International Journal of Audiology

ISSN: 1499-2027 (Print) 1708-8186 (Online) Journal homepage: http://www.tandfonline.com/loi/iija20

Diagnosis and treatment of anterior canal benign

paroxysmal positional vertigo

Xia Ling, Kang-Zhi Li, Bo Shen, Li-Hong Si, Yuan Hong & Xu Yang

To cite this article: Xia Ling, Kang-Zhi Li, Bo Shen, Li-Hong Si, Yuan Hong & Xu Yang (2018):
Diagnosis and treatment of anterior canal benign paroxysmal positional vertigo, International
Journal of Audiology, DOI: 10.1080/14992027.2018.1472397

To link to this article: https://doi.org/10.1080/14992027.2018.1472397

Published online: 15 Oct 2018.

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INTERNATIONAL JOURNAL OF AUDIOLOGY
https://doi.org/10.1080/14992027.2018.1472397

ORIGINAL ARTICLE

Diagnosis and treatment of anterior canal benign paroxysmal positional vertigo

Xia Linga, Kang-Zhi Lia, Bo Shenb, Li-Hong Sia, Yuan Hongc and Xu Yanga
a
Peking University Aerospace School of Clinical Medicine, Beijing, PR China; bDepartment of Neurology, The First Affiliated Hospital of Jinzhou
Medical University, Jinzhou, PR China; cDepartment of Neurology, Aerospace Center Hospital, Peking University Aerospace School of Clinical
Medicine, Beijing, PR China

ABSTRACT ARTICLE HISTORY

Objective: To investigate the diagnosis and treatment of anterior canal benign paroxysmal positional ver- Received 19 October 2017
tigo (AC-BPPV). Accepted 26 April 2018
Design: Retrospective analysis of clinical data regarding the diagnosis and treatment of patients with
AC-BPPV. KEYWORDS
Anterior canal; benign
Study sample: Six patients with AC-BPPV. paroxysmal positional
Results: All patients underwent the Dix–Hallpike test and/or the straight head-hanging test to induce ver- vertigo; nystagmus; follow-
tigo and down-beating nystagmus with or without torsional components. Down-beating nystagmus up diagnosis;
in patients 1, 3 and 6 lasted <1 min and was successfully treated with the Yacovino manoeuvre. Down- Yacovino manoeuvre
beating nystagmus in patients 2, 4 and 5 lasted >1 min. The Yacovino manoeuvre was not effective in
patient 4, whereas it was effective in patient 2 but with frequently recurring symptoms. Patients 3, 4 and
6 also had other types of typical BPPV. Canal conversion appeared in patients 4 and 5 during the follow-
up period.
Conclusion: Typical BPPV, canal conversion, a therapeutic diagnosis after applying the Yacovino man-
oeuvre, and the follow-up outcome contribute to AC-BPPV diagnosis in patients with dizziness and vertigo
presenting with down-beating positional nystagmus. Yacovino manoeuvre was more effective in AC-BPPV
patients with down-beating positional nystagmus lasted <1 min than in those in whom it lasted >1 min.

Introduction
There is evidence that anterior canal benign paroxysmal pos-
itional vertigo (AC-BPPV) is the least common type of BPPV
(von Brevern 2013). A recent systematic review on AC-BPPV
reported that the incidence of AC-BPPV was about 3% (range
1.0%–17.1%) (Anagnostou, Kouzi, and Spengos 2015). Before the
1980s, BPPV was considered to occur mainly in the posterior,
horizontal canal, and AC-BPPV was rarely observed clinically. In
1994, Herdman et al. (Herdman, Tusa, and Clendaniel 1994)
found that 9 of 77 patients with BPPV had AC-BPPV. In 1999,
Honrubia et al. (1999) used infra-red video cameras and Frenzel
lenses to record nystagmus in 292 BPPV patients and found 4
patients with AC-BPPV. Thus, AC-BPPV has been recognised
only during the past two decades.
Honrubia et al. (1999) noted that AC-BPPV is likely present
when torsional down-beating nystagmus appears during the
Dix–Hallpike test and/or the straight head-hanging test if there is
no central evidence. In clinical practice, it is difficult to differen-
tiate vertical down-beating nystagmus from a central disease or
AC-BPPV. Diagnosis of AC-BPPV thus remains challenging
for clinicians.
Manoeuvre reduction has been reported to be effective treat-
ment for AC-BPPV (Casani et al. 2011). At present, the Rahko
(Rahko 2002), reverse Epley (Parnes, Agrawal, and Atlas 2003),
Kim (Kim, Shin, and Chung 2005) and Yacovino (Yacovino,
Hain, and Gualtieri 2009) manoeuvres are primarily used for
reducing AC-BPPV. For the Rahko manoeuvre (Rahko 2002), the
patient lies on the healthy side with the head tilted downward
45
, then horizontally and upward 45
for 30 s, finally sitting up
and staying there for at least 3 min. This method was proposed
by Rahko (2002), who treated 57 patients with it and found that
53 patients’ (93%) symptoms were relieved.
With the reverse Epley manoeuvre (Parnes, Agrawal, and
Atlas 2003), the patient sits on the examination bed while the
physician turns the patient’s head 45
toward the healthy side,
and then quickly positions the patient supine with the head
hanging at 30
over the edge of the bed. This position is held
there for at least 30 s or until nystagmus or vertigo are absent.
The patient’s head is then turned 90
toward the affected side,
with the position held for 30 s or until the nystagmus or vertigo
is relieved or has disappeared. The patient’s head and body are
then turned another 90
toward the affected side, with the pos-
ition held for 1–2 min or until nystagmus or vertigo disappears.
The patient is then brought back up to the sitting position.
Honrubia et al. (1999) found that the reverse Epley manoeuvre
had a success rate of >90%. Anagnostou, Kouzi, and Spengos
(2015) found that the mean success rate for reverse Epley man-
oeuvre was 75.9%.
For the Kim manoeuvre (Kim, Shin, and Chung 2005), the
patient sits on the bed with head turned 45
toward the healthy
side. The physician then positions the patient supine position
with the head hanging 45
over the end of the bed. This position
is held for 2 min, after which the patient’s head is raised while
maintaining it at 45
, and the position held for 1 min. The
patient is returned to the sitting position with the chin tilted
down 30
while maintaining the head at 45
, finally, keeping
chin tilted down, the head is turned forward and returned to the

