Management of tri-canal benign paroxysmal positional vertigo using sequential repositioning maneuvers: a case report

Multi-canal benign paroxysmal positional vertigo (MC-BPPV) is a rare form of BPPV characterized by the simultaneous involvement of multiple semicircular canals, often resulting in complex diagnostic and therapeutic challenges. While MC-BPPV most commonly affects the posterior and horizontal semicircular canals, tri-canal involvement - especially with bilateral asymmetry - is exceedingly rare.

To describe a unique case of tri-canal BPPV involving right posterior and horizontal semicircular cupulolithiasis and left horizontal semicircular canalolithiasis, successfully managed with a structured, sequential protocol of repositioning maneuvers including a novel Bascule maneuver.

A 43-year-old woman presented with vertigo triggered by positional changes. Detailed positional testing identified cupulolithiasis in the right posterior and horizontal canals and canalolithiasis in the left horizontal canal. Sequential diagnostic maneuvers, including half Dix-Hallpike, inversion, and supine roll tests, revealed complex nystagmus patterns indicating multicanal involvement. Treatment began with mastoid oscillations and the Bascule maneuver targeting the right posterior canal, followed by the Zuma and Gufoni maneuvers for horizontal canal involvement.

Right posterior canal cupulolithiasis resolved within 24 hours. On day 2, transformation of horizontal nystagmus patterns enabled identification and successful treatment of right horizontal canal cupulolithiasis. On day 3, the left horizontal canalolithiasis was confirmed and treated. Complete symptom resolution and negative positional testing were achieved within 72 hours.

This case highlights the importance of comprehensive positional testing and a sequential, canal-specific therapeutic approach in managing complex MC-BPPV. The Bascule maneuver, combined with tailored repositioning techniques, proved highly effective in resolving tri-canal involvement rapidly and completely.