Horizontal Cupulolithiasis
Definition
Horizontal or lateral cupulolithiasis BPPV (Benign Paroxysmal Positional Vertigo) typically occurs when otoconia (tiny calcium carbonate crystals) adhere to the cupula of the horizontal semicircular canal, rendering it abnormally sensitive to gravity. This results in a persistent, apogeotropic horizontal nystagmus (beating away from the ground) during the supine roll test. The altered cupular density causes sustained deflection and prolonged vertigo as long as the head remains in the provocative position.
Clinical Findings
- In horizontal canal BPPV, nystagmus on BOTH sides of the supine roll test is observed, with two distinct presentations:
- Geotropic (more common): Nystagmus beats toward the ground, stronger on the affected side — suggests canalithiasis in the long arm of the horizontal canal.
- Apogeotropic (less common): Nystagmus beats away from the ground, often due to cupulolithiasis or debris near the ampulla.
- Postural Instability, especially with eyes closed or head turns
- Oculomotor Examination
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Spontaneous Nystagmus – could be present if BPPV is in a horizontal canal
- Abnormal Head Impulse Test (HIT) – could be abnormal if BPPV started with concurrent acute unilateral vestibular hypofunction, otherwise typically negative
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An example of apogeotropic nystagmus, consistent with right horizontal cupulolithiasis BPPV (confirmed during the Bow and Lean test).
3 Easy Steps to find the affected side in HC BPPV
- Identify if the patient has horizontal canalithiasis (geotropic nystagmus) or horizontal cupulolithiasis (apogeotropic nystagmus) during the supine roll test
- An optional test to substitute for the supine roll test would be the upright head roll test (Malara et al., 2020), which can work in a complimentary way with other testing such as the Bow and Lean test described in Step 3.
- Utilize symptom and nystagmus strength as a strategy for identifying the affected side if possible
- For canalithiasis, during the supine roll test, the side where the patient’s head was turned when they have the STRONGER symptoms and nystagmus is usually the affected side
- For cupulolithiasis, during the supine roll test, the side where the patient’s head was turned when they have the WEAKER symptoms and nystagmus is usually the affected side.
- If needed, utilize the Bow and Lean (or Sit to/from Supine) test when Step 2 doesn’t clearly indicate a side with stronger symptoms
Tests
Treatment Maneuvers
- Kim
- Gufoni for horizontal cupulolithiasis
- Zuma
- Universal Maneuver
Patient Focused Treatment Handouts (PDFs)
Research Highlights
- In a 2025 study by Chang et al., over half of patients with persistent geotropic or apogeotropic nystagmus (PGN/PAGN) met criteria for definite or probable vestibular migraine, with most experiencing short, recurrent episodes of vertigo. These findings suggest a correlation between PGN/PAGN and migraine-related vestibular dysfunction, indicating that nystagmus could be central rather than purely peripheral in origin.
- A 2023 study by Kalmanson et al., found apogeotropic horizontal nystagmus may result from cupulolithiasis or canalith jam and can sometimes convert to geotropic nystagmus with vibration, head shaking, or brisk movement. If nystagmus persists after 3–5 appropriate maneuvers, a central cause should be considered.
Want to learn more about BPPV? – Check out these resources
Sources
- Bhattacharyya, Neil, et al. “Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update).” Otolaryngology–Head and Neck Surgery, vol. 156, no. 3_suppl, 2017, pp. S1–S47. https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599816689667
- Chang TP, Hong YC, Kuo YH, Schubert MC. Persistent geotropic or apogeotropic nystagmus: recurrence and association with vestibular migraine. J Neurol. 2025 Feb 11;272(3):184. doi: 10.1007/s00415-025-12921-8. PMID: 39932582. https://pubmed.ncbi.nlm.nih.gov/39932582/
- Kalmanson O, Foster CA. Cupulolithiasis: A Critical Reappraisal. OTO Open. 2023 Mar 1;7(1):e38. doi: 10.1002/oto2.38. PMID: 36998555; PMCID: PMC10046726. https://pmc.ncbi.nlm.nih.gov/articles/PMC10046726/
- Malara P, Castellucci A, Martellucci S. Upright head roll test: A new contribution for the diagnosis of lateral semicircular canal benign paroxysmal positional vertigo. Audiol Res. 2020 Jul 7;10(1):236. doi: 10.4081/audiores.2020.236. PMID: 32676175; PMCID: PMC7358984. https://pmc.ncbi.nlm.nih.gov/articles/PMC7358984/
- von Brevern M, Bertholon P, Brandt T, Fife T, Imai T, Nuti D, Newman-Toker D. Benign paroxysmal positional vertigo: Diagnostic criteria. J Vestib Res. 2015;25(3-4):105-17. doi: 10.3233/VES-150553. PMID: 26756126. https://pubmed.ncbi.nlm.nih.gov/26756126/