Humanistic Care in Clinical Diagnosis and Treatment of Elderly Benign Paroxysmal Positional Vertigo Patients / 中国医学伦理学

Benign paroxysmal positional vertigo (BPPV) is a peripheral vestibular disease with the highest incidence rate, and the elderly are the high incidence population. Particle repositioning maneuver, simple and practicable, and has good clinical effects, is recognized as the preferred treatment method for BPPV. However, the elderly patients have a higher prevalence rate, often suffer from multiple chronic diseases, and their various bodily functions have entered a declining stage, with poor response to treatment and a tendency to recur. Based on these, medical staff should continuously improve their professional abilities, and pay attention to and implement some comprehensive and multi-dimensional humanistic care measures from physiological to psychological aspects such as verbal encouragement, behavioral support, and spiritual integration during the diagnosis and treatment process, to improve the quality of life of elderly BPPV patients, reduce medical disputes, and save medical resources.

Complex benign horizontal canal positional vertigo: new perceptual management

Abstract Objective: Horizontal semicircular canal site pathology of benign paroxysmal positional vertigo demonstrating three types of nystagmi on positional test were studied. We have attempted to design a protocol for its diagnosis and treatment. Methods: 320 patients of HSC-BPPV were subjected to two types of positional tests. Of these, patients with bilateral steady apogeotropic nysatgmus were treated with VAV modification of Semont's maneuver. Patients with unsteady or changing apo/geotropic signs were converted into steady geotropic ones by repetitive positional tests; followed by barbecue maneuver with forced prolong positioning. Results: Overall 88% of patients had a total recovery. 92% of patients with geotropic nystagmus showed no symptoms after second maneuveral sitting. 85% of patients with apogeotropic nystagmus recovered fully after third maneuveral sitting. Conclusion: Correct identification of subtypes of HSC-BPPV is based on provoked nystagmus by positional tests. After locating the site and side on the basis of nystagmic pattern, physician can apply the appropriate PRM. Level of evidence: II a.

Efectos posturográficos de la maniobra de Epley en pacientes con vértigo posicional paroxístico del canal posterior / Posturographic effects of the Epley maneuver on patients with benign paroxysmal positional vertigo of the posterior canal

Resumen Introducción: El vértigo posicional paroxístico benigno (VPPB) es la afección periférica más común en las enfermedades otoneurológicas. Con el reposicionamiento de partículas se busca eliminar el vértigo y sus síntomas asociados como lo son el mareo residual y la inestabilidad. Objetivo: Determinar si la maniobra de reposicionamiento de Epley (MRE) produce una modificación significativa del control postural (CP) en aquellos pacientes con VPPB de canal semicircular posterior (VPPB-CSC-P). Material y Método: Se realizó un estudio descriptivo prospectivo en una muestra de 21 pacientes con diagnóstico de VPPB-CSC-P. Comparamos el desplazamiento, la velocidad y el área del centro de presión (CoP) antes y después de la MRE. Resultados: La velocidad y el área de la CoP estudiada por posturografía computarizada muestra una disminución significativa en sus valores después de la MRE, mientras que el desplazamiento de la CoP se mantuvo sin cambios. Conclusión: La MRE ejecutada en pacientes con VPPB-CSC-P produce una modulación en el control de la CoP, demostrada por la disminución de la velocidad y el área de desplazamiento de la CoP. El éxito de la MRE produce modulación del CP.

Abstract Introduction: Benign paroxysmal positional vertigo (BPPV) is the most common peripheral condition in otoneurologic diseases. With the repositioning of particles, the aim is to eliminate vertigo and its associated symptoms, such as residual dizziness and instability. Aim: To determine if the Epley repositioning maneuver (ERM) produces a significant modification of postural control (PC) in those patients with posterior semicircular canal BPPV (BPPV-CSC-P). Material and Method: A prospective descriptive study was carried out in a sample of 21 patients diagnosed with BPPV-CSC-P. We compared the displacement, velocity, and area of the center of pressure (CoP) before and after the Epley repositioning maneuver. Results: The velocity and the area of the CoP studied by computed posturography show a significant decrease in its values after the MRE, while the CoP shift remained unchanged. Conclusion: ERM performed in patients with BPPV-CSC-P produces an improvement in the control of the CoP, demonstrated by the decrease in the speed and the area of movement of the CoP. The success of the MRE produces modulation of the PC.