CONTACT Xu Yang yangxu2011@163.com Peking University Aerospace School of Clinical Medicine, Beijing 100049, PR China
ß 2018 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society
2 X. LING ET AL.

upright position. This manoeuvre was proposed by Kim, Shin,

presence of typical BPPV

and Chung (2005), who achieved complete remission of symp-

Therapeutic diagnosis, and

Presence of typical BPPV,

Presence of typical BPPV,

Diagnosis strategy
toms in 29 of 30 patients (96.7%) with AC-BPPV.

Therapeutic diagnosis

Therapeutic diagnosis

Therapeutic diagnosis

during the follow-

The Yacovino manoeuvre, also called the deep head-hanging

canal conversion

canal conversion
manoeuvre (Yacovino, Hain, and Gualtieri 2009), includes the
following. steps: (1) The patient is positioned in the sitting pos-

up period
ition on the examination bed and then rapidly lies down with
the head hanging 30
–75
over the end of the bed for 30 s. The
head is then brought up quickly to touch the chest; and 30 s after
that the patient is brought back to a seated position with head

AC-BPPV (probably the right side)

Left lateral vestibular dysfunction
bent slightly forward. When vertigo and nystagmus disappear,

RAC-RPC-BPPV became into RPC-

RPC-RHC-BPPV (AC-BPPV ectopic
and it became into RAC-RHC-
AC-BPPV (probably the left side)

RAC-RPC-BPPV was followed up

the patient is brought back to a neutral head position. The man-

Right lateral vestibular func-

Right lateral vestibular func-

BPPV during the follow-

oeuvre can be repeated if symptoms are not alleviated or the

Final diagnosis
reduction fails. Yacovino et al., who proposed this manoeuvre,
found that it was effective in all 13 patients with AC-BPPV who

tion impairment

tion impairment
they treated with it. Anagnostou, Kouzi, and Spengos (2015)

possibility)

up period
found that the Yacovino manoeuvre had an average effectiveness

RHC-BPPV
RAC-BPPV
rate of 78.8%.

BPPV
These first three of these four manoeuvres (Rahko, reverse
Epley, Kim) can be used to treat AC-BPPV with an identified
affected side. The fourth, Yacovino manoeuvre can be used to
reduce AC-BPPV with an unknown affected side. We chose the

Right lateral vestibular func-

Right lateral vestibular func-

Central vestibular lesions?

Central vestibular lesions?

Yacovino manoeuvre to treat AC-BPPV in the present study.

Initial diagnosis

RAC-BPPV? HC-BPPV？
Left lateral vestibular

tion impairment?

tion impairment
Subjects and methods

dysfunction

AC-PC-BPPV?
Subjects

RAC-BPPV?
RPC-BPPV
AC-BPPV?

AC-BPPV?

AC-BPPV?
Six patients with AC-BPPV (one man, five women; aged 54–82
years) who underwent treatment between 1 January 2017, and 31
June 2017, were included in this study. All patients underwent
Normal

Normal

Normal

Normal

Normal

Normal
MRI

routine neuro-otology examinations (including cranial nerve

examination, Romberg’s sign and Fukuda test), pure-tone audi-
ometry, and eye movement, vestibular function, and dynamic
Canal paresisa

positional examinations. Eye movement examinations included Right (100%)

Right (33%)
Left (37%)

the gaze test, saccade test, smooth pursuit test, and optokinetic
Table 1. Clinical data for six patients with anterior canal benign paroxysmal positional vertigo.

nystagmus test, and fixation suppression test. Vestibular function

No

No

No
examinations included the head-shaking nystagmus and caloric
test. Dynamic positional tests included the Dix–Hallpike (D–H)
disease (day)
Duration of

test, straight head-hanging (SHH) test and Roll test. All patients
1

1
14

21

720

underwent magnetic resonance imaging (MRI) examination.

