The anticipated movements of canaliths in the left posterior canal are shown during the Canalith Repositioning Procedure, resulting in deposition of canaliths in the utricle at the macula and at the base of the posterior canal ampulla. The membranous labyrinths have been positioned with a horizontal canals/ Reids plane angle of +22° and a posterior canal /posterior canal angle of 82°.

The movement of a canalith in the left posterior canal around the circumference of the semicircular duct that is provoked with Brandt-Daroff exercises can be seen. This is an excellent therapeutic option when the side of unilateral disease is not known. There would seem to be no therapeutic benefit to the repetitions performed in the direction opposite the side of canalithiasis as no additional otoconia movement is induced.

This demonstration shows the expected motion of otoconia in the posterior and horizontal canals of the same labyrinth provoked by conventional Brandt-Daroff Exercises. These exercises promote approximately 90° of movement around the circumference of both canals. Note that certain movements cause almost no movement in one canal and maximal movement in the other, and others cause simultaneous movement. These patterns can be confusing to the practitioner.

This treatment modification for posterior canal BPPV was developed in August 2006 by Dr. Teixido in the 3D visualization laboratory at the Delaware Biotechnology Institute. This exercise is appropriate for any BPPV patient, even if the side of disease is not known. The posterior canal exercise moves otoconia 60° farther around the circumference of the posterior semicircular duct with each repetition than conventional Brandt-Daroff exercises. The extra motion toward the posterior canal ampulla may enhance contact of the otoconia with dark cells at the base of the ampulla. Dark cells may play an important role in otoconia resorption. The exercise has 6 head positions, but is easy to teach.

1. The patient lies on the right side with the nose pointed 45° upward (head turned toward the left). Wait 20 seconds.
2. The patient sits upright, keeping the head turned to the left. Wait 20 seconds.
3. The patient lies on the left side with the nose pointed 45° downward (head remains turned toward the left). Wait 20 seconds.
4. The patient remains on the left side, but turns the nose to 45° above the horizontal (head now turned toward the right). Wait 20 seconds.
5. The patient sits upright, keeping the head turned to the right. Wait 20 seconds.
6. The patient lies on the right side with the nose pointed 45° downward (head remains turned toward the right). Wait 20 seconds.
   Repeat steps 1 through 6 four more times.

Each repetition (steps 1-6) takes 2 minutes. Five repetitions, three times a day will usually eliminate symptoms faster than conventional Brandt-Daroff exercises.  A single-blinded study comparing time to complete symptom resolution using the posterior canal exercises or Brandt-Daroff exercises is currently in progress.

This animation shows otolith movements expected in a left ear with combined horizontal and posterior canal BPPV when posterior canal exercises are performed. Much greater movement around the circumference of the posterior canal is induced than by conventional Brandt-Daroff exercises. Movement around the circumference of the horizontal canal is roughly equivalent in posterior canal exercises and Brandt-Daroff exercises. Contact of otoliths with the dark cell areas of the crista is promoted in both canals.

This strategy for canalith repositioning moves otoliths around the circumference of the posterior semicircular canal in fewer steps than the CRP. An extreme head tilt is helpful in the first position to displace otoliths as far around the canal as possible. The patient is then rapidly moved to the second position. This rapid motion is essential to allow gravity in the second position to move the otoliths to the common crus before they start to fall back into the posterior canal. When the patient sits upright the otoliths move to the utricle and to the infundibulum of the posterior canal. Dark cells at these sites may facilitate resorption of otoliths