Effects of Customized Vestibular Rehabilitation on Static balance among Adults with Benign Paroxysmal Positional Vertigo (Kesan Rehabilitasi Vestibular Disesuaikan Ke Atas Keseimbangan Static Dalam Kalangan Dewasa Dengan Masalah Benign Paroxysmal Positional Vertigo) / Jurnal Sains Kesihatan Malaysia

@#The aim of this study was to detemine the effectiveness of Customized vestibular rehabilitation (CVR) in addition to the standard Canalith repositioning maneuver (CRM) on static balance among adults with posterior canal Benign Paroxysmal Positional Vertigo (BPPV). In this randomised controlled trial, 28 adults with idiopathic unilateral posterior canal BPPV were randomized to either the control or experimental group. The experimental group (n=14, mean age: 50.71±9.88 years) received CVR in addition to CRM, and the control group (n=14, mean age: 54.36±8.55 years) received only CRM for 6 weeks. Measurements of static balance (postural sway) using a portable kinematic sensor were performed at baseline, four and six weeks after treatment for both groups while standing on firm and foam surface with eyes open (EO) and closed (EC). Only standing on foam surface with EC was observed to have a significant interaction effect, F (2, 52) =5.28, p<0.05. This suggest that the groups were affected differently by the intervention and greater improvement was demonstrated in the experimental group. Post hoc test showed that a significant difference (p<0.05) in static balance was shown between baseline and 6th week after intervention. The results of our study indicate that CVR in addition to CRM improved static balance in adults with UPC BPPV at 6th week after intervention for persons with BPPV.

Zuma Modified Maneuver as a Treatment to Geotropic Lateral Semicircular Canal Benign Paroxysmal Positional Vertigo

Abstract Introduction Benign Paroxysmal Positional Vertigo (BPPV) is the most common vestibular disorder, resulting from detached otoliths that migrate to one of the semicircular canals - canalolithiasis - or one of the cupulas - cupulolithiasis. The present study is related to lateral canal BPPVs, which may be either geotropic or apogeotropic. The geotropic variant of lateral semicircular canal benign paroxysmal positional vertigo (LC-BPPV) is attributed to free floating particles in the posterior arm of the lateral semicircular canal. Objectives To verify the possibility of employing the Zuma repositioning maneuver, with a brief modification, as an alternative treatment for geotropic LC-BPPV. Methods Seven patients with geotropic LC-BPPV were enrolled and treated with the Zuma modified maneuver. Patients were reevaluated 1 hour after a single maneuver, to confirm the resolution of vertigo and positional nystagmus. Results All seven patients achieved immediate resolution of vertigo and positional nystagmus as measured 1 hour after the application of the maneuver. Conclusion The Zuma modified maneuver was effective for geotropic LC-BPPV after a single application. The use of the Zuma maneuver for both apogeotropic and geotropic LC-BPPV may simplify the treatment of these patients.

Cases requiring increased number of repositioning maneuvers in benign paroxysmal positional vertigo / Casos de vertigem posicional paroxística benigna que exigem uma série de manobras de reposicionamento

ABSTRACT INTRODUCTION: Benign paroxysmal positional vertigo (BPPV) is a clinical syndrome that is proposed to be caused by dislocated utricular debris into semicircular canals. Although the majority of patients are treated by one or two repositioning maneuvers, some of the patients need repeated maneuvers for relief. OBJECTIVE: The goal of this study was to investigate the factors associated with patients with benign paroxysmal positional vertigo who required multiple repositioning procedures for treatment. METHODS: Data were obtained from the clinical records of 153 patients diagnosed with benign paroxysmal positional vertigo. Patients were treated by repositioning maneuvers. Demographic data and the factors including age, sex, canal type, duration of symptoms, comorbidities and number of repositioning maneuvers for relief were documented for statistical analysis. RESULTS: Age, sex, canal type and the duration of symptoms had no impact on the number of maneuvers. The most common comorbidity was spine problems. Hypertension was the only comorbidity that significantly associated with increased number of maneuvers. CONCLUSION: The presence of hypertension is a risk factor for repeated maneuvers in benign paroxysmal positional vertigo treatment. Physicians should be aware of the increased probability of repeated repositioning maneuvers in these group of patients. The role of comorbidities and vascular factors need to be further clarified in the course of benign paroxysmal positional vertigo.

