By canal
Anterior canal
The anterior (superior) canal is the rare variant — 3–12% of BPPV. Its upward-sloping orientation means debris usually finds its own way out, and when it presents it does so with downbeat nystagmus, which always raises the question of a central cause.
Recognising it — and excluding central causes
Anterior-canal BPPV is uncommon. On positional testing the eyes beat downward rather than up. Because downbeating eyes can also signal a brain cause, this pattern is always checked carefully before treating.
AC-BPPV produces downbeat or downbeat-torsional nystagmus, best provoked on the straight head-hanging test rather than the standard Dix–Hallpike. Fatigue on repetition and a benign examination support a peripheral cause.3
Central causes of downbeat nystagmus — cerebellar infarction, Chiari malformation, multiple sclerosis — must be excluded, especially where there are neurological features or no fatigability.4 Side determination is often impossible in AC-BPPV, which is why the non-lateralising Yacovino is first-line.
Yacovino manoeuvre
Today's first-line technique for AC-BPPV. A simple three-position sequence — deep head-hanging, then chin-to-chest, then sitting — that needs no side determination, which is precisely its advantage when the affected canal cannot be lateralised. Reported resolution ranges from 70–100% in small series.1
Yacovino manoeuvre
Patient sits upright on the table, head neutral, no rotation.
Why: Baseline before head-hanging.
Deep head-hanging manoeuvre
A deeper, longer-held variant of the Yacovino, holding the head-hanging position to 60–120 seconds. Useful in bilateral, refractory or residual AC-BPPV, and likewise non-lateralising and well tolerated where the neck is restricted.2
Deep head-hanging manoeuvre
Patient sits upright on the table, head in a neutral forward-facing position.
Why: Baseline before deep extension.
Reverse (short) Epley
A mirror-image of the posterior-canal Epley adapted to anterior-canal anatomy. It is not first-line: biomechanical models show a higher risk of canal conversion to the posterior canal, and it requires confident side determination. Reserve it for confirmed unilateral AC-BPPV that has not responded to Yacovino or deep head-hanging.4
Reverse (short) Epley
Patient sits upright, head turned 45° toward the unaffected (left) side.
Why: Prepares the canal orientation for gravity-assisted repositioning.
Key points
- AC-BPPV is rare and presents with downbeat nystagmus — exclude central causes first.
- The straight head-hanging test localises it better than the standard Dix–Hallpike.
- Yacovino is first-line because it is non-lateralising.
- Deep head-hanging is the longer-held variant for refractory or bilateral cases.
- Reverse Epley is a last resort — higher canal-conversion risk, needs a confirmed side.