Comparison of the Efficacy of Appiani and Zuma Maneuvers in Patients with Apogeotropic Horizontal Canal Benign Paroxysmal Positional Vertigo.

Abstract

Background: Apogeotropic horizontal canal benign paroxysmal positional vertigo (HC-BPPV) is a challenging variant of BPPV with lower treatment success rates compared to the geotropic form. The Appiani maneuver (ApM) and the Zuma maneuver (ZmM) represent 2 repositioning strategies targeting this condition, but head-to-head comparative data remain limited.

Methods: A prospective randomized comparative study was conducted between December 2024 and November 2025. Patients with unilateral apogeotropic HC-BPPV confirmed by videonystagmography (VNG)-assisted supine roll testing were assigned to either the ApM (n = 38) or the ZmM (n = 39). The primary outcome was resolution of positional nystagmus; the secondary outcome was the number of maneuver sessions required (maximum 4). Patients who developed canal conversion to another semicircular canal during follow-up were excluded from efficacy analysis.

Results: Among 77 patients (63.6% female; 59.7% aged ≥ 60 years), the overall single-session resolution rate was 63.6%. Resolution after 1 session was achieved in 68.4% (ApM) and 59.0% (ZmM) of patients, with no significant between-group difference (P = .389). Older age (≥60 years) was the only factor significantly associated with requiring ≥2 sessions (82.1% vs. 46.9%; P = .002).

Conclusion: Both the ApM and ZmM are effective and comparable treatments for apogeotropic HC-BPPV. Advanced age (≥60 years) was identified as an exploratory factor associated with requiring multiple treatment sessions.