Clinical data of six patients were shown in Table 1.

Diagnostic criteria
Hypertension, diabetes mellitus,

Hypertension, diabetes mellitus,

Hypertension, diabetes mellitus,

AC-BPPV, anterior canal benign paroxysmal positional vertigo.

BPPV was diagnosed according to the diagnostic criteria for

Previous history

BPPV formulated by the Barany Society (von Brevern et al.

2015): (1) Recurrent attacks of positional vertigo or dizziness
hyperlipoidemia

hyperlipoidemia

hyperlipoidemia

triggered by changes in head position. (2) Positive D–H and/or

SHH tests. Vertical down-beating nystagmus with or without tor-
Hypertension

sional component is observed in D–H and SHH tests indicating

AC-BPPV. Vertical up-beating nystagmus with torsional compo-
None

None

nent observed in a D–H test indicates PC-BPPV. If the Roll test

On caloric testing, more than 25%.

is positive, the presence of apo geotropic/geotropic horizontal

Age (year)

nystagmus during the Roll tests is evidence of HC-BPPV. (3)

Identifying the affected side in BPPV. For AC-BPPV: In the
54

78

63

82

57

54

D–H position, nystagmus may be stronger or exclusively present

with the affected ear up. If the D–H or SHH test induces down-
Female

Female

Female

Female

Female

beating nystagmus with a torsion component, the torsion direc-

Sex

Male

tion of the upper pole of the eyes indicate the affected side. For
PC-BPPV, if the D–H test induces up-beating nystagmus with a
torsion component, the torsion direction of the upper pole of the
Cases

