Ask the Doctor: Slow-to-resolve Horizontal canal BPPV (H-BPPV)

I recently had a few bouts of horizontal canal BPPV. A few log rolls and Gufonis took care of it, except this last one has been stubborn.

It seems between positions one and two of the Gufoni (lying on the  good side, then turning the head to face the bed), the particles are not making it back where they belong. They seem to get stuck before they can get to the utricle, and fall back into the canal either soon after I finish the maneuver, or when I lie back in bed (propped with two pillows).

Read more: Ask the Doctor: Slow-to-resolve Horizontal canal BPPV (H-BPPV)

This problem has to do with the anatomy of the canal.  All three canals are about 2/3 of a circle, with a sensor blocking one end, and the opening at the other.  You need to move all the particles out of the opening.  Imagine this as a clock face, with the sensor/block at 12 o’clock, and the canal circling from 12:00 clockwise around to 8:00, where the opening is.  Between 8 and 12:00 there is another structure, a sac called the utricle, where the particles came from and where you want them to end up.

In the usual Gufoni, you lie on your good side, facing forward, and then turn your head to face the bed.  This moves particles through about half of a circle, (180 degrees or 30 minutes on the clockface model).

This is fine if the particles are located between 3 and 8.  They will rotate 30 minutes or less on the clockface, and exit (the particles at 3 will rotate to the 9, moving them out of the canal at 8).  But the problem is greater if the particles are located near the sensor/block between 12:00 and 2:00 on the clock.  Now when you lie on your side, the particles can only move halfway around the clock, so a particle at 12 ends up at 6—not far enough to exit the canal at 8.  Using the log roll as a treatment for H-BPPV can cause particles to penetrate to this 12-2 position close to the sensor if you accidentally do the log roll toward the bad ear rather than away from it.

This means you must have an extra step to move the particles that start near 12 to the 6 o’clock position, and then a second movement to move them from 6 to 8 and out of the canal. 

The key is that in this circumstance, you need to lie on your good side with your head FACING STRAIGHT UP, not forward as in the original Gufoni.  You want to be looking at the ceiling.  You can tap behind your ear to help get particles moving if needed, and it’s a good sign if you feel dizzy in this step.  This position means that at the end, all particles that are loose will be at the 6:00 position.   Wait for at least 15 seconds or until the spinning stops, and then turn your head toward  the good ear over the course of 10 seconds or so, and roll a bit toward the good side until your head is facing the bed.  This will roll them out of the opening at 8. 

It’s possible for particles to get blocked in the canal near the sensor, because there is a natural narrowing  there.  In that case, vigorously shaking the head can sometimes break up the clump and allow it to pass out.  Repeated tries are usually necessary when there is a blockage, and you may need to see a provider for this.