Canalith-Repositioning Maneuvers
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One of the most common causes of vertigo is benign positional vertigo (BPV), also known as benign paroxysmal positional vertigo (BPPV), which is usually due to free-floating, misplaced otoliths that have inappropriately entered one of the semicircular canals of the inner ear.
The Epley maneuver, or canalith repositioning procedure (CRP), was invented by John Epley. [1] The Epley maneuver with various modifications can be used to move these otoliths out of the posterior or anterior semicircular canals and place them in the utricle where they belong. [2] The Epley maneuver is now widely used as a first-line treatment of vertical (posterior or anterior) canal BPPV. [3] It is safe in elderly patients and can be performed at the bedside within a matter of minutes. [4] The Semont maneuver may also used for this condition [5, 6] as well as for the cupulolithiasis variant (in which the otoliths are not free-floating but instead are attached to the cupula in the semicircular canal). Many do not recommend the Semont maneuver in elderly patients because of the more violent nature of the maneuver.
Horizontal canal BPV (H-BPV) is less common than posterior canal BPV but causes more severe symptoms of nausea and vertigo. [7] Numerous effective maneuvers are available for treating H-BPV, including the Gufoni, [8] Vannuchi-Asprella, [9] and barbecue roll [10] methods.
The inner ear, also called the labyrinthine cavity, functions to conduct sound to the central nervous system (CNS) as well as to assist in balance. Auditory transduction, the conversion of acoustic (mechanical) energy to electrochemical energy, takes place within the labyrinthine cavity.
The labyrinthine cavity is essentially formed of the membranous labyrinth encased in the bony osseus labyrinth. The osseus labyrinth is a series of bony cavities within the petrous temporal bone; the membranous labyrinth is the communicating membranous sacs and ducts housed within the osseus labyrinth. The membranous labyrinth is cushioned by the surrounding perilymph and contains the endolymph within its confines. The membranous labyrinth also has cochlear, vestibular, and semicircular components.
There are 3 bony semicircular canals; each stands at right angles to the other 2 canals. The superior, posterior, and lateral semicircular canals sit behind and superior to the vestibule (see the following image). At one end of each canal is the ampulla, a dilatation of the end. These canals open into the vestibule (utricle) via 5 ampullae.
For more information about the relevant anatomy, see Ear Anatomy and Inner Ear Anatomy.
The American Academy of Otolaryngology—Head and Neck Surgery Foundation set a panel representing of different fields concerned with managing patients with BPPV. [11] The panel made strong recommendation that physicians should diagnose posterior semicircular canal BPPV when the Dix-Hallpike maneuver provokes vertigo associated with nystagmus.
The panel made the following recommendations:
Patients with posterior canal BPPV should be treated with a particle repositioning maneuver (PRM).
Patients should be reevaluated within 1 month to confirm symptom resolution.
Patients should be counseled regarding their safety, potential for disease recurrence, and the importance of follow-up.
Patients with BPPV in whom treatment fails should be assessed for underlying vestibular or CNS disorders.
In case of a history compatible with BPPV and the Dix-Hallpike test is negative, clinicians should assess for lateral semicircular canal BPPV by performing a supine roll test.
Other causes of imbalance, dizziness, and vertigo should be differentiated from BPPV.
Factors that may modify the management (eg, impaired mobility or balance, increased risk for falling, CNS disorders, and lack of home support) should be assessed.
The panel made an option that observation may be offered as initial management for patients with BPPV and that clinicians may offer vestibular rehabilitation for management of BPPV.
The panel made recommendations against (1) radiographic imaging and/or vestibular testing in patients diagnosed with BPPV, unless the diagnosis is uncertain or to assess other symptoms and signs not related to BPPV, and (2) to routinely offer vestibular suppressant medications to manage BPPV.
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Variations of the Epley maneuver are indicated in patients who have classic benign positional vertigo (BPV) of the posterior or (more rarely) anterior semicircular canal due to canalithiasis (free-floating particles in the semicircular canal).
These maneuvers should be used in patients with a characteristic BPV history (after movement of the head in the vertical plane, vertigo develops and then resolves in less than 1 minute) and an abnormal Dix-Hallpike (Hallpike, Nylen-Barany) test. The video below demonstrates the Dix-Hallpike test.