Resumo Introdução: A vertigem posicional paroxística benigna (VPPB) é uma síndrome clínica propostamente causada por detritos utriculares desprendidos dentro dos canais semicirculares. Embora a maioria dos pacientes seja tratada com uma ou duas manobras de reposicionamento, alguns pacientes precisam de manobras repetidas para o alívio dos sintomas. Objetivo: O objetivo deste estudo foi investigar os fatores associados a pacientes com VPPB que precisam de vários procedimentos de reposicionamento para o tratamento. Método: Os dados foram obtidos a partir de prontuários médicos de 153 pacientes diagnosticados com VPPB e tratados. Os pacientes foram tratados com manobras de reposicionamento. Os dados demográficos e fatores, incluindo idade, sexo, tipo de canal, duração dos sintomas, comorbidades e número de manobras de reposicionamento para alívio, foram registrados para análise estatística. Resultados: Idade, sexo, tipo de canal e a duração dos sintomas não tiveram impacto sobre o número de manobras. A comorbidade mais comum foi problemas de coluna. Hipertensão foi a única comorbidade significantemente associada ao aumento do número de manobras. Conclusão: A presença de hipertensão é um fator de risco para necessidade de manobras repetidas no tratamento da VPPB. Os médicos devem estar cientes do aumento da probabilidade de manobras de reposicionamento repetidas nesse grupo de pacientes. O papel das comorbidades e dos fatores vasculares precisa ser mais bem esclarecido no curso da VPPB.

Clinical Manifestations of Benign Paroxysmal Positional Vertigo after Head Trauma / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The purpose of this study was to identify the clinical characteristics of benign paroxysmal positional vertigo (BPPV) occurring after head trauma by comparing them to those of idiopathic BPPV (i-BPPV). SUBJECTS AND METHOD: We analyzed retrospectively 820 patients diagnosed with BPPV. Patients were classified into two groups: post-traumatic BPPV (t-BPPV) group and i-BPPV group. We compared the clinical characteristics (age, sex, affected side, duration of vertigo, types of BPPV) and treatment outcomes between the two groups. RESULTS: The study included 497 patients with i-BPPV and 56 patients with t-BPPV. There were no differences in age distribution and the affected side. The t-BPPV group had greater male preponderance (48%) than the i-BPPV group (24%) did and longer duration of vertigo compared to i-BPPV group (p=0.028). In addition, the t-BPPV group demonstrated higher horizontal canal BPPV/posterior canal BPPV ratio (t-BPPV vs. i-BPPV=0.54 vs. 0.20, p=0.008). Although the results of a single treatment outcome did not differ between the two groups (p=0.127), there was a greater tendency for the t-BPPV group to receive a higher number of therapeutic maneuvers until resolution than for the i-BPPV group (p=0.056). Recurrence rate also did not differ between the two groups (p=0.125). CONCLUSION: The clinical features did not differ significantly between the two groups, although t-BPPV demonstrated a tendency of low therapeutic efficacy and high recurrence rates compared to i-BPPV. This information may be helpful for clinicians in counseling and managing patients with t-BPPV.

Persistent Direction-Fixed Nystagmus Following Canalith Repositioning Maneuver for Horizontal Canal BPPV: A Case of Canalith Jam

The authors report a 64-year-old man who developed persistent direction fixed nystagmus after a canalith repositioning maneuver for horizontal canal benign paroxysmal positional vertigo (HC-BPPV). The patient was initially diagnosed with right HC-BPPV given that the Dix-Hallpike test showed geotropic horizontal nystagmus that was more pronounced on the right side, although the roll test did not show any positional nystagmus. The patient was treated with a canalith repositioning maneuver (Lempert maneuver). The next day, the patient experienced a different character of dizziness, and left-beating spontaneous nystagmus regardless of head position was observed. After a forced prolonged left decubitus and frequent head shaking, his symptoms and nystagmus resolved. This condition, referred to as canalith jam, can be a complication after the repositioning maneuver in patients with BPPV. Atypical positional tests suggest that abnormal canal anatomy could be the underlying cause of canalith jam.

