By canal
Horizontal canal
The horizontal canal accounts for 10–15% of BPPV and splits into two forms — geotropic and apogeotropic — that need different manoeuvres. Reading the supine roll test correctly is what tells them apart.
Geotropic vs apogeotropic
Horizontal-canal BPPV is tested by rolling the head side to side while lying down — the supine roll test. Which way the eyes jump, and which side is stronger, tells you which ear is affected and which manoeuvre to use.
On the supine roll test, geotropic nystagmus (beating toward the ground) indicates canalithiasis; the stronger side is the affected ear. Apogeotropic nystagmus (beating away from the ground) indicates cupulolithiasis or anterior-arm debris; here the weaker side is affected.3
Localisation drives selection. Geotropic forms respond to the Lempert roll or the Gufoni; both significantly outperform sham, with no major efficacy difference between them in a meta-analysis of over a thousand patients.2 Apogeotropic forms are first converted to geotropic — by an apogeotropic Gufoni or a Casani/Zuma manoeuvre — then treated conventionally.
Lempert (barbecue) roll
The best-established manoeuvre for geotropic HC-BPPV: a 360° rotation of the head and body in 90° increments that walks otoconia around the canal back to the utricle. Resolution is 75–92% after one or two cycles.1
Lempert (barbecue) roll
Lies supine with the head turned 90° toward the affected (right) ear.
Why: Triggers geotropic nystagmus and starts otoconia along the canal.
Gufoni manoeuvre — geotropic
Quicker and less physically demanding than the barbecue roll, which makes it a first choice for elderly or mobility-limited patients. For the geotropic form: lie toward the unaffected side, then turn the nose down toward the bed.2,4
Gufoni manoeuvre — geotropic
Patient sits upright on the table with the head in a neutral position.
Why: Baseline before the rapid lateral movement.
Gufoni manoeuvre — apogeotropic
The mirror logic for cupulolithiasis: lie toward the affected side, then turn the nose up. The aim is to free debris from the cupula and convert apogeotropic to the more treatable geotropic form.4
Gufoni manoeuvre — apogeotropic
Patient sits upright with the head in a neutral position.
Why: Baseline before the rapid lateral movement.
Forced prolonged positioning (FPP)
A home, gravity-over-time technique requiring no head turns — useful early in HC-BPPV, as an adjunct after failed repositioning, and in frail or bedridden patients. Geotropic: lie on the unaffected side overnight. Apogeotropic: lie on the affected side.5
Forced prolonged positioning (FPP)
Supine head-roll test localises the canal and side by the direction of nystagmus.
Why: Determines which side to lie on — opposite rules apply to geotropic vs apogeotropic forms.
Casani / Zuma e Maia manoeuvre
A geometric refinement for refractory apogeotropic (anterior-arm) HC-BPPV that resists Gufoni or Lempert. Promising in small series; larger validation is still pending, so reserve it for resistant cases.4,6
Casani / Zuma e Maia manoeuvre
Patient sits upright on a flat surface, head in neutral.
Why: Baseline before a rapid, brisk descent.
Key points
- Read the supine roll test: geotropic = canalithiasis; apogeotropic = cupulolithiasis.
- Localise the affected ear — stronger side in geotropic, weaker side in apogeotropic forms.
- Geotropic: Gufoni or Lempert (comparable efficacy); Gufoni is gentler for frail patients.
- Apogeotropic: convert to geotropic first (apogeotropic Gufoni or Casani/Zuma), then treat.
- FPP is a no-head-turn home option when manoeuvres aren't feasible.