Quick definition
Cupulolithiasis is a variant of BPPV in which displaced otoconia adhere to the cupula of a semicircular canal — instead of floating freely in the canal fluid (which is the more common form, called canalithiasis). The result is positional vertigo and nystagmus that last longer and behave differently from the more common variant.
Medical definition
In cupulolithiasis, otoconia stick to the cupula and effectively make it gravity-sensitive — which it normally is not. On positional testing, the resulting nystagmus has a shorter or absent latency, lasts longer than 60 seconds, and may not fatigue on repeat testing. The Semont maneuver is often preferred over Epley for cupulolithiasis, because it generates a sharper inertial impulse to dislodge the crystals from the cupula.
Why it matters in vertigo and balance disorders
Recognising cupulolithiasis matters because the standard Epley maneuver, designed for canalithiasis, may not work as reliably. Misclassifying a cupulolithiasis case as a treatment-resistant BPPV often means the wrong maneuver was used.
Where I see this in clinic
I see this pattern a few times a year — a patient who has had multiple unsuccessful Epley maneuvers elsewhere, where the eye-movement video recording on VNG shows a long-duration positional nystagmus that does not behave like classical canalithiasis. A switched maneuver almost always works.
Related terms
Part of: Vestibular and ENT Glossary — A to Z of vestibular, balance, and ENT terms by Dr. Prateek Porwal.
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