shows fatigability with a progressive decline of inten-
sity upon repetition of the maneuvers [Dix and Hallpike,
1952]. Among the most widely accepted theories aiming
to explain this phenomenon is the canalithiasis theory,
which states that otoconial debris are freely floating in
the endolymph of the semicircular canal [Parnes and Mc-
Clure, 1992], and the cupulolithiasis theory, in which the
particles are at least partly adhered to the cupula of the
ampullar end of the canal [Schuknecht, 1969]. For the last
few years, BPPV treatment has been based on particle-
repositioning maneuvers or canalith repositioning pro-
cedures (CRPs) that aim at removing otoconial debris
from the semicircular canal and returning them to the
vestibule [Soto-Varela et al., 2011].
Several articles have been published on the utility and
the efficacy of various CRPs for the treatment of BPPV. It
is widely accepted that the majority of these CRPs can
result in substantial benefit with extremely low risk for
harm [Kerber and Helmchen, 2012]. This fact, as well as
the existence of several BPPV forms, poses questions re-
garding the real benefit of CRPs. Short- and long-term
outcomes have been published, and several predictors of
persistence or recurrence have been proposed [Lee and
Kim, 2010]. Moreover, several hypotheses regarding
causes of otolith debris detachment exist. Hormones, cal-
cium metabolism, aging, or trauma may have an effect on
the pathogenesis [Lee and Kim, 2010].
Direct histopathological and molecular studies are
difficult to perform either due to the self-limiting nature
of the disease or because BPPV resolves in the majority of
patients with conservative treatment [Prokopakis et al.,
2005]. Epidemiological data, especially in relation to re-
currence of BPPV, can provide indirect estimations of
pathogenic factors and assessment of prognostic indices.
Large prospective studies on short- and long-term out-
comes of CRPs offer valuable information in this respect.
Herein we report one of the short- and long-term out-
84 Audiol Neurotol 2013;18:83–88
Reversal phase
Downbeat and clockwise torsional nystagmus
Upbeat and clockwise torsional nystagmus
Upbeat and counterclockwise torsional nystagmus
comes of CRP among the largest to date prospective case
series with 965 patients treated for BPPV over a period of
16 years in the Department of Otorhinolaryngology at
the University of Crete, School of Medicine, Greece.
Patients and Methods
This prospective, nonrandomized, uncontrolled study was
based on a previously accepted protocol by the Institutional Re-
view Board for Human Subjects of the University Hospital of
Crete. More specifically, 965 patients (481 men and 484 women,
from 18 to 87 years of age) suffering from BPPV were enrolled in
the study, which was conducted between January 1995 and De-
cember 2010. Inclusion criteria were a positive history and a pos-
itive provocative maneuver at the time of admission (either Dix-
Hallpike or Roll test). The Dix-Hallpike maneuver was also used
for the determination of the involved semicircular canal (table 1).
If the patient’s history was suggestive of BPPV but the provoking
maneuver was negative, the subjects were asked to be re-evaluated
when an acute episode of vertigo reoccurred. Patients with un-
stable heart disease, significant stenosis of carotid arteries, disor-
ders of the spine, suspected central lesion, or Ménière’s attack
were excluded. A central lesion can be suspected either by the Dix-
Hallpike maneuver or the rest clinical examination. More spe-
cifically, neurological consultation and an MRI scan were re-
quested in cases of severe occipital headache, focal neurological
signs, vertical or torsional nystagmus or persistent nystagmus (no
fatigue) during the Dix-Hallpike maneuver. A variant of Epley’s
5-position cycle maneuver was performed for posterior and ante-
rior canal involvement, whereas a variant of the Barbeque maneu-
ver was used for diagnosing horizontal canal BPPV. An Oster
handheld vibrator at 80 Hz was used on the ipsilateral mastoid at
the second position of CRP in the first 110 cases of posterior or
anterior canal involvement. For all the remaining patients, we
manually shook their head or tapped the cranium during CRP
[Epley, 1992; Parnes and McClure, 1992]. Another difference from
the originally described maneuvers was that patients were left
in each position for approximately 3 min as they were rotated
through the maneuver. Although it seems that 3 min is probably
long enough to wait, we decided not to modify our initial protocol
regarding this issue. In all cases, CRP was repeated until no fur-
ther vertigo or nystagmus was provoked. After CRP, patients were
advised not to bend over, move their head up or down, or lie su-
pine for 2 days. Patients returned for re-evaluation 48 h and 7 days
after the maneuver. If the provocative maneuver was positive on
follow-up evaluation, the CRP was repeated (fig. 1). No premedi-
Prokopakis /Vlastos /Tsagournisakis /
Christodoulou /Kawauchi /Velegrakis
cation was routinely administered. For long-term follow-up, pa- Table 2. Number of CRPs performed on admission
tients were contacted by phone every 6 months. They were also
advised to contact us immediately if vertigo reoccurred during Number of patients Number of CRP
the intervals of routine communication. We did not perform im- (total n = 965 = 100%)
aging studies (computed tomography scan or magnetic resonance
imaging) except when vertigo of central origin was suspected. 819 (85%) 1
The importance of increased age and history of head trauma 88 (9%) 2
or vestibular neuropathy in symptom recurrence was evaluated 39 (4%) 3
by means of univariate analysis using the Kaplan-Meier method, 19 (2%) >3
and the log rank test.