An abnormal Dix-Hallpike test consists of reproduction of vertigo symptoms in the head-hanging position along with torsional nystagmus. The posterior semicircular canal is by far the most commonly involved canal, and the torsional nystagmus is characteristically upbeating (upper poles of the eyes appear to beat toward the patient’s forehead). Typically, the finding is present on only one side, but occasional patients have bilaterally abnormal Dix-Hallpike results, indicating bilateral canalithiasis. [12]
In anterior canal BPV, a paroxysm of downbeating and torsional nystagmus occurs on the Dix-Hallpike test, usually in a person with a prior history of posterior canal BPV. Caution must be used in interpretation of this type of nystagmus because prolonged downbeating nystagmus without a torsional component is indicative of more serious central vestibular disorders. [13]
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The Semont maneuver is useful when the Epley maneuver fails to remove particles or when particles are suspected to have become adherent to the cupula of the semicircular canals (cupulolithiasis). This maneuver is popular in Europe but is used less frequently in the United States than the Epley maneuver.
The diagnosis of cupulolithiasis is made using the Dix-Hallpike test. The nystagmus has a mixed vertical and torsional direction and is persistent as long as the patient remains in the head-hanging position (it does not have a paroxysmal quality).
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Horizontal canal maneuvers are used to treat horizontal canal BPV, which may occur spontaneously or arise as a complication when treating posterior canal BPV.
Usually, a sudden violent vertigo is noted during the Dix-Hallpike test, accompanied by a coarse horizontal nystagmus. Vomiting is common. A simple diagnostic test is to rapidly lower the patient from a seated to supine position onto a bed with the head of the bed raised to 30 degrees. A sudden horizontal nystagmus will be evident that will change direction as the head is moved briskly to the right and then to the left.
When horizontal BPV occurs during treatment maneuvers, the side of involvement is the side being treated. When the patient presents with this variant and the side is not already known, the vertigo and nystagmus is usually most severe when turning the head toward the affected ear in the above test.
The Gufoni method is an efficient and effective method to remove particles from the horizontal canal when it arises as a complication during the Epley maneuver. The method devised by Vannuchi and Asprella is effective for spontaneous cases, particularly when the side of involvement is uncertain.
Older techniques (eg, barbecue roll) can also be used but are technically more difficult to perform in larger or less mobile individuals.
Canalith repositioning maneuvers are generally safe in patients, including elderly and pregnant patients.
Contraindications to these maneuvers include the following:
Acute fractures that prevent the patient from lying down quickly or rolling over
Recent neck fracture, surgery, or instability
History of vertebral dissection or unstable carotid disease
Recent retinal detachment
Anesthesia is not required for this procedure.
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The use of vibrators is controversial. Some research suggests that the use of vibration, head taps, or speed during movements may assist in the movement of the particles. A small handheld vibrator can be held over the mastoid on the affected side during the entire maneuver.
See the list below:
If present, guard rails should be lowered to allow access to the patient from both sides during the maneuver. The examiner and the assistant are positioned closely against the bed to prevent falls.
Patients that are too large to move safely on a table or bed can be treated on an exercise mat on the floor.
See the Technique section for specific positioning for various techniques.
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The patient is seated on the examination table or gurney, facing the end of the table, with the examiner standing on the side to be treated and an assistant standing on the opposite side.
If the examiner desires to achieve complete dependency of the patient’s head during the maneuver, the patient should be positioned so that his or her shoulders will meet the head of the table or gurney when he or she is reclined. See image below.
Some research suggests that the use of vibration, head taps, or speed during movements may assist in the movement of the particles. A small handheld vibrator can be held over the mastoid on the affected side during the entire maneuver. Very brisk tapping with the fingertips over the mastoid while being held in each position may also be effective. Moving the patient quickly during the initial Dix-Hallpike test while rolling the patient onto the shoulder or when arising from reclining may also help dislodge the particles.
The examiner grasps the patient’s head and turns it 45 degrees to the involved side as determined by the Dix-Hallpike test. The patient should hold the examiner’s near elbow with both hands. This positioning allows complete control over the position of the neck during the initial portions of the maneuver. In the classic Epley version, the examiner is seated behind the patient and holds the neck and head of the patient in one hand during reclining; this is also effective. See image below.
The patient is then reclined to the supine position, with the head maintained in its 45-degree rotation toward the shoulder (this is identical to the Dix-Hallpike test). See image below.
Classically, the head of the patient is held dependent off the end of the examination table during the maneuver, with the top of the head directed toward the floor. If the table position or type prevents this or if the patient is frail, the patient’s head can be lowered to the bed; in this case, the patient’s chin should be elevated and the head tipped back so that the vertex is relatively dependent on the table or gurney.
