The Dix-Hallpike test and the canalith repositioning maneuver

The Dix-Hallpike test and the canalith repositioning maneuver (CRM) are used to diagnose and treat benign positional vertigo (BPV). Dix-Hallpike is the standard procedure for diagnosis of BPV, but if the horizontal canal is not tested for BPV and the Dix-Hallpike is only carried out once, the condition may not be diagnosed and appropriately treated. We describe our method of testing for BPV and treating it with CRM. The Dix-Hallpike test involves rapidly moving the patient from a sitting position to "head hanging," where the patient's head is at least 10 degrees below horizontal. This is performed initially for the posterior semicircular canals. If these movements fail to elicit vertigo and nystagmus, tests of the horizontal semicircular canals are performed by laying the patient on each side. Importantly, if there is no vertigo or nystagmus elicited by testing the horizontal semi-circular canals, the posterior semicircular canals are tested again. It appears that being held in the head hanging positions and then left and right lateral positions will often allow the canaliths to collect such that the Dix-Hallpike test will become positive. Failure to repeat the tests of the posterior semicircular canals may result in a falsely negative test. Testing the horizontal canals and repeating the Dix-Hallpike test will reduce the likelihood of patients undergoing extra testing or other consequences of misdiagnosis. If, during any of this testing, a movement elicits vertigo or nystagmus, the appropriate CRM is then carried out.     

A novel maneuver for diagnosis and treatment of torsional-vertical down beating positioning nystagmus: anterior canal and apogeotropic posterior canal BPPV

IntroductionIn patients with benign paroxysmal positional vertigo, BPPV; a torsional-vertical down beating positioning nystagmus can be elicited in the supine straight head-hanging position test or in the Dix-Hallpike test to either side. This type of nystagmus can be explained by either an anterior canal BPPV or by an apogeotropic variant of the contralateral posterior canal BPPV Until now all the therapeutic maneuvers that have been proposed address only one possibility, and without first performing a clear differential diagnosis between them.ObjectiveTo propose a new maneuver for torsional-vertical down beating positioning nystagmus with a clear lateralization that takes into account both possible diagnoses (anterior canal-BPPV and posterior canal-BPPV).MethodsA prospective cohort study was conducted on 157 consecutive patients with BPPV. The new maneuver was performed only in those with torsional-vertical down beating positioning nystagmus with clear lateralization.ResultsTwenty patients (12.7%) were diagnosed with a torsional-vertical down beating positioning nystagmus. The maneuver was performed in 10 (6.35%) patients, in whom the affected side was clearly determined. Seven (4.45%) patients were diagnosed with an anterior canal-BPPV and successfully treated. Two (1.25%) patients were diagnosed with a posterior canal-BPPV and successfully treated with an Epley maneuver after its conversion into a geotropic posterior BPPV.ConclusionThis new maneuver was found to be effective in resolving all the cases of torsional-vertical down beating positioning nystagmus-BPPV caused by an anterior canal-BPPV, and in shifting in a controlled way the posterior canal-BPPV cases of the contralateral side into a geotropic-posterior-BPPV successfully treated during the followup visit. Moreover, this new maneuver helped in the differential diagnosis between anterior canal-BPPV and a contralateral posterior canal-BPPV.     

Multiple positional nystagmus suggests multiple canal involvement in benign paroxysmal vertigo