Results
Dix-Hallpike test

Between January 1995 and December 2010, we treated (–) (+)

a total of 965 patients with BPPV. The posterior semicir- Follow-up Dix-Hallpike (other side)
cular canal was involved in 849 (88%) of them, whereas (–) (+)
the horizontal and anterior semicircular canals were in- Consider HSC
Epley maneuver (perform Roll test)
volved in 96 (10%) and 20 (2%) patients, respectively. At
the time of the initial examination, duration of symptoms
varied from a few hours to over a year. Thirteen percent Dix-Hallpike test
of patients experienced vertigo for over 3 years, with the
(+) (–)
majority of them reporting more than 3 episodes per year.
Symptoms subsided immediately in 819 patients (85%) af- Epley maneuver Dix-Hallpike in
48 h
ter the first CRP. In 88 patients, the CRP had to be per- (–)
formed twice and only 19 patients (2%) required CRP 3
Dix-Hallpike test Follow-up
times or more (table 2).
Regarding immediate adverse events of CRPs, 5.7% of
patients experienced severe nausea and vertigo during the Fig. 1. Flow chart of a patient presenting with BPPV. HSC = Hor-
procedure, postponing the therapeutic maneuvers. CRPs izontal semicircular canal.
were performed after the administration of antiemetic
therapy (mainly dimenhydrinate or metoclopramide).
Eighty-three percent of patients experienced instability or
‘light-headedness’ for approximately 48 h after CRP. A viduals reported no symptoms of vertigo when contacted
canalith jam was observed in 47 (5%) subjects during the by telephone and were considered cured. One hundred
CRP or the Dix-Hallpike maneuver after the CRP. thirty-nine (15.5%) patients reported recurrence of their
At the follow-up visit, 48 h after initial treatment, the symptoms. Older age and history of head trauma or ves-
provoking maneuver was positive in 135 patients (14%). tibular neuropathy (group B) increase the risk of recur-
Sixty-five of them were over 70 years of age, 22 had a his- rence significantly (p ! 0.001) (fig. 2). The estimated risk
tory of vestibular neuropathy, and 5 of them had experi- of symptom recurrence using a Kaplan-Meier analysis is
enced serious head trauma. CRP was repeated on all these 7 and 55% in groups A (younger patients without history
patients. During the third evaluation (i.e., a week after of head trauma or vestibular neuropathy who encoun-
initial treatment), the provoking maneuver was still pos- tered recurrence of symptoms) and B, respectively, by 16
itive in 77 (8% of total) patients. Thirty-six were over 70 years (fig. 2).
years of age, 7 and 2 had a history of vestibular neuropa-
thy and head trauma, respectively (table 3). CRP was per-
formed again on all these patients with a positive provok- Discussion
ing maneuver as during the first admission.
In our group of patients, the mean follow-up was 74 To our knowledge, this is the largest prospective BPPV
months. Seventy people were lost to follow-up or died series study that has been published in English to date. It
from other causes. Seven hundred fifty-six (84%) indi- clearly indicates the importance of older age and history