The position should be maintained until any nystagmus and vertigo subsides or approximately 30 seconds have passed. Tapping or vibration of the mastoid can be applied. The examiner should then move to the head of the bed and reposition his or her hands on either side of the patient’s head. See image below.
The head is then turned 90 degrees away from the affected ear, placing it at 45 degrees toward the opposite shoulder. Allow any vertigo to subside before resuming the maneuver. See images below.
The assistant grasps the patient’s far hand and helps roll the patient quickly up onto the shoulder so the torso faces the assistant. The examiner maintains the head at its 45 degree orientation to the shoulder, so that when the patient is rolled toward the assistant, the patient’s face will be directed at a 45-degree angle to the floor. The position should be maintained until the nystagmus and vertigo subsides or 30 seconds have passed. See images below.
The patient is then asked to move his or her legs off the side of the table toward the assistant in preparation to sit up. The examiner moves back to the side of the table behind the patient and stabilizes the patient’s head. The patient is then asked to sit up, keeping the head turned to the shoulder, chin down, and leaning forward. From behind, the examiner maintains the proper 45-degree head orientation and prevents the patient from leaning back, as the assistant helps pull the patient to the seated position facing the assistant. See images below.
After approximately 30 seconds, the patient can resume free movement.
The maneuver may be repeated in approximately 30 minutes if significant nystagmus or vertigo is still elicited during the Dix-Hallpike test.
The video below demonstrates the Epley maneuver.
See the list below:
The patient is seated upright on the side of the examination table facing the examiner. For simplicity, treatment of the right ear is described here; to treat the left ear, reverse the direction of each step.
The examiner grasps the patient’s head and gently turns it horizontally away from the affected right ear until it is 45 degrees toward the opposite (left) shoulder.
The patient is then rapidly reclined down onto the right shoulder, head toward the head of the bed. The examiner keeps the head aligned at 45 degrees toward the left shoulder. When the patient is fully reclined, the head is at a 45-degree angle to the bed and floor, with the affected right ear down, just as in the Dix-Hallpike test.
Allow any nystagmus or vertigo to subside, or wait 30 seconds.
Maintaining the head turn at a 45-degree angle to the left shoulder, the patient is then rapidly moved from the right shoulder down to the left shoulder down position. Because the head is turned at a 45-degree angle to the left shoulder, once the left shoulder is down and the patient is reclining, the patient’s face is directed toward the bed and floor at a 45-degree angle.
Again, allow any nystagmus or vertigo to subside, or wait 30 seconds.
The patient is then briskly raised to the seated position, with the patient’s head maintained at a 45-degree angle toward his or her left shoulder.
Several repetitions at one sitting may be required to fully relieve symptoms.
The video below demonstrates the Semont maneuver.
See the list below:
If horizontal nystagmus is noted during a Dix-Hallpike test following an Epley maneuver, immediately raise the patient to the seated position facing the examiner.
Swiftly recline the seated patient sideways onto his or her opposite shoulder with his or her face slightly upward.
Smoothly rotate the head through a 90-degree rotation toward the examiner until the patient’s nose is face down on the examination table. Wait several seconds.
Keeping the patient’s head turned toward his or her shoulder, raise the patient to the seated upright position facing the examiner. After several seconds, the patient is free to move.
One maneuver is usually sufficient.
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Raise the head of the bed to 30 degrees.
Rapidly recline the patient to the supine position with the patient’s head centered. A horizontal nystagmus will be noted. Wait until it declines or for at least 30 seconds, then smoothly turn the patient’s head horizontally toward his or her shoulder opposite to the affected ear. Wait 30 seconds.
Keeping the head turned toward the shoulder, raise the patient to the seated position with the patient’s torso facing the end of the bed.
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Recline the patient in the supine position with the head turned toward the affected ear. Wait for a horizontal nystagmus to become evident.
Roll the patient away from the affected ear in steps of 90 degrees, stopping about 30 seconds after each step.
The patient will need to be adjusted on the gurney to maintain a central position when rolling from supine to side, from side to prone, and from prone to side positions. Continue rolling until the original supine position is reached.
Additional repetitions are usually required.
The video below demonstrates the barbecue roll method.
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Use of vibration in the canalith repositioning procedure: Some practitioners advocate the use of vibration applied over the mastoid bone of the affected ear during repositioning while the patient is moved relatively slowly through the positions. [14, 1] Other authors have found that vibration applied during slowly performed maneuvers does not significantly affect short-term or long-term outcomes when compared with the use of rapid positioning without vibration. [15, 16] Vibration, brisk repositioning movements, or head tapping are likely to be equally efficacious in mobilizing particles.