CONCLUSION: Video-oculography demonstrates a higher occurrence of atypical positional nystagmus in patients with benign paroxysmal positional vertigo (BPPV). This includes anterior and horizontal canal variants and multiple positional nystagmus, suggesting combined lesions affecting several canals. OBJECTIVE: To analyse the video-oculographic findings of positional tests in patients with BPPV. MATERIAL AND METHODS: Seventy individuals with symptoms of BPPV and positional nystagmus were included in this study. The diagnosis was based on a history of brief episodes of vertigo and the presence of positional nystagmus as confirmed by video-oculographic examination during the Dix-Hallpike test, the McClure test or the head-hanging manoeuvre. Patients were treated by means of different particle repositioning manoeuvres according to the affected canal (Epley's manoeuvre for the posterior or anterior canals and Lempert's manoeuvre for the lateral canal) and the effectiveness was evaluated at 7 and 30 days. RESULTS: Twenty-nine individuals (41.43%) presented an affected unilateral posterior canal. Fifteen patients (21.43%) presented a pure horizontal direction-changing positional nystagmus consistent with a diagnosis of horizontal canal BPPV. Twelve individuals (17.14%) presented a unilateral down-beating nystagmus, suggesting possible anterior canal BPPV. In addition, 14 patients (20%) showed multiple positional nystagmus during the examination corresponding to simultaneous multi-canal BPPV, 5 had bilateral posterior canal BPPV and 2 presented a positional down-beating nystagmus in both left and right Dix-Hallpike manoeuvres and the head-hanging manoeuvre, which is highly suggestive of anterior canal BPPV. However, seven individuals showed positional horizontal and vertical side-changing nystagmus that could not be explained by single-canal BPPV. These patients with multiple positional nystagmus showed changing patterns of positional nystagmus at follow-up.     

Effect of applying head-shaking maneuver before Epley maneuver in BPPV

IntroductionThe Epley maneuver is applied in the treatment of benign paroxysmal positional vertigo, the BPPV. However, dizziness and balance problems do not improve immediately after the treatment.ObjectiveIn this study, the effectiveness of the head-shaking maneuver before the Epley maneuver was investigated in the treatment of BPPV.MethodsBetween March 2020 and August 2020, ninety-six patients with posterior semicircular canal BPPV were analyzed prospectively. The patients were divided into two groups: patients who underwent the Epley maneuver only in the treatment (Group 1) and patients who underwent the Epley maneuver after the head-shaking maneuver (Group 2). The results of the Berg balance scale and dizziness handicap index were evaluated before the treatment and at the first week after the treatment.ResultsThe improvement in functional, emotional, and physical dizziness handicap index and Berg balance scale values after the treatment was found to be statistically significant in both groups. It was determined that the change in functional and physical dizziness handicap index and Berg balance scale values of the patients in Group 2 was statistically higher than those in Group 1. Although, the change in emotional dizziness handicap index values in Group 2 was higher than those in Group 1, no statistical significance was found between the groups.ConclusionAs a result of our hypothesis, we think that in the treatment of posterior semicircular canal BPPV, the otoliths adhered to the canal can be mobilized by the head-shaking maneuver, and this will contribute to the increase of the effectiveness of the Epley maneuver.     

Diagnosis and treatment of the short-arm type posterior semicircular canal BPPV

IntroductionThe Epley maneuver is useful for the otoconia to return from the long arm of the posterior semicircular canal into the utricle. To move otoconia out of the posterior semicircular canal short arm and into the utricle, we need different maneuvers.ObjectiveTo diagnose the short-arm type BPPV of the posterior semicircular canal and treat them with bow-and-yaw maneuver.Methods171 cases were diagnosed as BPPV of the posterior semicircular canal based on a positive Dix–Hallpike maneuver. We first attempted to treat patients with the bow-and-yaw maneuver and then performed the Dix–Hallpike maneuver again. If the repeated Dix–Hallpike maneuver gave negative results, we diagnosed the patient with the short-arm type of BPPV of the posterior semicircular canal and considered the patient to have been cured by the bow-and-yaw maneuver; otherwise, probably the long-arm type BPPV of the posterior semicircular canal existed and we treated the patient with the Epley maneuver.ResultsApproximately 40% of the cases were cured by the bow-and-yaw maneuver, giving negative results on repeated Dix–Hallpike maneuvers, and were diagnosed with short-arm lithiasis.ConclusionThe short-arm type posterior semicircular canal BPPV can be diagnosed and treated in a convenient and comfortable manner.     

