In this blog, I will discuss five posterior canal BPPV variants and effective treatments for each variant.

Classic Presentation of Definite Posterior Canal BPPV

BPPV in the posterior canal classically shows nystagmus in the testing position. The patient feels lightheadedness or “spinning vertigo” during BPPV testing, correlated with the positional nystagmus.

That describes classic or “definite” posterior canal BPPV.

The crystals are usually displaced to the long arm of the posterior canal.

This type of BPPV typically resolves with BPPV treatments like modified Epley or Semont maneuver.

Variant 1: Type 2 BPPV

Type 2 BPPV is “without nystagmus.” This variant of BPPV causes symptoms but does not show nystagmus during BPPV testing.

In my experience, type 2 BPPV is usually in the long arm of the posterior canal especially if it initially occurred while lying down.

The treatments for type 2 BPPV in the long arm are the same as classic BPPV, such as modified Epley maneuver or Semont maneuver.

Type 2 BPPV is proven in hindsight based on the results of these treatments.

Type 2 BPPV is a newer term. For many years, we used to call this “symptomatic BPPV.”

Research about Type 2 BPPV can be found here.

I wrote two blogs about it here:

Symptomatic BPPV: BPPV without Nystagmus

Latest Research: BPPV Without Nystagmus

Variant 2: Short Arm Posterior Canal BPPV

This type of BPPV often shows classic posterior canal nystagmus during BPPV testing, but does not clear up with traditional treatments like modified Epley or Semont maneuvers.

It can also show atypical nystagmus during BPPV testing, depending on the patient’s inner ear anatomy. Advanced skills in BPPV assessment and treatment may be needed to identify this condition, if the nystagmus is atypical or if the posterior canal BPPV will not clear.

I wrote an article about this type of BPPV and one treatment I use for it here:

Using The Bow-and-Yaw Maneuver to Treat BPPV=

Variant 3: Posterior Canal Cupulolithiasis

Classic BPPV is a condition of loose crystals displaced in the canals within the ear. Free-floating crystals is the common type of BPPV, called canalithiasis.

If the displaced crystals are stuck on the sensory apparatus within the posterior canal, then the BPPV variant is called cupulolithiasis.

In those cases, a vibration tool is usually applied during an Epley. A Semont maneuver with or without vibration may be effective to resolve this condition.

Variant 4: Vestibular Agnosia

If a patient has posterior canal BPPV in the long arm with classic nystagmus but they don’t feel vertigo during BPPV testing, they may have a condition called vestibular agnosia.

This can occur in younger patients with traumatic brain injuries and older adults with neurodegenerative disorders.

In this condition, the BPPV exhibits classic nystagmus during BPPV testing and resolves with treatment.

However, the patient does not feel any vertigo during BPPV testing or treatment.

This type of BPPV typically resolves with BPPV treatments like modified Epley or Semont maneuver.

Variant 5: Apogeotropic Posterior Canal BPPV

Within the long arm of the posterior canal, there are different segments. Picture a race track and then split it up into segments.

Typically loose BPPV crystals settle in the segment near the sensory apparatus within the long arm of the posterior canal. Thereby, the classic nystagmus pattern during BPPV testing is produced.

If loose BPPV crystals are in the posterior canal heading towards the classic position but have not yet arrived in that segment, then they are in a different segment of the posterior canal closer to the common crus.

Interestingly, the nystagmus patterns shown during BPPV testing become inverted like a mirror image.

For example, the nystagmus pattern during BPPV testing may appear to be anterior canal but it’s really an apogeotropic posterior canal BPPV (on the same side or opposite side).

This type of BPPV can be successfully resolved with typical posterior canal treatments like a modified Epley or Semont maneuver. The risk of this treatment option would be an ipsicanal switch during the treatment, which may cause confusion.

Another treatment option for apogeotropic  BPPV is a Demi-Semont maneuver.

Research about Apogeotropic Posterior Canal BPPV and ipsicanal switch can be found here.

As you can see, posterior canal BPPV is a very detailed and complex topic. I hope this blog sheds light on why “trying the Epley maneuver” does not always work.