eyes indicates the affected side. For HC-BPPV, if geotropic

1

a

nystagmus is induced on both sides during the Roll test, the
intensity of positional nystagmus is stronger with the head
turned to the affected ear, whereas for apogeotropic nystagmus,
the intensity of positional nystagmus is stronger with the head
turned away from the affected ear during the Roll test.
(4) Cupulolithiasis and canalolithiasis: Canalolithiasis is charac-
terised by nystagmus lasting <1 min, whereas cupulolithiasis is
evidenced by nystagmus lasting >1 min. (5) Conditions not
attributable to other disorders, such as acute cerebrovascular dis-
ease, vestibular paroxysmia, vestibular migraine
Case analyses
Case 1
A 54-year-old woman was admitted because of a 2-week history
of recurrent vertigo. When vertigo occurred, she was dizzy, with
nausea and vomiting, but no other symptoms. Vertigo often
occurred when she bowed or raised her head, and each episode
lasted for about 1 min. After rest, these symptoms self-mitigated.
She had a 5-year history of hypertension. Otology examination
showed that her hearing was normal. No abnormal physical signs
were found during a neurological examination.
The left D–H test did not show nystagmus. The right D–H
test, however, revealed down-beating nystagmus, approximately
5
/s (slow-phase velocity, SPV), that lasted about 30 s. When she
sat up, up-beating nystagmus, approximately 4
/s (SPV),
occurred, lasting about 10 s. Down-beating nystagmus, approxi-
mately 6
/s (SPV), lasting about 10 s, was observed during the
SHH test. When she sat up, up-beating nystagmus, approximately
3
/s (SPV), occurred lasting about 10 s. The canal paresis value
was 37% (left), indicating that the function of the left horizontal
semicircular canal was reduced. No other abnormality was
observed on brain MRI or diffusion-weighted imaging (DWI).
The patient was preliminarily diagnosed as having probable AC-
BPPV-induced (?) or central vestibular lesions-induced (?) left
peripheral vestibular functional impairment.
After two manual reduction operations using the Yacovino
manoeuvre, D–H and SHH tests showed that the down-beating
nystagmus disappeared, and the symptoms of vertigo had greatly
diminished. The patient was finally diagnosed as suffering from
AC-BPPV (probably due to canalolithiasis of the left anterior
canal) and left peripheral vestibular function impairment.
Case 2
A 78-year-old woman was admitted because of a 3-week history
of recurrent vertigo. Three weeks previously, vertigo occurred
when she bowed her head while standing. It lasted about 30 min,
without nausea, vomiting, or other accompanying symptoms.
Vertigo symptoms occurred mostly during postural changes. She
had a history of hypertension, diabetes mellitus and hyperlipid-
aemia. Otology examination showed that her hearing was nor-
mal. No abnormal physical signs were found by neurological
examination.
Down-beating nystagmus, approximately 8
/s (SPV) and las-
ting >1 min, was observed during the left D–H test. When she
sat up, up-beating nystagmus was observed. Nystagmus was not
observed in the right D–H test or the Roll test. The caloric test
revealed a canal paresis value of 16%, indicating normal function
of the bilateral horizontal semicircular canals. The patient was
preliminarily diagnosed as likely AC-BPPV (?).
INTERNATIONAL JOURNAL OF AUDIOLOGY 3
After two manual reduction operations using the Yacovino
manoeuvre, the D–H test showed that the nystagmus had weak-
ened, but the patient still complained of vertigo. One week later,
her vertigo recurred, with and the same symptom. The left D–H
test revealed down-beating nystagmus, approximately 6
/s (SPV),
lasting about 40 s. When she sat up, up-beating nystagmus was
observed in the left D–H test. No nystagmus was observed in the
right D–H test or the Roll test. After two more tentative manual
repositioning operations using the Yacovino manoeuvre, her nys-
tagmus disappeared. The patient was finally diagnosed as having
AC-BPPV (probably due to cupulolithiasis of the right anter-
ior canal).
Case 3
A 63-year-old woman was admitted because of a 1-day history of
vertigo. One day before admission, the patient felt dizzy when
she arose, with nausea and omitting, but without the sense of
rotation or other accompanying symptoms. When she lay down
and turned left and right, the dizziness worsened. Each episode
lasted 1–2 min, after which the dizziness self-mitigated.
The left D–H test revealed apogeotropic torsional, down-beat-
ing nystagmus (the upper pole of the eyes beating toward the
right ear) with a rightward horizontal component of approxi-
mately 22
/s (SPV) and a vertical component of approximately
8
/s (SPV) lasting about 40 s. When she sat up, no nystagmus
was observed. The right D–H test revealed apogeotropic horizon-
tal nystagmus, approximately 8
/s (SPV), that lasted >1 min. The
Roll test, with the patient in the left lateral position, revealed
apogeotropic horizontal nystagmus, approximately 29
/s (SPV),
that lasted >1 min. When she was in the right lateral position,
she exhibited apogeotropic horizontal nystagmus, approximately
12
/s (SPV), lasting >1 min. When she was in the head vertical-
hanging position, she exhibited down-beating nystagmus,
approximately 6
/s (SPV), lasting about 5 s. When she sat up,
nystagmus was not observed. The canal paresis value was 33%
(right). These findings suggested reduced function of the right
semicircular canal.
The patient was preliminarily diagnosed as having right AC-
BPPV (canalolithiasis of the anterior canal), right HC-BPPV-CU
(cupulolithiasis of the horizontal canal) and impaired right per-
ipheral vestibular function.
After tentative manual reduction using the Yacovino and
Barbecue manoeuvres, dynamic position testing was performed
again. The left D–H test revealed apogeotropic horizontal nystag-
mus of approximately 7
/s (SPV), lasting >1 min. The right D–H
test revealed apogeotropic horizontal nystagmus of approximately
8
/s (SPV), lasting >1 min. When the patient was in the vertical
head-hanging position, no nystagmus was observed. When the
patient was in the left lateral position, the Roll test revealed no
nystagmus. When she was in the right lateral position, the Roll
test showed apogeotropic horizontal nystagmus, approximately
8
/s (SPV) lasting >1 min. The patient’s vertigo was obviously
mitigated. Brain MRI and DWI revealed an old lacunar ischae-
mic locus under the bilateral frontal lobe cortices.
Five days later, the left D–H test showed apogeotropic hori-
zontal nystagmus of approximately 7
/s (SPV) and lasting 1 min.
Apogeotropic horizontal nystagmus of approximately 8
/s (SPV)
and lasting >1 min was also present. No nystagmus was observed
with the SHH test or the Roll test. During the positional
tests, patient noted that the symptoms of vertigo were
obviously alleviated. Ten days after one more manual
4 X. LING ET AL.
repositioning using the Barbecue manoeuvre, the patient was fol-
lowed up via telephone, and she reported no dizziness or vertigo.
The patient was finally diagnosed as suffering from right