Combined horizontal and posterior canal benign paroxysmal positional vertigo in three patients with head trauma

We report 3 patients who complained of positional vertigo shortly after head trauma. Positional maneuvers performed in the plane of the posterior canal (PC; Dix-Hallpike maneuver) and the horizontal canal (HC; patients were rolled to either side in a supine position with the head raised 30 degrees) revealed a complex positional nystagmus that could only be interpreted as the result of combined PC and HC benign paroxysmal positional vertigo (BPPV). Two patients had a right PC BPPV and an ageotropic HC BPPV, and 1 patient had a bilateral PC BPPV and a left geotropic HC BPPV. All 3 patients were rapidly free of vertigo after the PC BPPV was cured by the Epley maneuver and the geotropic HC BPPV was cured by the Vannucchi method. The ageotropic HC BPPV resolved spontaneously. Neuroimaging (brain computed tomography and/or magnetic resonance imaging scans) findings were normal in all 3 patients. From a physiopathological viewpoint, it is easy to conceive that head trauma could throw otoconial debris into different canals of each labyrinth and be responsible for these combined forms of BPPV. Consequently, in trauma patients with vertigo, it is mandatory to perform the Dix-Hallpike maneuver, as well as supine lateral head turns, in order to diagnose PC BPPV, HC BPPV, or the association of both. Early diagnosis and treatment of BPPV may help to reduce the postconcussion syndrome.     

Benign paroxysmal positional vertigo due to a simultaneous involvement of both horizontal and posterior semicircular canals

From April 2001 to November 2003, we investigated 8 patients with benign paroxysmal positional vertigo (BPPV) that was suspected to simultaneously affect both the horizontal and posterior semicircular canals (HSCC and PSCC). These cases showed typical vertical-torsional nystagmus induced by the Dix-Hallpike maneuver, followed by a horizontal nystagmus. They also showed a direction-changing geotropic or apogeotropic positional nystagmus triggered by lateral head rotations in the supine position. Using the three-dimensional analysis of the positional nystagmus, the rotation axis of the positional nystagmus had a component perpendicular to the plane of PSCC and another component perpendicular to the plane of HSCC. All these findings suggest that BPPV in these patients was a combination of posterior and horizontal canal BPPV. The observation of a vertical-torsional positional nystagmus should prompt the specialist to perform not only the canalith repositioning procedure, but also to execute lateral head turns in the supine position.     

Side-lying as an alternative to the Dix-Hallpike test of the posterior canal.

OBJECTIVE: Limitations in passive or active range of motion preclude testing some patients suspected of benign paroxysmal positional vertigo of the posterior semicircular canal (BPPV) with the Dix-Hallpike maneuver. The goal of this study was to determine if an alternative test, brisk side-lying with the nose turned 45 degrees away from the tested side, yields the same results as the Dix-Hallpike maneuver. STUDY DESIGN: Prospective, within-groups. SETTING: Diagnostic laboratory at a tertiary care center. PATIENTS: The 61 patients, seen before their physicians had determined their diagnoses, were all referred by their physicians for objective diagnostic tests. All subjects complained of vertigo elicited by up or down rotations of the head or turning over in bed, often provocative positions for BPPV. METHODS: Results from the Dix-Hallpike maneuver and side-lying maneuver were compared. Group 1 was tested with the Dix-Hallpike maneuver followed up by side-lying; Group 2 was tested in reverse order. MAIN OUTCOME MEASURES: Slow-phase eye velocity of nystagmus. RESULTS: With the groups collapsed to eliminate possible order effects, no significant differences were found between the tests. Significantly more subjects had no response to testing than minimal or stronger responses. CONCLUSIONS: Side-lying is a valid alternative test to the Dix-Hallpike maneuver, which could be useful when range-of-motion limitations or other problems preclude use of the Dix-Hallpike maneuver.     