Premedication: Some patients may experience nausea and vomiting during canalith repositioning procedures, and they may require an antiemetic before undergoing the maneuver. Patients with a history of migraine headaches are more susceptible.
Postural restriction after canalith repositioning procedure: Some centers advocate restrictions on head positions and movement following the maneuver, such as immobilization in a cervical collar, sleeping in the upright seated position for a few days, or avoiding sleeping positions with the affected ear down. Some have found that the efficacy of the Epley maneuver was not improved by certain postural restrictions. [17] Others found that postural restriction enhanced the therapeutic effect of the canalith repositioning procedure but did not prevent benign positional vertigo (BPV) recurrence. [18] Essentially, the issue depends on the length of time required for the otoliths to become reattached to the hair cells in the utricle. How long this process takes is unclear, but it may be as short as 30 minutes. Basic postural restriction instructions include the following:
Instruct the patient to sleep with the head elevated 30 degrees or more for the first 1-2 nights following the maneuver.
For one week, instruct the patient to avoid head positions that can cause recurrence such as placing the head in a dependent position or sleeping on the side with the affected ear down.
Success rates: Variation exists between centers based on treatment methods and the number of maneuvers applied in each sitting, but the overall efficacy exceeds 90%. Repetition of the maneuver until the patient is free of symptoms improves its efficacy.
Recurrences: Recurrences occur in 30-50% of patients. [1, 15, 6] These can be treated with repeat maneuvers. Patients who exercise vigorously with the head dependent, those who make motions similar to the Dix-Hallpike test (eg, yoga, sit-ups, flips in the pool), and those with a history of trauma are more prone to recurrence.
Canals affected: The posterior semicircular canal is the most frequently affected in benign paroxysmal positional vertigo (BPPV). The horizontal semicircular canal is less commonly affected, representing 10-13% of all cases. [7] The anterior canal variant accounts for about 2% of BPV cases. [19] The posterior canal predominates because this canal is the lowest part of the ear when the head is upright or when lying prone.
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Conversion of posterior canal benign paroxysmal positional vertigo (BPPV) to horizontal canal benign positional vertigo (BPV): This must be treated as soon as a horizontal nystagmus is identified, using one of the maneuvers for horizontal canal BPV. [20] Rarely, conversion can involve the anterior canal. Treatment requires application of the Epley maneuver to the opposite ear. [21] After conversion has been treated, the Dix-Hallpike maneuver should not be repeated in the same session, as reconversion is likely.
Reentry of particles into the posterior canal: Occasional patients experience severe vertigo upon being raised to the upright position during the Epley maneuver. They forcefully tip the head upward and lean back as they experience severe vertigo. This results when particles that have almost exited the canal slide back into it, traversing the full extent of the canal. Another Epley maneuver can be used to remove the particles. Positioning the patient with the face directed downward and with the body leaning over toward the assistant as the patient is raised to the sitting position can reduce the incidence of this problem.
Canalith jam: A very rare complication of maneuvers, canalith jam is identified by sudden conversion from a paroxysmal positional nystagmus to a rapid persistent nystagmus unaffected by head position. The mechanism is thought to be jamming of the canaliths as they pass en masse from a dilated area of the canals, such as the ampulla or common crus, into the narrower canal proper. It can be managed by reversing the preceding movement or by breaking the jam up with the aid of a handheld vibrator. [22]
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Canalith repositioning procedures are based on the canalithiasis theory, in which transient nystagmus induced by position change is believed to be caused by free-moving, relatively heavy canaliths misplaced from the gravity-sensing utricle into a semicircular canal.
The procedure is designed to move canaliths back to the utricle through the nonampullated, open end of the canal.
Maneuvers use motion of the head in the plane of the affected canal to move the canaliths toward the utricle both through endolymph movement and through the effect of gravity on the particles. [22]
Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 1992 Sep. 107(3):399-404. [Medline].
Epley JM. Human experience with canalith repositioning maneuvers. Ann N Y Acad Sci. 2001 Oct. 942:179-91. [Medline].
Hilton MP, Pinder DK. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2014 Dec 8. 12:CD003162. [Medline].
Parham K, Kuchel GA. A Geriatric Perspective on Benign Paroxysmal Positional Vertigo. J Am Geriatr Soc. 2016 Feb. 64 (2):378-85. [Medline].
Semont A, Freyss G, Vitte E. Curing the BPPV with a liberatory maneuver. Adv Otorhinolaryngol. 1988. 42:290-3. [Medline].