AC-BPPV (canalolithiasis of the anterior canal), right HC-BPPV-
CU (cupulolithiasis of the horizontal canal) and impaired right
peripheral vestibular function.
Case 4
An 82-year-old man was admitted because of a 2-year history of
recurrent vertigo. The patient complained of recurrent paroxys-
mal dizziness and instability. These symptoms were present when
he stood up or turned left or right. Each episode lasted 1–2 min
and then self-mitigated, with nausea and vomiting, but with no
other accompanying symptoms. Otology examination showed
that his hearing was normal. No abnormal physical sign was
found by neurological examination.
The left D–H test revealed down-beating nystagmus, approxi-
mately 11
/s (SPV) and lasting >1 min. When he sat up, up-beat-
ing nystagmus, approximately 6
/s (SPV), was observed. the right
D–H test revealed geotropic torsional, up-beating nystagmus,
with a leftward horizontal component of approximately 11
/s
(SPV) and a vertical component of approximately 11
/s (SPV),
lasting about 20 s. When he sat up, the direction of the nystag-
mus was reversed. The Roll test, when the patient was in the left
lateral position, showed no nystagmus. When he was in the right
lateral position, it showed apogeotropic horizontal nystagmus of
approximately 10
/s (SPV), lasting >1 min. The canal paresis
value was 100%, indicating reduced function of the right hori-
zontal semicircular canal. During the bilateral D–H test, the
patient complained of vertigo regardless of whether he kept his
head in the head-hanging position or when he sat up, which was
more severe in the right D–H test. No any abnormality was
observed on the skull MRI or DWI evaluations.
The patient was preliminarily diagnosed as having right PC-
BPPV (canalolithiasis of the posterior canal), probably right AC-
BPPV (cupulolithiasis of the anterior canal) and impaired right
peripheral vestibular function.
After manual repositioning using the Epely and Yacovino
manoeuvres, the left D–H test revealed down-beating nystagmus,
approximately 10
/s (SPV), lasting >1 min. During the right D–H
test, however, nystagmus was not apparent. No nystagmus was
observed in the Roll test. The patient complained of mild vertigo
during the left D–H test but not during the right D–H test. The
patient did not complain of vertigo during the Roll test.
Five days later, the left D–H test revealed down-beating nys-
tagmus of approximately 18
/s (SPV) and lasting >1 min. No
nystagmus was observed during the right D–H test. The SHH
test revealed down-beating nystagmus of approximately 4
/s
(SPV) and lasting >1 min. The Roll test, when the patient was in
the left lateral position, revealed apogeotropic horizontal nystag-
mus of approximately 11
/s (SPV) that lasted about 50 s. With
the patient in the right lateral position, the Roll test revealed apo-
geotropic horizontal nystagmus of approximately 6
/s (SPV) and
lasting >1 min. The canal paresis value was 100%, indicating
reduced function of the right horizontal semicircular canal. The
patient was thought probably to have right AC-BPPV/HC-BPPV
(cupulolithiasis of the anterior and horizontal canal).
After manual reduction using the Yacovino and Barbecue
manoeuvres, the left D–H test showed down-beating nystagmus
of approximately 6
/s (SPV) that lasted >1 min. The right D–H
test showed no nystagmus. When the patient was in the vertical
head-hanging position, the Roll test revealed down-beating
nystagmus of approximately 4
/s (SPV), lasting >1 min. When
the patient was in the left lateral position, the Roll test showed
apogeotropic horizontal nystagmus of approximately 11
/s (SPV)
and lasting about 50 s. No nystagmus was observed with the Roll
test when the patient was in the right lateral position. The patient
still complained of vertigo, but the symptoms had diminished.
After 3 months, the vertigo symptoms had disappeared. The
patient was finally diagnosed as suffering from right AC-BPPV/
HC-BPPV (cupulolithiasis of the anterior and horizontal canal),
and impaired right peripheral vestibular function.
Case 5
A 57-year-old woman was admitted because of a 5-day history of
recurrent vertigo. The patient complained of recurrent vertigo
and instability when she bowed or raised her head or turned left
or right. Each episode lasted for about 1 min after which the
symptoms self-mitigated. There were no other accompanying
symptoms. The patient had a history of hypertension and dia-
betes mellitus. Otological examination showed normal hearing.
Neurological examination revealed no abnormalities.
The left D–H test revealed down-beating nystagmus of
approximately 17
/s (SPV) and lasting >1 min. No nystagmus
was observed when the patient sat up. The right D–H test
showed down-beating nystagmus of approximately 8
/s (SPV)
that lasted >1 min. No nystagmus was observed when the patient
sat up. In the When the patient was in the left lateral position,
the Roll test showed down-beating nystagmus of approximately
5
/s (SPV) that lasted about 50 s. When the patient was in the
right lateral position, the Roll test showed rightward horizontal
nystagmus of approximately 6
/s (SPV) that lasted about 20 s.
The canal paresis value in the caloric test was 18%, indicating
normal function of the bilateral horizontal semicircular canals.
The patient was preliminarily diagnosed as possibly having A
C-BPPV or central vestibular lesion, with the latter a greater pos-
sibility. Manual reduction was not administered. MRI and DWI
images revealed no abnormalities.
Two days later, the left D–H test showed geotropic horizontal
nystagmus of approximately 12
/s (SPV) and lasting about 15 s,
but no nystagmus was observed when the patient sat up. The
right D–H test showed geotropic torsional, up-beating nystagmus
with a rightward horizontal component of approximately 6
/s
(SPV) and a vertical downbeat component of approximately
11
/s (SPV) that lasted 10 s. When the patient sat up, rightward
torsional, down-beating nystagmus with a leftward horizontal
component of approximately 13
/s (SPV) and a vertical down-
beat component of approximately 10
/s (SPV) that lasted about
10 s was observed. When the patient was in the left lateral pos-
ition, the Roll test showed geotropic horizontal nystagmus of
approximately 10
/s (SPV) that last about 15 s. When the patient
was in the right lateral position, the Roll test showed geotropic
horizontal nystagmus of approximately 14
/s (SPV) that lasted
about 20 s. The patient was considered as probably having right
PC-BPPV/HC-BPPV (canalolithiasis of the posterior and hori-
zontal canal) and canal conversion of AC-BPPV to PC-BPPV/
HC-BPPV because of otoconial dislocation.
After manual reduction using tentative Epley and Barbecue
manoeuvres, the left D–H test revealed geotropic horizontal nys-
tagmus of approximately 7
/s (SPV) that lasted about 40 s. The
right D–H test did not show any nystagmus. In the Roll test,
geotropic horizontal nystagmus, approximately 5
/s (SPV), lasting
for about 20 seconds was observed in the left lateral position.
After 1 month, the symptom of vertigo disappeared. The patient