Multiple positional nystagmus suggests multiple canal involvement in benign paroxysmal positional vertigo

Conclusion. Video-oculography demonstrates a higher occurrence of atypical positional nystagmus in patients with benign paroxysmal positional vertigo (BPPV). This includes anterior and horizontal canal variants and multiple positional nystagmus, suggesting combined lesions affecting several canals. Objective. To analyse the video-oculographic findings of positional tests in patients with BPPV. Material and methods. Seventy individuals with symptoms of BPPV and positional nystagmus were included in this study. The diagnosis was based on a history of brief episodes of vertigo and the presence of positional nystagmus as confirmed by video-oculographic examination during the Dix–Hallpike test, the McClure test or the head-hanging manoeuvre. Patients were treated by means of different particle repositioning manoeuvres according to the affected canal (Epley's manoeuvre for the posterior or anterior canals and Lempert's manoeuvre for the lateral canal) and the effectiveness was evaluated at 7 and 30 days. Results. Twenty-nine individuals (41.43%) presented an affected unilateral posterior canal. Fifteen patients (21.43%) presented a pure horizontal direction-changing positional nystagmus consistent with a diagnosis of horizontal canal BPPV. Twelve individuals (17.14%) presented a unilateral down-beating nystagmus, suggesting possible anterior canal BPPV. In addition, 14 patients (20%) showed multiple positional nystagmus during the examination corresponding to simultaneous multi-canal BPPV, 5 had bilateral posterior canal BPPV and 2 presented a positional down-beating nystagmus in both left and right Dix–Hallpike manoeuvres and the head-hanging manoeuvre, which is highly suggestive of anterior canal BPPV. However, seven individuals showed positional horizontal and vertical side-changing nystagmus that could not be explained by single-canal BPPV. These patients with multiple positional nystagmus showed changing patterns of positional nystagmus at follow-up.     

Persistent Direction-Fixed Nystagmus Following Canalith Repositioning Maneuver for Horizontal Canal BPPV: A Case of Canalith Jam

The authors report a 64-year-old man who developed persistent direction fixed nystagmus after a canalith repositioning maneuver for horizontal canal benign paroxysmal positional vertigo (HC-BPPV). The patient was initially diagnosed with right HC-BPPV given that the Dix-Hallpike test showed geotropic horizontal nystagmus that was more pronounced on the right side, although the roll test did not show any positional nystagmus. The patient was treated with a canalith repositioning maneuver (Lempert maneuver). The next day, the patient experienced a different character of dizziness, and left-beating spontaneous nystagmus regardless of head position was observed. After a forced prolonged left decubitus and frequent head shaking, his symptoms and nystagmus resolved. This condition, referred to as canalith jam, can be a complication after the repositioning maneuver in patients with BPPV. Atypical positional tests suggest that abnormal canal anatomy could be the underlying cause of canalith jam.     

咳嗽对良性阵发性位置性眩晕手法复位疗效的影响

目的：分析患良性阵发性位置性眩晕（BPPV）的慢性咳嗽患者经手法复位治疗后的疗效,为BPPV的综合治疗及病因探索提供帮助。方法：分析2009—10—2012—12期间400例BPPV患者的治疗效果,包括观察患者的症状和行体位试验检查。结果：后半规管BPPV的一次治疗成功率为93．4％,水平半规管BPPV治疗成功率为83．0％。在400例BPPV患者中随访到372例,一次治疗成功的复诊患者中,有35例复位治疗好转后又出现阵发性眩晕发作,再次行手法复位仍取得良好效果。追问病史,有29例存在不同程度的咳嗽。控制咳嗽后再行手法复位治疗,眩晕症状消失,随访半年未再发作。结论：BPPV的发生机制可能与咳嗽所致的头部震动有关。     

Three-dimensional eye rotation axis analysis of benign paroxysmal positioning nystagmus

