On the supine head roll test, a 58-year-old woman develops nystagmus that beats toward the uppermost ear when she lies with her right ear down, and reverses direction when rolled to the other side. Which variant of BPPV does this indicate, and what is the standard treatment?

• A Posterior canal BPPV, treated with the Epley manoeuvre
• B Horizontal canal BPPV, treated with the barbecue roll or Gufoni manoeuvre ✓
• C Anterior canal BPPV, treated with the Yacovino manoeuvre
• D Horizontal canal BPPV, treated with the Semont liberatory manoeuvre

Explanation

Geotropic horizontal canal BPPV gives nystagmus beating toward the dependent ear, which is the lowermost position during the roll test, but here the fast phase beats toward the unaffected uppermost ear, consistent with geotropic nystagmus elicited by placing the affected canal below. Direction changes between sides, unlike posterior canal BPPV where the direction stays fixed. The Semont and Epley manoeuvres target the posterior canal, and the Yacovino manoeuvre targets the anterior canal.

Reference: Cummings Otolaryngology: Head and Neck Surgery, 7th ed.

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Written and medically reviewed by the StethoPrep medical team.