Canalith Repositioning Procedures Audiol Neurotol 2013;18:83–88 85

among Patients with BPPV
Table 3. Recurrences noticed in the short-
Evaluation
term follow-up period (percentages are
referred to the total number of the study
patients)
2nd (48 h)
3rd (1 week)
150
Percent of no recurrence
100
50
0
0 5 10 15
Duration (years)
Fig. 2. Long-term recurrence of BPPV after CRP. Kaplan-Meier
estimation of recurrence rates in patients younger than 70 years
of age without history of vestibular neuropathy or head trauma
(group A, upper curve) and in group B (lower curve, includes all
patients not in group A).
of head trauma, as well as vestibular neuropathy as pre-
disposing factors for symptom recurrence.
A number of possible pathomechanisms have been
proposed for BPPV. The ‘cupulolithiasis’ or the ‘heavy
cupula’ theory was addressed by Schuknecht in 1962
[Schuknecht, 1969] and a liberatory maneuver, the so-
called Semont maneuver [Semont et al., 1988], is used in
order to release the debris from the cupula of the poste-
rior semicircular canal. Although there are some histo-
logical findings of debris attaching to the cupula, several
features of vertigo are contradictory to the cupulolithiasis
theory. This led to a second theory, proposed by Hall and
McClure [Hall et al., 1979] in 1979, known as the canali-
thiasis hypothesis. After the identification of free-float-
ing particles within the posterior canal endolymph dur-
ing surgical canal occlusions by Parnes and McClure
[Parnes and McClure, 1992], the canalithiasis theory has
been widely accepted as the main pathophysiologic mech-
anism for BPPV. CRPs have been proposed as an effective
86 Audiol Neurotol 2013;18:83–88
(+) provoking >70 years old (+) history of vestibular (+) history of
maneuver neuropathy head trauma
135 65 (48%) 22 (16%) 5 (4%)
77 36 (47%) 7 (9%) 2 (3%)
conservative method of treatment based on this hypoth-
esis. However, this does not necessarily mean that cupu-
lolithiasis is a failed theory. The current convention is to
consider both as subclasses of BPPV, since both cause po-
sitional vertigo. Cupulolithiasis, contrary to canalithia-
sis, has minimal latency, minimal fatigability, and mini-
mal response decline on repeated maneuvers. It is be-
lieved that it can be converted to canalithiasis by CRPs
for treatment purposes.
The Epley maneuver and its variant represent the CRP
for posterior and anterior canal BPPV. It involves posi-
tioning the patient through 5 positions with the aim of
20 moving the free-floating particles from the posterior or
anterior semicircular canal through the common crus to
the utricle [Epley, 1992]. For horizontal canal BPPV, the
repositioning procedure is the Barbeque maneuver (i.e.,
rolling the patient 360 degrees in the direction opposite
from the involved canal) [Lempert and Tiel-Wilck, 1996].
It is of interest that in both the Semont and Epley maneu-
ver, otoconia moves in the same manner during the re-
positioning procedure. However, the main disadvantage
of Semont’s maneuver is that there may be difficulty in
execution, especially when the patient is rather corpulent
or has cervical spine or back problems [Semont et al.,
1988].
Recently, a new concept has suggested that the major
pathologic change in BPPV involves degeneration of ves-
tibular neurons. Histopathology of temporal bones ob-
tained at autopsy from 5 individuals with the clinical his-
tory of BPPV showed significant loss of ganglion cells in
the superior and inferior vestibular division of the eighth
cranial nerve [Gacek, 2003]. Loss of the inhibitory action
of otolith organs on canal activation caused by degen-
eration of otolith neurons innervating within the saccule
and utricle is a possible explanation of the brief canal re-
sponse induced by the positional stimulus [Gacek, 2003].
Brandt-Daroff habituation exercises [Brandt and Daroff,
1980] may have a positive effect on otolith organ func-
tion regarding this ‘neuronic’ theory. We generally do
not advise our patients to follow these exercises because
of a risk of inappropriate performance and inadequate
follow-up.
Prokopakis /Vlastos /Tsagournisakis /
Christodoulou /Kawauchi /Velegrakis
 On the contrary, we used a modified Epley reposition-
ing maneuver for the management of both the posterior
and anterior semicircular canalithiasis, and a modified
Barbeque maneuver for horizontal canal involvement.
The main modification in our CRP procedures is that the
patient is left in every position for 3 min. Epley described
the CRP with the use of a bone vibrator (either a conven-
tional audiometric bone vibrator at 700 Hz or an Oster
handheld vibrator at 80 Hz) placed on the mastoid of the
affected ear [Epley, 1992]. We used an Oster handheld vi-
brator on the ipsilateral mastoid in the first 110 patients
at position 2 of the Epley maneuver, but found the use of
the vibrator did not change our rates of successful treat-
ment. Head shaking or tapping of the cranium accom-
plishes the same action as Epley’s skull vibrator, and is
more easily performed [Hain et al., 2000; Prokopakis et
al., 2005].
Symptoms subsided in 86% of patients after one CRP.
Our practice of repeating the CRP until the Dix-Hallpike
