Novel Case of Bilateral Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo with Asymmetric Mechanisms: Left Cupulolithiasis and Right Short-Arm Canalolithiasis

Articles in Press

Document Type : Case Report

Authors

1 Clinical Vestibulology Observer, Otoneurology Centre, 6-A, Block-B, Shikarbadi, Udaipur-313001, Rajasthan, India.

2 Consultant Neurophysician, ShantiRaj Hospital Kesar Kunj, New Bhupal Pura, India.

3 Department of Neurology, Poona Hospital and Research Centre, Pune, Maharashtra, India.

10.22038/ijorl.2026.92534.4081

Abstract

Introduction:
Benign paroxysmal positional vertigo (BPPV) involving multiple semicircular canals (MC-BPPV) is an uncommon variant in which otoconia dislodged from the utricular macula migrate into two or more canals, provoking brief vertigo episodes with positional changes. The single-canal variant predominates, most often affecting the posterior canal, followed by the horizontal and anterior canals. MC-BPPV typically presents with ipsilateral or contralateral posterior-horizontal canal combinations, while atypical posterior canal variants are rarer and require careful nystagmus evaluation during positional testing.
Case Report:
A 62-year-old man presented with a one-day history of vertigo triggered by rising from the supine position, along with retropulsion and vertigo during transitions to lateral recumbent positions. Standard right Dix-Hallpike test (DHT) and right half DHT were unremarkable. Augmented right half-DHT elicited persistent upbeat right-torsional nystagmus; a negative inversion test indicated right short-arm posterior canalolithiasis. Left half-DHT evoked persistent left torsional upbeating nystagmus that reversed to downbeating nystagmus with a subtle right-torsional component on right lateral rolling nose-down, consistent with left posterior cupulolithiasis. The Bascule maneuver was used to treat the left ear, and the prone pitch-and-yaw maneuver was used to treat the right ear. Follow-up showed conversion of left posterior cupulolithiasis to typical canalolithiasis, which resolved with the Epley maneuver, resulting in complete symptom remission.
Conclusions:
This case highlights the importance of comprehensive positional testing and mechanism-specific therapeutic maneuvers for successful management of atypical bilateral MC-BPPV.
 

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References

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Vats, Ajay Kumar (2025). Bilateral Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo with Asymmetric Mechanisms: Left Cupulolithiasis and Right Short-Arm Canalolithiasis. figshare. Media. https: // doi.org/10. 6084/m9.figshare.30480149.v1

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Iranian Journal of Otorhinolaryngology

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Available Online from 26 May 2026

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