Immediate and short‐term effects of Gufoni and Appiani liberatory maneuver for treatment of ageotropic horizontal canal benign paroxysmal positional vertigo: A prospective randomized trial

Abstract

Objective To examine the treatment effects of repositioning maneuvers with the head turned 45° downwards (Gufoni maneuver) and 45° upwards (Appiani maneuver) in 25 patients with ageotropic horizontal semicircular canal (HSCC) benign paroxysmal positional vertigo (BPPV). Methods Patients were randomly assigned to the Gufoni or Appiani maneuvers, and their immediate and short‐term efficacy was investigated. Results The immediate treatment response was successful in four of 16 patients who were treated with the Appiani maneuver and were not successful in any of the nine patients treated with the Gufoni maneuver. The patients who showed spontaneous resolution during follow‐up outnumbered the patients who showed resolution of ageotropic HSCC BPPV immediately after the repositioning maneuvers. Conclusion This study showed a very low immediate resolution rate of ageotropic HSCC BPPV after the Gufoni maneuver; this may be attributed to the less effectiveness of the Gufoni maneuver against debris that often exists in the canal side of the cupula. Another interesting finding was that the rate of spontaneous resolution during the follow‐up period was higher than that of immediate resolution after the repositioning maneuvers, which may support the recently proposed hypothesis that ageotropic positional nystagmus can also be evoked by causes other than the otolithic attachment on the cupula, such as a slight change in the biochemical composition of the inner ear fluids. Level of Evidence 3.

New Therapeutic Maneuver for Horizontal Semicircular Canal Cupulolithiasis: A Prospective Randomized Trial

“…Some early maneuvers for HSCC cupulolithiasis were limited in covering all possible locations of the otolithic debris in positional relation with the cupula (canal-side or utricular-side debris). For example, considering the current anatomical point of view, the Gufoni maneuver seems to be more effective for the utricular-side debris than the canal-side debris [ 1 , 16 , 28 , 29 ]. The Appiani maneuver, on the other hand, seems to be more effective for the canal-side debris than the utricular-side debris [ 1 , 30 ].…”

“…All patients underwent positioning maneuvers including bowing, lying down, supine head roll, Dix-Hallpike, and straight head hanging position. During the positioning maneuvers, nystagmus was observed without eyeball fixation using a video-Frenzel goggle device (SLMED, Seoul, Korea) [ 16 ]. A typical HSCC cupulolithiasis was diagnosed by the following nystagmus findings: (1) direction-changing horizontal nystagmus beating towards the uppermost ear (apogeotropic nystagmus) in both right and left head turning in the supine position, (2) persistent apogeotropic nystagmus without latency in the supine head roll test to exclude canalolithiasis of the anterior arm of HSCC, and (3) no evidence of prominent vertical or torsional nystagmus component suggesting BPPV involving the anterior or posterior semicircular canal.…”

“…The affected side was determined with the following assumptions: (1) the intensity of the apogeotropic nystagmus is weaker when the head is turned to the affected side according to Ewald’s second law [ 8 , 17 , 18 ]; (2) the lying-down nystagmus beats mostly towards the affected side, while the bowing nystagmus beats mostly towards the healthy side [ 8 , 17 , 19 ]; and (3) a null point, where the nystagmus is suppressed, is mostly observed on the affected side with a 15- to 30-degree head turn [ 16 ].…”