maneuver is negative is based on the fact that not all of
the debris may have moved into the vestibule with the
first CRP. Apart from the insufficient completion of the
CRP maneuver, especially in the elderly people, several
other explanations can be provided for the failure of the
first CRP, especially in cases with atypical features, for
example, a combination of possible pathophysiological
mechanisms, bilateral cases of cupulolithiasis or even the
so-called canalith jam. The latter phenomenon can be
noticed by a sudden conversion of transient nystagmus to
a rapid form that persists irrespective of head position
[Epley, 2001; Imai et al., 2006]. We observed canalith jam
(conversion of one canal variant to another) in 47 (5%)
patients of our cases. This phenomenon is probably re-
lated to the jamming of the canaliths when migrating
from a wider to a narrower segment [Epley, 2001]. Thera-
peutically, after the identification of the probable location
of the obstruction, reversing the just completed maneu-
ver is effective in clearing the jam. Regarding bilateral
BPPV, our protocol did not allow us to distinguish be-
tween bilateral posterior BPPV and horizontal canal
BPPV cases. Thus, in our series, bilateral BPPV can only
be speculated in cases of persistent vertigo despite 2 or
more CRPs (table 2).
Regarding short-term outcomes of CRPs, these ma-
neuvers can be considered both effective and safe. We
neither prescribed any medication for BPPV, other than
to relieve nausea, nor performed any surgical procedure
due to the excellent results that were achieved with our
conservative treatment. Eight hundred one patients (83%)
complained of instability or a ‘light-headedness’ sensa-
Canalith Repositioning Procedures
among Patients with BPPV
tion for 48–72 h after the CRP. This is probably caused by
the new position of the particulate matter in the vestibule
resting against the utricle in an unfamiliar position
[Welling and Barnes, 1994]. Because of the new attach-
ment of debris to the otolithic membrane of the utricle,
an adaptation to the signals received from the changed
otolith pressure occurs, which leads to an altered stimula-
tion of the sensory epithelium of the utricle.
Vertigo often recurs in BPPV, with reported recur-
rence rates of 15–50% after effective initial CRPs [Brandt
et al., 2006; Del Rio and Arriaga, 2004; Epley, 1992; Fur-
man and Cass, 1999; Gordon et al., 2004; Nunez et al.,
2000; Sakaida et al., 2003]. Factors associated with a
higher recurrence rate include being female, presence of
preceding illnesses such as trauma, labyrinthitis, and en-
dolymphatic hydrops, presence of osteopenia/osteopo-
rosis, horizontal canal type of BPPV, and a history of 3
or more BPPV attacks prior to treatment [Lee and Kim,
2010]. In our cases, a statistically significantly higher re-
currence rate was noted in elderly people or those with a
head trauma or a history of vestibular neuropathy. This
is consistent with the aforementioned studies [Lee and
Kim, 2010].
The prevalence rates of osteopenia and osteoporosis
have been found to be higher in both women and men
with BPPV than in normal controls, suggesting the in-
volvement of deranged calcium metabolism in idiopathic
BPPV [Lee and Kim, 2010]. Moreover, scanning electron
microscopy in rats shows a progressive degeneration of
otoconial structure in the oldest rats [Jang et al., 2006], a
phenomenon consistent with our findings of worse prog-
nosis in the elderly. This is of importance since it could
increase the rate of falls and the morbidity or even mor-
tality in the elderly [Bhattacharyya et al., 2008]. BPPV
may also develop secondary to various disorders that
damage the inner ear and detach the otolith from the
utricular macule like head trauma [Katsarkas, 1999].
Nevertheless, as for many other inner ear disorders, cer-
tain details of its pathophysiology, in particular sponta-
neous recovery, remain elusive, largely due to the inabil-
ity to internally image the inner ear in enough detail
[Hornibrook, 2011].
A possible report bias that is introduced by the tele-
phone assessment can be considered a limitation of this
study. Nevertheless, the study population lives on an is-
land (Crete) and can be easily assessed. This explains the
small attrition rate, despite the large number of partici-
pants and the long follow-up period. Moreover, it allows
for the development of a specific flow chart (fig. 1).
Audiol Neurotol 2013;18:83–88 87
 In conclusion, CRP (either Epley or Barbeque maneu- Disclosure Statement
ver) is an effective (up to 92% success rate in the short
The authors report no conflicts of interest or financial rela-
term) and safe conservative treatment option for BPPV. tionships.
Patients should be counseled on the possibility of recur-
rence which is 7–55% in the long term. This is especially
important for elderly patients who have an increased re-
currence rate of BPPV, and are more vulnerable with falls.

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88 Audiol Neurotol 2013;18:83–88 Prokopakis /Vlastos /Tsagournisakis /

     

Christodoulou /Kawauchi /Velegrakis

     
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