was diagnosed as right PC-, HC-BPPV (canalolithiasis of the pos-
terior, horizontal canal), probably canal conversion of AC-BPPV
to PC-, HC-BPPV because of dislocation of otoconia.
Case 6
A 54-year-old woman was admitted because of a 4-day history of
recurrent vertigo. The patient complained of the first attack of
vertigo when she got up. After 50 s, the symptom self-mitigated,
with nausea and vomiting but no blood and brown matter in the
stomach content. There were no other accompanying symptoms.
The patient complained of vertigo onset whenever she turned left
or right in bed or when she bowed or raised her head, with the
symptom mitigating when she lay down with her eyes closed.
She had a 5-year history of hypertension and a 6-year history of
diabetes mellitus and hyperlipidaemia. Otological examination
showed that her hearing was normal. Neurological examination
revealed no abnormal physical sign.
The left D–H test showed apogeotropic torsional, down-
beating nystagmus (the upper pole of the eyes beating toward the
right ear) with a leftward horizontal component of approximately
5
/s (SPV) and vertical downbeat nystagmus of approximately
10
/s (SPV) that lasted about 50 s. The right D–H test showed no
nystagmus when the patient sat up. The SHH test showed down-
beating nystagmus of approximately 12
/s (SPV) and lasting
about 50 s. No nystagmus was observed when she sat up. The
Roll test showed no nystagmus in the left lateral position. When
the patient was in the right lateral position, geotropic torsional,
up-beating nystagmus, with no obvious horizontal component
but a vertical component of approximately 7
/s (SPV), las-
ting >1 min was observed. The canal paresis value in the caloric
test was 3%, indicating normal function of the bilateral horizon-
tal semicircular canals. No abnormalities were observed on skull
MRI images.
The patient was preliminarily diagnosed as possibly having
right AC-BPPV/PC-BPPV (canalolithiasis of the anterior and
posterior canal).
After manual reduction using tentative Yacovino and Epley
manoeuvres, nystagmus disappeared. Fifteen days later, the
patient was admitted because of recurrent vertigo. No nystagmus
was observed in the left D–H test. In the right D–H test, geo-
tropic torsional up-beating nystagmus (the upper pole of the eyes
beating toward the right ear), with vertical component approxi-
mately 4
/s (SPV), and non-obvious horizontal component, last-
ing for about 10 seconds, was observed in the right D–H test. In
the Roll test and the SHH test no nystagmus was observed.
After two reduction treatments using the Epley manoeuvre,
the nystagmus disappeared. The patient was finally diagnosed as
suffering from right AC-BPPV/PC-BPPV.
Results
Six AC-BPPV patients, consisting of one man and five women
(aged 54–82 years, average 64.7 years) were included in this study.
Among them, 4 (66.7%) had hypertension, 3 (50%) had diabetes
mellitus and 3 (50%) had hyperlipidaemia. They each had a nor-
mal in gaze test, saccade test, smooth pursuit test, optokinetic
nystagmus test, and fixation suppression test. The vestibular
function examination showed weakened function of the right
horizontal semicircular canal in two patients, the function of left
horizontal semicircular canal was reduced in one patient and the
function of bilateral horizontal semicircular canal was normal in
INTERNATIONAL JOURNAL OF AUDIOLOGY 5
3 patients. Dynamic positioning test results are shown in
Table 2. The MRI examination was normal in all patients.
Patients 1 and 2 were diagnosed as having AC-BPPV during
the preliminary evaluation. They each underwent two manual
reduction operations using the Yacovino manoeuvre, which was
very effective in the patients, although symptoms recurred in
patient 2 after 1 week. The Yacovino manoeuvre was effective in
this patient after two more manual reduction operations. Patient
3 was diagnosed as having AC-BPPV/HC-BPPV during the pre-
liminary evaluation. This patient underwent two manual reduc-
tion operations using the Yacovino manoeuvre, which was highly
effective. Patient 4 was preliminarily diagnosed as having AC-
BPPV/PC-BPPV. After two manual reduction operations with
the Yacovino manoeuvre, which were not effective, the patient
was diagnosed as having AC-BPPV/HC-BPPV. After four manual
reduction operations using the Yacovino manoeuvre, the treat-
ment was effective in this patient. Patient 5 was preliminarily
diagnosed as possibly having AC-BPPV or a central vestibular
lesion. Manual reduction was not attempted. Two days later, the
patient was finally diagnosed with PC-BPPV/HC-BPPV. Patient 6
was diagnosed as having AC-BPPV/PC-BPPV. The Yacovino
manoeuvre was applied during two manual reduction operations
and was effective
The therapeutic diagnosis was used for diagnosing three
patients, typical BPPV characteristics and subsequent presence of
canal conversion during the second visit were used diagnostically
in two patients, and the therapeutic diagnosis and subsequent
presence of typical BPPV characteristics were used to diagnose
one patient.
Discussion
Compared with lithiasis in the posterior semicircular canal and
horizontal semicircular canal, lithiasis in the anterior semicircular
canal is rare (Honrubia et al. 1999; Nakayama and Epley 2005;
Yacovino, Hain, and Gualtieri 2009). It could occur possibly
because of the following reasons. (1) During daily activities, the
spatial anatomical position of the anterior semicircular canal is
high, and it is difficult for otolith fragments to move retrogradely
from the ampullary ridge to the front forearm of the anterior
semicircular canal. (2) The opening of the forearm of the anter-
ior semicircular canal is in the cornu cutaneum and vestibule,
and otolithic fragments can easily leave the semicircular canal
while lying down (Epley 2001). Therefore, AC-BPPV is rarely
detected. Hence, there are few reports on AC-BPPV.
At present, the diagnosis of AC-BPPV is mainly dependent on
the D–H and SHH tests. The most typical form of nystagmus is
down-beating nystagmus, with or without a small torsional com-
ponent. There is evidence that during the D–H test of the
affected side, the torsional direction of the nystagmus points to a
high-position ear (on the affected side). When the patient’s eye
was asked to gaze toward the high position on the ear, vertical
down-beating nystagmus was the main outcome. When the
patient’s eye was asked to gaze toward the low position of the
ear (on the healthy side), the torsional component was the main
outcome (Korres et al. 2008).
It is difficult to determine which side is affected in AC-BPPV
cases. The affected side in typical AC-BPPV is generally deter-
mined according to the mechanism that the unilateral anterior
semicircular canal corresponds to the ipsilateral upper rectus and
contralateral inferior oblique. Therefore, lithiasis in the anterior
semicircular canal is often manifested by torsional down-beating
nystagmus, and the torsional direction points to the affected ear
 6
X. LING ET AL.