We have developed a new technique for analyzing the rotation vector of eye movement with an infrared CCD camera [Imai et al.: Acta Otolaryngol 1999;119:24-28]. We used this technique to analyze the eye rotation axis of benign paroxysmal positioning nystagmus (BPPN) that was induced by the Dix-Hallpike maneuver in 14 patients with benign paroxysmal positioning vertigo (BPPV). Eye rotation axes of BPPN in 8 patients were closely perpendicular to the posterior canal of the undermost ear in the provocative head position. Under the hypothesis that BPPN is due to a mechanical stimulation of the posterior canal by canalolithiasis, this finding suggested that the posterior canal of the undermost ear is the lesion. On the other hand, eye rotation axes of BPPN in the other 6 patients were closely aligned with the naso-occipital axis. It is suggested that canalolithiasis induces endolymphatic flow in both posterior and anterior canals via the common crus and the summation of the eye movements induced by stimulation of both the posterior and anterior canals rotates the eye along the naso-occipital axis.     

Theoretical observation on diagnosis maneuver for benign paroxysmal positional vertigo

Conclusion: To make a comprehensive analysis with a variety of diagnostic maneuvers is conducive to the correct diagnosis and classification of BPPV.

Objective: Based on the standard spatial coordinate-based semicircular canal model for theoretical observation on diagnostic maneuvers for benign paroxysmal positional vertigo (BPPV) to analyze the meaning and key point of each step of the maneuver.

Materials and methods: This study started by building a standard model of semicircular canal with space orientation by segmentation of the inner ear done with the 3D Slicer software based on MRI scans, then gives a demonstration and observation of BPPV diagnostic maneuvers by using the model.

Results: The supine roll maneuver is mainly for diagnosis of lateral semicircular canal BPPV. The Modified Dix-Hallpike maneuver is more specific for the diagnosis of posterior semicircular canal BPPV. The side-lying bow maneuver designed here is theoretically suitable for diagnosis of anterior semicircular canal BPPV.     

正中悬头位Dix-Hallpike法诊断良性阵发性位置性眩晕

目的评价正中悬头位Dix-Hallpike诱发检查法在诊断后半规管良性阵发性位置性眩晕(benign paroxysmal positional vertigo,BPPV)中的意义。方法回顾性总结广东省人民医院耳鼻咽喉科眩晕门诊2008年4月1日到5月29日根据经典或者正中悬头位Dix-Hallpike法诊断为后半规管BPPV患者28例的临床资料,均首先进行正中悬头位Dix-Hallpike诱发试验,如结果为阴性后继续行经典Dix-Hallpike检测证实为后半规管性BPPV。比较正中悬头位Dix-Hallpike相对于经典Dix-Hallpike的阳性率。结果28例后半规管BPPV患者中,正中悬头位Dix-Hallpike诱发试验相对于经典Dix-Hallpike诱发实验的阳性率为78.57%(22/28)。结论正中悬头位Dix-Hallpike法诊断BPPV可以有效地简化诊治程序,并减轻部分患者诱发的眩晕及眼震强度,具有一定的临床意义。但由于其阳性率低于经典方法,故在临床上不能完全代替经典方法。     

190例特发性良性阵发性位置性眩晕患者半规管功能分析

目的 分析特发性良性阵发性位置性眩晕(benign paroxysmal position vertigo,BPPV)患者半规管功能的特征,为患者的治疗提供进一步帮助.方法 选择本院2019年8月至2020年2月收治的单侧特发性BPPV患者190例,包括后半规管BPPV患者162例,水平半规管BPPV患者28例.行冷热...     