Brandt T, Huppert D, Hecht J, Karch C, Strupp M. Benign paroxysmal positioning vertigo: a long-term follow-up (6-17 years) of 125 patients. Acta Otolaryngol. 2006 Feb. 126(2):160-3. [Medline].
Cakir BO, Ercan I, Cakir ZA, Civelek S, Sayin I, Turgut S. What is the true incidence of horizontal semicircular canal benign paroxysmal positional vertigo?. Otolaryngol Head Neck Surg. 2006 Mar. 134(3):451-4. [Medline].
Asprella Libonati G, Gufoni M. Parossistica vertigo from CSL: maneuvers of barbecue and varying others. Nuti D, Pagnini P, Neighbors C, eds. Actions of XIX the Day of Clinical Nistagmografia. Milan: Formenti; 1999. 321-36.
Vannuchi P, Asprella Libonati G, Gufoni M. The physical treatment of lateral semicircular canal canalolithiasis. Audiological Medicine. 2005. 3:52-57.
Escher A, Ruffieux C, Maire R. Efficacy of the barbecue manoeuvre in benign paroxysmal vertigo of the horizontal canal. Eur Arch Otorhinolaryngol. 2007 Oct. 264(10):1239-41. [Medline].
[Guideline] Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov. 139(5 Suppl 4):S47-81. [Medline].
Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med. 1999 Nov 18. 341(21):1590-6. [Medline].
Zapala DA. Down-beating nystagmus in anterior canal benign paroxysmal positional vertigo. J Am Acad Audiol. 2008 Mar. 19(3):257-66. [Medline].
Li JC. Mastoid oscillation: a critical factor for success in canalith repositioning procedure. Otolaryngol Head Neck Surg. 1995 Jun. 112(6):670-5. [Medline].
Hain TC, Helminski JO, Reis IL, Uddin MK. Vibration does not improve results of the canalith repositioning procedure. Arch Otolaryngol Head Neck Surg. 2000 May. 126(5):617-22. [Medline].
Ruckenstein MJ, Shepard NT. The canalith repositioning procedure with and without mastoid oscillation for the treatment of benign paroxysmal positional vertigo. ORL J Otorhinolaryngol Relat Spec. 2007. 69(5):295-8. [Medline].
Casqueiro JC, Ayala A, Monedero G. No more postural restrictions in posterior canal benign paroxysmal positional vertigo. Otol Neurotol. 2008 Aug. 29(5):706-9. [Medline].
Cakir BO, Ercan I, Cakir ZA, Turgut S. Efficacy of postural restriction in treating benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg. 2006 May. 132(5):501-5. [Medline].
Prokopakis EP, Chimona T, Tsagournisakis M, et al. Benign paroxysmal positional vertigo: 10-year experience in treating 592 patients with canalith repositioning procedure. Laryngoscope. 2005 Sep. 115(9):1667-71. [Medline].
White JA, Oas JG. Diagnosis and management of lateral semicircular canal conversions during particle repositioning therapy. Laryngoscope. 2005 Oct. 115(10):1895-7. [Medline].
Koelliker P, Summers RL, Hawkins B. Benign paroxysmal positional vertigo: diagnosis and treatment in the emergency department–a review of the literature and discussion of canalith-repositioning maneuvers. Ann Emerg Med. 2001 Apr. 37(4):392-8. [Medline].
Epley JM. Positional vertigo related to semicircular canalithiasis. Otolaryngol Head Neck Surg. 1995 Jan. 112(1):154-61. [Medline].
Amr Nabil Rabie, MD, MS International Research Fellow, Department of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School; Lecturer, Department of Otolaryngology-Head and Neck Surgery, Ain Shams University, Egypt
Amr Nabil Rabie, MD, MS is a member of the following medical societies: European Academy of Facial Plastic Surgery, Egyptian Society of Otorhinolaryngology
Disclosure: Nothing to disclose.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
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Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.
Andrew K Chang, MD, MS Vincent P Verdile, MD, Endowed Chair in Emergency Medicine, Professor of Emergency Medicine, Vice Chair of Research and Academic Affairs, Albany Medical College; Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Emergency Medicine, Montefiore Medical Center
Andrew K Chang, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American Academy of Pain Medicine, American College of Emergency Physicians, American Geriatrics Society, American Pain Society, Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
Carol A Foster, MD Associate Professor, Department of Otolaryngology, Department of Rehabilitation Medicine, and Department of Audiology, Director, Balance Laboratory, University of Colorado Health Sciences Center
Carol A Foster, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and American Medical Association
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Canalith-Repositioning Maneuvers
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