Table 2. Characterization of nystagmus in six patients with anterior canal benign paroxysmal positional vertigo
Straight
Left Dix–Hallpike Right Dix–Hallpike head-hanging Roll test
Before/ Head
Number after Sitting Sitting hanging Sitting
Cases of visits treatment Head hanging position position Head hanging position position position position Left Right
1 1 Before (–) (–) DBN UBN DBN UBN (–) (–)
2 1 Before DBN UBN (–) (–) / / (–) (–)
2 Before DBN UBN (–) (–) / / (–) (–)
3 1 Before Apogeotropic torsional with DBN (–) Apogeotropic horizontal (–) DBN (–) Apogeotropic horizontal Apogeotropic horizontal
nystagmus nystagmus nystagmus
(stronger than the right side)
1 After Apogeotropic horizontal (–) Apogeotropic horizontal (–) (–) (–) (–) Apogeotropic horizontal
nystagmus nystagmus nystagmus
2 Before Apogeotropic horizontal (–) Apogeotropic horizontal (–) (–) (–) (–) (–)
nystagmus nystagmus
4 1 Before DBN UBN Geotropic torsional with UBN DBN / / (–) Apogeotropic horizontal
nystagmus
1 After DBN (–) (–) (–) / / (–) (–)
2 Before DBN (–) (–) (–) DBN (–) Apogeotropic horizontal Apogeotropic horizontal
nystagmus nystagmus
(stronger than the right side)
2 After (–) (–) (–) DBN (–) Apogeotropic horizontal (–)
DBN nystagmus

