Treatment of horizontal canal BPPV (Hc-BPPV) is not without controversy due to the several repositioning manoeuvres advocated for its treatment. Among the many, barbecue rotation (Br) is perhaps the most commonly used for canalithiasis of Hc-BPPV. Should the rotation be 270° or 360°? To muddy the waters, the author proposes a 540° degree rotation on the basis that “a 540° rotation starting with the affected ear down settles any particles in the anterior limb of the horizontal canal downwards so that they join those located in the posterior limb of the canal and move toward the utricle during the six stepwise 90° rolls. Ending with the affected ear up enhances the chance that particles remain in the utricle.” In this prospective study over a four-year period, 60 adult patients with Hc canalithiasis were alternately allocated to two treatment groups: Br360 and Br540. Excluding canal conversion and those lost to follow-up, the analyses involved 26 and 21 patients in the Br360 and Br540 groups respectively. Br360 involved five steps: nose-up, affected ear-up, nose-down, affected ear-down and nose-up whereas the Br540 were in seven steps: affected ear down, nose-up, affected ear-up, nose-down, affected ear-down, nose-up and affected ear-up. Each step was maintained for three minutes before returning to sitting up. One manoeuvre was performed per visit and repeated once weekly till vertigo/nystagmus resolved.
The cure rate after one attempt was significantly better in the Br540 group (90%) compared with 61% in the Br360 group. Two and four visits were needed in two and one patients respectively in the Br540 group whereas in the other group, two and three were required in six and four patients respectively.
Another finding was that the drop-out rate was very low. The author argued that canal conversion rate was also lower in the Br540 manoeuvre compared to other manoeuvres such as Gufoni and the traditional barbecue manoeuvre. A limitation of the non-randomised allocation was highlighted. There was no mention of recurrence figures in the study. I think this is a manoeuvre worth considering but it may take in excess of 21 minutes to complete a single treatment.