Cupulolithiasis vs. canalithiasis: what happens when inner ear crystals stick to the cupula?

How do you tell cupulolithiasis from canalithiasis?

The timing of the nystagmus under infrared video goggles is the main clue. Canalithiasis produces a burst that builds and fades within about a minute. Cupulolithiasis produces nystagmus that persists while the position is held. In the horizontal canal, cupulolithiasis typically causes apogeotropic nystagmus, beating away from the ground, in the roll test¹.

How is cupulolithiasis treated?

Liberatory maneuvers use quick, controlled head movements to free crystals from the cupula. For the posterior canal, the Semont maneuver is commonly used. For the horizontal canal, a modified Gufoni maneuver or head-shaking can convert apogeotropic BPPV to the free-floating geotropic form, which is then treated with a roll or Gufoni maneuver. More sessions are often needed than for canalithiasis².

Could persistent positional nystagmus be something else?

Yes. A so-called light cupula and central positional nystagmus can also produce persistent nystagmus. If the pattern does not respond to treatment as expected, or comes with other neurological signs, we refer you to your physician for further evaluation.

Where can I get help for stubborn positional vertigo near Alpharetta or Cumming?

Our Cumming and Alpharetta clinics treat complex and stubborn BPPV in 60-minute, one-on-one visits, retesting after each maneuver. Patients come from Johns Creek, Milton, Suwanee and Forsyth County.

Where can I get help in Alpharetta, Cumming and nearby?

Dr. Manan Patel, PT, DPT, TPS and our team of physical therapists see patients from Alpharetta, Johns Creek, Milton, Roswell, Cumming, Suwanee, Sugar Hill, Buford, Duluth and Forsyth County at two North Atlanta clinics. Every visit is 60 minutes, one-on-one, and urgent appointments are available within 48 hours. We are in-network with Traditional Medicare, BCBS / Anthem and Tricare, and offer a $129 rate per visit for self-pay and out-of-network plans. Not sure where to start? Take the free symptom self-check, or visit our Alpharetta clinic or Cumming clinic page.

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Related questions

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References

1. von Brevern M, et al. Benign paroxysmal positional vertigo: Diagnostic criteria. Journal of Vestibular Research. 2015.
2. Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology–Head and Neck Surgery. 2017.

Answered by Dr. Manan Patel, PT, DPT, TPSDoctor of Physical Therapy, Certified Vestibular Specialist and one of the few certified Therapeutic Pain Specialists in North Atlanta, with 15+ years of outpatient care. About Dr. Patel

This answer is general education, not a diagnosis or a substitute for an examination. If you have new or worsening symptoms, contact your doctor. Call 911 for sudden severe dizziness with trouble speaking, weakness, numbness, double vision or a severe headache.