5 1 Before DBN (–) DBN (–) / / DBN Geotropic horizontal

nystagmus
2 Before Geotropic horizontal (–) Geotropic torsional with UBN DBN / / Geotropic horizontal Geotropic horizontal
nystagmus nystagmus Nystagmus (stronger
than the left side)
After Geotropic horizontal (–) (–) (–) / / Geotropic horizontal (–)
nystagmus nystagmus
6 1 Before Apogeotropic torsional with DBN (–) (–) (–) DBN (–) (–) Geotropic torsional with UBN
2 Before (–) (–) Geotropic torsional with UBN (–) / / (–) (–)
DBN: down-beating nystagmus; UBN: up-beating nystagmus, (–): there is no nystagmus; /: not done; Geotropic, beats toward the ground; Apogeotropic, beats toward the ceiling. Geotropic torsional nystagmus is the
upper pole of the eyes beating toward the lower ear. Apogeotropic torsional nystagmus is the upper pole of the eyes beating toward the upper ear.

(Korres et al. 2008, 2010). Hence, the torsional component of
the nystagmus contributes to determining the side affected by
AC-BPPV. However, because of the anatomical structure of the
semicircular canal in some patients, the D–H test often stimu-
lates the bilateral tube of the ampulla ridge of the anterior semi-
circular canal to induce bilateral down-beating nystagmus
without an obvious torsional component (Bertholon et al. 2002;
Ogawa et al. 2009), leading to difficulty identifying the affected
side of AC-BPPV. This subject deserves further investigation.
As for typical AC-BPPV, the D–H test can lead to diagnosing
severe torsional down-beating nystagmus. It is very difficult to
diagnose non-typical AC-BPPV, however, particularly when only
vertical down-beating nystagmus without a torsional component
is induced during the D–H test. In this study, we found that (1)
as for non-typical AC-BPPV, if the tentative manoeuvre is effect-
ive, AC-BPPV can be diagnosed. For example, in patients 1, 2
and 3 in this study, down-beating nystagmus immediately disap-
peared after reduction by Yacovino manoeuvre administration.
(2) During the preliminary diagnosis and follow-up period, if
other types of typical BPPV nystagmus are observed during the
D–H, SHH and Roll tests, AC-BPPV can be diagnosed, as in
patients 3, 4, 5 and 6 included in this study. (3) Otolithic frag-
ments translocating to the posterior, horizontal semicircular canal
after spontaneous activities or reduction treatment strongly sup-
ports a diagnosis of AC-BPPV (von Brevern et al. 2015), as in
patients 4 and 5 in this study. However, only a few studies have
reported on canal conversion, during and after manual reduction.
The reported incidence of the movement of otoliths from the
posterior semicircular canal into the horizontal semicircular canal
was about 6%–8% (Anagnostou, Stamboulis, and Kararizou 2014;
Yimtae et al. 2003; Herdman and Tusa 1996), and the incidence
for the movement of otoliths from the horizontal semicircular
canal into the posterior semicircular canal was about 6% (Nuti
et al. 1998). Park et al. (2013) found that the movement of oto-
liths from the anterior semicircular canal to the posterior semi-
circular canal during manual reduction has an incidence of up to
12.1%. In the present study, down-beating nystagmus was
observed in patient 5 upon the patient’s first visit to the hospital.
Manual reduction was not administered, however, and 2 days
later the presence of typical nystagmus of the right PC-BPPV/
HC-BPPV was observed. Administering manoeuvre was effective
in the patient, however, which strongly supports the diagnosis of
AC-BPPV. We speculate that it may be related to the anatomical
position of the anterior semicircular canal. The anterior semicir-
cular canal is higher during spontaneous activities of patients,
and vertigo symptoms can self-heal. Alternatively, the otolith
could move into other semicircular canals, so we speculate the
occurrence of canal conversion. The presence of typical nystag-
mus of the right PC-BPPV/AC-BPPV was observed in patient 4
at the first visit. Manual reduction was performed, and during
the second visit 5 days after the manual reduction, a typical pat-
tern of nystagmus for right AC-BPPV/HC-BPPV was observed.
This result might be due to advanced age because it is more diffi-
cult for the older patient to cooperate with the doctor and
achieve the standard position during manual reduction, resulting
in movement of the otoliths from the posterior semicircular canal
to the ipsilateral horizontal semicircular canal.
In this study, when down-beating nystagmus lasted >30 min,
the time taken for each body position was appropriately pro-
longed. Among the six patients with AC-BPPV, the Yacovino
manoeuvre was effective in three patients, particularly the treat-
ment of canalolithiasis, which was successfully reduced by two
intentions. The reduction effect was not very good in the other
INTERNATIONAL JOURNAL OF AUDIOLOGY 7
two patients, possibly because of (1) old age, obesity, severe cer-
vical spondylosis, each of which could lead to decreased mobility
and poorly cooperation during reduction, make it more difficult
for the patient to achieve reduction according to the standard
speed and position, thus lowering the rate of successful reduc-
tion. (2) Complex conditions involving multiple-canal BPPV
could lead to poor reduction.
Altogether, our results showed that, as for vertical down-
beating nystagmus present during the diagnosis, if its nature—
benign or malignant—cannot be identified temporarily, then ten-
tative manoeuvres can be used for reduction. If positional nystag-
mus rapidly disappears after otolith reduction, AC-BPPV can be
diagnosed. During the reduction or follow-up process, the pres-
ence of canal conversion and accompanying typical semicircular
BPPV contribute to the diagnosis of AC-BPPV. In addition, if
the therapeutic effects of multiple manoeuvres are worse, other
possible diseases similar to BPPV should be considered.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
The Project Supported by Aerospace Center Hospital [Grant
No. YN201305].
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