后半规管良性阵发性位置性眩晕患者复位中眼震分析

目的 分析后半规管良性阵发性位置性眩晕(posterior semicircular canal benign paroxysmal positional vertigo,PC-BPPV)患者复位中的眼震,探讨BPPV可能的发病机制.方法 2007年12月至2008年4月眩晕门诊就诊的66例PC-BPPV患者,详细记录病史、体位试验及复位中不同位置眼震的情况,对PC-BPPV患者可能发病机制进行探讨.结果 变位试验完伞符合贵阳会议诊断标准的66例PC-BPPV患者,采用改良Epley复位,视频眼震记录技术记录复位中四个位置的眼震方向及强度,24例患者复位中出现的眼震均为垂直扭转向上眼震;21例除第一个位置出现上向扭转眼震,其余三个位置眼震阴性;7例变位试验初诊PC-BPPV的患者在第二次复位中出现强烈水平眼震;14例患者复位的第二或第三个位置出现下向垂直眼震.由复位中不同位置出现的眼震分析,66例确诊为PC-BPPV的患者,52例复位中的表现符合管石及嵴顶耳石症理论,占78.8%.结论 除了目前公认的管石症及嵴顶耳石症理论外,推测部分PC-BPPV可能与耳石器官及球囊椭圆囊神经病变有关.     

Adverse effect of the Epley maneuver: Anterior canal crisis

ObjectiveIn the Epley maneuver performed on patients with posterior semicircular canal-benign paroxysmal positional vertigo-canalolithiasis (P-BPPV-Can), an intense downbeat nystagmus and retropulsion rarely appear as soon as they reach the last upright sitting position. It is considered an anterior canal crisis that appears when the otoliths move to the ampullofugal direction in the anterior semicircular canal by changing head and body positions from the healthy-ear-down 135° head position (the third head position) to the upright sitting position (the fourth head position). This study aimed to determine the prevention of this anterior canal crisis.MethodsThe anterior canal crisis frequency was compared among the 178 cases that underwent general Epley maneuver (uncorrected Epley maneuver) and the 228 cases that underwent Epley maneuver (corrected Epley maneuver) by preventing head rotation beyond 135° to the healthy ear and the top of the head going down at the third head position.ResultsIn 6% of patients with P-BPPV-Can who underwent the Epley maneuver, a transient mixed downbeat and torsional nystagmus to the affected ear and retropulsion were observed at the fourth head position (anterior canal crisis). The corrected Epley maneuver significantly reduced the incidence of unpredictable anterior canal crisis (p = 0.017). Additionally, there was no difference in the effect of the Epley maneuver the next day regardless of the anterior canal crisis appearance.ConclusionAnterior canal crisis is an adverse effect of the Epley maneuver, and its prevention is important for safety. Avoiding head rotation beyond 135° to the healthy ear and/or the top of the head going down at the healthy-ear-down 135° head position is expected to reduce anterior canal crisis.     

Horizontal canal type BPPV: bilaterally affected case treated with canal plugging and Lempert's maneuver

A 54-year-old woman complained of positional vertigo. During 3 months' observation, the patient showed mostly geotropic or apogeotropic nystagmus due to right canalolithiasis or cupulolithiasis, however, she sometimes showed nystagmus which suggested left horizontal canalolithiasis. We suspected that she suffered from bilateral horizontal canal type benign paroxysmal positional vertigo (BPPV) and performed Lempert's maneuver for both directions, however, they were ineffective. She underwent canal plugging for right horizontal canal. After surgery she showed no positional nystagmus of right horizontal canal origin. However, apogeotropic nystagmus of the left horizontal canal origin was still observed. This nystagmus changed to geotropic nystagmus and finally disappeared following Lempert's maneuver for the left side. Bilateral horizontal canal BPPV is difficult to be resolved, probably because physical treatment for one side would move debris to the cupula in the other canal. Canal plugging combined with Lempert's maneuver to the other side is one treatment option for intractable bilateral horizontal canal BPPV.     

