Iranian Journal of Otorhinolaryngology

Iranian Journal of Otorhinolaryngology

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

Document Type : Case Report

Authors
Shreya Vats 1
Ajay Kumar Vats 2
Sudhir Kothari 3
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, Udaipur, 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.
 
Keywords
Benign paroxysmal positional vertigo
Multi-canal BPPV
Cupulolithiasis
Canalolithiasis
Posterior semicircular canal
Positional nystagmus
Subjects
  1. von Brevern M, Bertholon P, Brandt T, Fife T, Imai T, Nuti D, et al. Benign paroxysmal positional vertigo: Diagnostic criteria. VES. 2015 Oct 15;25 (3,4): 105-117.
  2. Korres S, Balatsouras DG, Kaberos A, Economou C, Kandiloros D, Ferekidis E. Occurrence of Semicircular Canal Involvement in Benign Paroxysmal Positional Vertigo. Otology & Neurotology. 2002 Nov;23 (6): 926-32.
  3. Kim H, Gil Y, Kim J. Subjective BPPV revisited: identification of positional nystagmus with a new maneuver. J Neurol. 2024 Jul;271(7): 4640-3.
  4. Epley JM. Human Experience with Canalith Repositioning Maneuvers. Annals of the New York Academy of Sciences. 2001 Oct;942 (1): 179-191.
  5. Castellucci A, Mohamad A, Vats AK, Kothari S, Vats S, Bijlani A. Physical therapy for posterior semicircular cupulolithiasis: A case series of 15 patients from South Rajasthan. Hearing Balance and Communication. 2025 Apr;23 (2):92-8.
  6. Bijllani A, Vats AK, Mohammad A, Kothari S, Vats S. Multicanalicular Benign Paroxysmal Positional Vertigo (MC-BPPV) Involving Atypical Short Arm Posterior Canal Variant with Contralateral Horizontal Semicircular Cupulolithiasis. Indian J Otolaryngol Head Neck Surg. 2025 Nov;77 (11): 5190-3.
  7. Ping L, Yi-fei Z, Shu-zhi W, Yan-yan Z, Xiao-kai Y. Diagnosis and treatment of the short-arm type posterior semicircular canal BPPV. Brazilian Journal of Otorhinolaryngology. 2022 Sep;88 (5): 733-9.
  8. Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017 Mar;156 (3_suppl): S1-S47.

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

  1. Alfarghal M, Singh NK, Algarni MA, Jagadish N, Raveendran RK. Treatment efficacy of repositioning maneuvers in multiple canal benign paroxysmal positional vertigo: a systematic review and meta-analysis. Front Neurol 2023;14. https:// doi. org/10.3389/fneur.2023.1288150.
  2. Vats AK, Vats S, Kothari S, Aswani N. Atypical Bilateral Posterior Semicircular Canalolithiasis – A Case Series. Ann Indian Acad Neurol. 2024;27(6): 720-3.
Iranian Journal of Otorhinolaryngology
Volume 38, Issue 3
May and June 2026
Pages 197-201