Cupulolithiasis

Diagnosis of Cupulolithiasis / Light Cupula

Cupulolithiasis is a diagnostic challenge in BPPV management. The diagnosis is confirmed by the presence of continuous eye movements that correspond to the affected canal but that stop in the null position of the affected crista, and reverse when the head is inclined beyond the null point. The general head positions that correspond to the null positions of the cristae of all six canals are shown below.

Recently patients have been observed with paradoxical cupulolithiasis that may be related to a floating cupula. These patients have been patients with migrainous vertigo during an episode, and whose paradoxical eye movements disappeared after their episodes. Floating cupula may affect one or multiple cupulae and may be a manifestation of migraine in the inner ear.

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Null position for the left posterior crista.
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Null position for right posterior crista.
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Null position for the left anterior crista.

It should be noted that anterior cupulolithiasis is a very rare entity. Few very clear cases have been documented.

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Null position for the right anterior crista.

It should be noted that anterior cupulolithiasis is a very rare entity. Few very clear cases have been documented.

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Null position for the left lateral crista.
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Null position for the right lateral crista.

Headshake in the treatment of cupulolithiasis

Head shake or head vibration have been used to mobilize otoconia from the cupula in cupulolithiasis. Cupulolithiasis may be treated with standard or modified Brandt-Daroff exercises after head shaking in the plane of the affected canal crista. Five seconds of head shake while in the upright position during each repetition has been effective. This is a good alternative to head vibration used only in the office.