Approach to bilateral benign paroxysmal positioning vertigo

BACKGROUND: Bilateral benign paroxysmal positioning vertigo (bBPPV) is rather rare, accounting for up to 10% in the reported benign paroxysmal positioning vertigo (BPPV) series. Inappropriate head positioning during testing in unilateral BPPV causes the otolith debris in the uppermost ear to move toward the cupula, resulting in an inhibitory nystagmus and mimicking bBPPV. PURPOSE: We analyzed the clinical data of patients with bilaterally positive Dix-Hallpike maneuver and compared them with the characteristics of patients with unilateral BPPV. We further tried to propose a simple schematic approach to the treatment of patients with bilaterally positive Dix-Hallpike maneuver. MATERIALS AND METHODS: Medical records of 232 patients treated for BPPV at our dizziness clinic during 1999 to 2003 were reviewed. An algorithm used for the treatment of patients with bilaterally positive BPPV is discussed. RESULTS: Twenty-eight patients with bilaterally positive Dix-Hallpike test were found. Sixteen were diagnosed with bBPPV, and 12 were diagnosed with unilateral mimicking bBPPV. Thirty patients with unilateral posterior canal BPPV served as control subjects. No difference in age, sex distribution, duration of symptoms, number of treatments per ear, and recurrence was found between bBPPV and unilateral BPPV. The female sex appeared to be predisposed for more treatments. The total duration of BPPV symptoms obtained by history was found to correlate with the number of recurrences after treatment. CONCLUSIONS: We conclude that bBPPV can be readily distinguished from unilateral mimicking bBPPV. Patients with bBPPV do not differ from patients with unilateral BPPV in clinical characteristics. The mechanism of otolith debris dislodgment appears to be the main cause of bilaterality, trauma being a more common trigger than other known causes of BPPV.     

Clinical characteristics of patients with multi-canal benign paroxysmal positional vertigo

IntroductionMulti-canal benign paroxysmal positional vertigo is considered to be a rare and controversial type in the new diagnostic guidelines of Bárány because the nystagmus is more complicated or atypical, which is worthy of further study.ObjectiveBased on the diagnostic criteria for multi-canal benign paroxysmal positional vertigo proposed by International Bárány Society, the study aimed to investigate the clinical characteristics, diagnosis and treatment of multi-canal benign paroxysmal positional vertigo.MethodsA total of 41 patients with multi-canal benign paroxysmal positional vertigo were included and diagnosed by Roll, Dix-Hallpike and straight head hanging tests. Manual reduction was performed according to the involvement of semicircular canals.ResultsAmong the 41 cases, 19 (46.3%) patients showed vertical up-beating nystagmus with or without torsional component and geotropic, apogeotropic horizontal nystagmus, and were diagnosed with posterior-horizontal canal. 11 (26.8%) patients showed vertical up-beating nystagmus with torsional component on one side and vertical down-beating nystagmus with or without torsional component on the other side during Dix-Hallpike test or straight head hanging test and were diagnosed with posterior-anterior canal benign paroxysmal positional vertigo 9 (26.8%) patients showed vertical down-beating nystagmus with or without torsional component and geotropic, apogeotropic horizontal nystagmus, and were diagnosed with anterior-horizontal canal 2 (4.9%) patients showed vertical geotropic torsional up-beating nystagmus on both sides and were diagnosed with bilateral posterior canal benign paroxysmal positional vertigo. High correlation between the sides with reduced vestibular function or hearing loss and the side affected by Multi-canal benign paroxysmal positional vertigo was revealed (contingency coefficient = 0.602, p = 0.010). During one-week follow up, nystagmus/vertigo has been significantly alleviated or disappeared in 87.8% (36/41) patients.ConclusionPosterior-horizontal canal benign paroxysmal positional vertigo was the most common type. Multi-canal benign paroxysmal positional vertigo involving anterior canal was also not uncommon. Caloric tests and pure tone audiometry may help in the determination of the affected side. Manual reduction was effective in most of Multi-canal benign paroxysmal positional vertigo patients.