The Semont maneuver is also used to treat anterior canal cupulolithiasis, with the starting position the only difference. The starting position for the anterior canal is still sidelying on the affected side, but the head is rotated toward the affected side, resulting in a nose-down position . As with the posterior canal repositioning maneuver, the patient remains in this position for 1 to 2 minutes, allowing the otoconia to migrate to the lowest point in the canal with respect to gravity (the upper portion of the canal) and is then moved rapidly through the initial sitting position to the opposite side, without turning the head, coming to sidelying on the opposite side in a nose-up position. Horizontal canal CRM for horizontal canalithiasis has become known as the “Barbeque Roll” because the original maneuver resembled the movement around a barbeque spit. The initial technique had the patient rolling on the bed 360° in the direction away from the affected ear, hence the analogy of the barbeque spit. This technique has since been modified to primarily rotate the head through a 270° (3/4 roll) motion, eliminating the need for the patient to perform a full 360° roll. However, the original 360° roll can be done if the patient lacks sufficient cervical mobility, as it maintains a neutral head-on-body alignment. The Barbecue Roll technique starts with the patient in supine, with the affected ear down . The patient or therapist then rotates the head to midline (nose up), then to the unaffected side. Finally, the patient rolls to prone with nose pointing to the floor and the chin tucked into 30° of cervical flexion before coming to sit. The result of this sequence is the rotation of the head through a 270° arc of motion. Each position is maintained for 30 seconds, or until the dizziness stops, in order to allow the otoconia to move through the canal. If the patient is unable to tolerate the movements or positions of either version of the Barbeque Roll technique due to pain or difficulty or inability in assuming any of the positions, an alternate treatment is the Appiani maneuver. In this maneuver, the patient is brought quickly down to sidelying on the unaffected side (affected side up) with the therapist cradling the patient’s head, and remains in that position for 2 minutes to allow otoconia to settle in the gravity-dependent position in the posterior aspect of the horizontal canal (HC). Once 2 minutes have elapsed, the therapist then rotates the head quickly 45° toward the table (nose down), flushing the otoconia out of the canal. That position is maintained for 2 minutes. The patient can then move to a seated position while maintaining the 45° head- rotated position and can resume midline head orientation once he or she comes to a full upright sitting position (see Figure 8). Table 2: Canal Repositioning Maneuvers for BPPV Maneuvers Canal Initial Position
Figure 8: Appiani Maneuver for Left Horizontal Canalithiasis
For the patient with horizontal canal cupulolithiasis, the Casani maneuver has been found to be an effective treatment. The Casani maneuver is a modification of the Semont liberatory maneuver used in posterior canal cupulolithiasis. It is similar to the Semont position in that the patient is brought quickly into a sidelying position on the affected side to dislodge the otoconia from the cupula, but in this maneuver, there is no initial cervical rotation. The head is then rotated quickly 45° toward the floor, and the patient remains in that position for 3 minutes before returning to a seated position. Although this maneuver looks very similar to the Appiani maneuver, there are two distinct differences between them. First, the Appiani is indicated for horizontal canalithiasis, while the Casani is used to treat horizontal cupulolithiasis. Second, the Appiani maneuver starts with the unaffected ear down (affected ear up; Appiani, “up”), while the Casani starts with the affected ear down . Both move the head into 45° of cervical rotation toward the table (see Table 2). Appreciation for the position of the semicircular canals along a 3-dimensional axis of motion will help elucidate the mechanics of movement of debris through each position.
Treatment
Epley
Anterior or Posterior Canalithiasis Posterior Cupulolithiasis
Patient in supine with 20° neck extension and 45° head rotation to affected side. Affected side down , 45° head rotation away from affected side ( nose up ). Affected side down , 45° head rotation toward affected side ( nose down ). Sidelying on unaffected side for 2 minutes. Sidelying on affected side without cervical rotation. Supine, head turned toward affected side.
2 subsequent positions: head rotation to opposite side, then continue with trunk and head rotation, then to sit.
Semont
Move quickly to lying on unaffected side (through returning to sit), without rotating head (nose down).
Semont
Anterior Cupulolithiasis
Move quickly to lying on unaffected side (through returning to sit), without rotating head (nose up).
Appiani
Horizontal Canalithiasis Horizontal Cupulolithiasis Horizontal Canalithiasis
Quick 45° cervical rotation toward unaffected side (nose down). Immediate quick 45° cervical rotation toward affected side (nose down). Maintain 3 minutes. 3 subsequent steps: head roll to opposite side, patient rolls to side, patient rolls to prone.
Casani (aka Modified Semont)
Barbeque Roll (270° roll)
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