Risk Factors for Treatment Failure in Benign Paroxysmal Positional Vertigo / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Particular repositioning maneuver (PRM) have been recommended as a treatment of benign paroxysmal positional vertigo (BPPV). Some patients require multiple treatments for remission, although most of the patients are treated at the first trial of single maneuver. The purpose of this study was to evaluate risk factors for the treatment failure in patients with posterior canal BPPV (p-BPPV) and horizontal canal BPPV (h-BPPV). SUBJECTS AND METHOD: Retrospective review was performed for the 287 patients diagnosed as BPPV visiting the dizziness clinic between February 2011 and August 2012. The diagnostic criteria for BPPV were met by following the guidelines provided by the American Academy of Otolaryngology-Head and Neck Surgery. Patients were classified into two groups: Group 1 (treatment success) that requires only 1 PRM and Group 2 (treatment failure) that requires more than 2 PRMs. We analyzed the relationship between treatment failure and the clinical characteristics, and studied the etiology of BPPV. RESULTS: The study included 183 patients with p-BPPV, 54 patients with h-BPPV (geotropic type), and 50 patients with h-BPPV (apogeotropic type). The type of BPPV and average numbers of PRM required for remission were significantly related with treatment failure by statistical analysis (p<0.05, respectively). Statistically significant correlation was demonstrated between the history of ipsilateral inner ear viral infection (acute vestibular neuritis, sudden sensorineural hearing loss) and treatment failure (p<0.05). CONCLUSION: Multiple PRMs may be required in patients with h-BPPV (apogeotropic type) or with secondary BPPV caused by ipsilateral inner ear viral disease. Clinically, this information may be used to provide helpful information for clinicians performing PRM to treat BPPV.

Management of Benign Paroxysmal Positional Vertigo / 대한평형의학회지

Benign paroxysmal positional vertigo (BPPV) is characterized by brief recurrent episodes of vertigo triggered by head positional changes. BPPV is one of the most common causes of recurrent vertigo. BPPV results from abnormal stimulation of the cupula within any of the three semicircular canals by free-floating otoliths (canalithiasis) or otoliths adhered to the cupula (cupulolithiasis). Spontaneous recovery occurs frequently even with conservative treatment. However, canalith repositioning maneuvers are believed to be the best way to treat BPPV by moving the canaliths from the semicircular canal to the vestibule. Various treatment methods of posterior, superior, and lateral canal BPPV are discussed in this review.

Therapeutic effect canalith repositioning maneuver combined with Chinese and western medicine of treating benign paroxysmal positional vertigo / 中国基层医药

ObjectiveTo observe the therapeutic effect and recurrence of treating Benign Paroxysmal Positional Vertigo(BPPV) by the treatment that combined Canalith Repositioning Maneuver(CRM) with Chinese and Western medicine.MethodsCollecting 40 cases suffered from BPPV,and randomized controlled method was used.Control group:20 cases( using Western and Chinese medicine),treatment group:20cases( using Western and Chinese medicine wrbined with CRM),judge the effect after 7days and telephone followed up 3 months,inquiring about recurrence situation.ResultsCure rate of treatment group was 90％,total effective rate was 100％ which was higher than the control group which was 50％,the total effective rate was 95％ (P ＜0.001 ) ;20 cases in treatment group followed up by telephone didn't recur.1 case in control group recurred,but got better after the treatment of CRM.ConclusionCRM which was effective,safe,simple and convenient to treat BPPV could be used as the preferred treatment for BPPV,if combined with Chinese and western medicine,it could significantly alleviate the symptoms and reduce the relapse.

Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is characterized by brief recurrent episodes of vertigo triggered by changes in head position. BPPV is the most common etiology of recurrent vertigo and is caused by abnormal stimulation of the cupula by free-floating otoliths (canalolithiasis) or otoliths that have adhered to the cupula (cupulolithiasis) within any of the three semicircular canals. Typical symptoms and signs of BPPV are evoked when the head is positioned so that the plane of the affected semicircular canal is spatially vertical and thus aligned with gravity. Paroxysm of vertigo and nystagmus develops after a brief latency during the Dix-Hallpike maneuver in posterior-canal BPPV, and during the supine roll test in horizontal-canal BPPV. Positioning the head in the opposite direction usually reverses the direction of the nystagmus. The duration, frequency, and symptom intensity of BPPV vary depending on the involved canals and the location of otolithic debris. Spontaneous recovery may be expected even with conservative treatments. However, canalithrepositioning maneuvers usually provide an immediate resolution of symptoms by clearing the canaliths from the semicircular canal into the vestibule.

Residual Dizziness after Successful Repositioning Treatment in Patients with Benign Paroxysmal Positional Vertigo

BACKGROUND AND PURPOSE: Benign paroxysmal positional vertigo (BPPV) is the most common form of vertigo. Although the repositioning maneuver dramatically improves the vertigo, some patients complain of residual dizziness. We evaluated the incidence and characteristics of persistent dizziness after successful particle repositioning and the clinical factors associated with the residual dizziness. METHODS: We performed a prospective investigation in 49 consecutive patients with confirmed BPPV. The patients were treated with a repositioning maneuver appropriate for the type of BPPV. Success was defined by the resolution of nystagmus and positional vertigo. All patients were followed up until complete resolution of all dizziness, for a maximum of 3 months. We collected data on the characteristics and duration of any residual dizziness and analyzed the clinical factors associated with the residual dizziness. RESULTS: Of the 49 patients, 11 were men and 38 were women aged 60.4+/-13.0 years (mean +/-SD), and 30 (61%) of them complained of residual dizziness after successful repositioning treatment. There were two types of residual dizziness: continuous lightheadedness and short-lasting unsteadiness occurring during head movement, standing, or walking. The dizziness lasted for 16.4+/-17.6 days (range=2-80 days, median=10 days). A longer duration of BPPV before treatment was significantly associated with residual dizziness (p=0.04). CONCLUSIONS: Residual dizziness after successful repositioning was observed in two-thirds of the patients with BPPV and disappeared within 3 months without specific treatment in all cases. The results indicate that early successful repositioning can reduce the incidence of residual dizziness.

Benign Paroxysmal Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is characterized by brief recurrent episodes of vertigo triggered by head position changes. BPPV is one of the most common causes of recurrent vertigo. BPPV results from abnormal stimulation of the cupula within any of the three semicircular canals by free-floating otoliths (canalithiasis) or otoliths adhered to the cupula (cupulolithiasis). Typical symptoms and signs of BPPV are evoked when the head is positioned so that the plane of the affected semicircular canal is spatially vertical and thus aligned with gravity. Paroxysm of vertigo and nystagmus develops after a brief latency during Dix-Hallpike maneuver in posterior canal BPPV and supine roll test in horizontal canal BPPV. Usually positioning the head in the opposite direction reverses the direction of the nystagmus. The duration, frequency, and intensity of symptoms of BPPV vary depending on the involved canals and the nature of otolithic debris. Spontaneous recovery occurs frequently even with conservative treatment, however, canalith repositioning maneuvers are believed to be the best way to treat BPPV by moving the canaliths from the semicircular canal to the vestibule.

Clinical Significance of Vestibular Evoked Myogenic Potentials in Patients With Benign Paroxysmal Positional Vertigo

OBJECTIVES: To investigate the vestibular evoked myogenic potentials (VEMP) results in benign paroxysmal positional vertigo (BPPV) patients and to verify its clinical applications in BPPV. SUBJECTS AND METHODS: Forty-one patients with diagnosis of BPPV and 92 healthy volunteers who underwent VEMP testing. Patients were treated by canalith repositioning maneuvers according to the affected canal, and testing of VEMP was performed at diagnosis and after treatment. RESULTS: VEMP results of BPPV patients showed prolonged p13 and n23 latencies compared with those of the control group, and we could not find any significant difference in VEMP latencies between patients with posterior and horizontal canal type of BPPV. The number of times that the maneuver was repeated did not correlate with the degree of latency prolongation, but in the "no response" group, the number of times was considerably greater than those in the "response" group. CONCLUSIONS: We found that VEMP latencies are increased in BPPV patients, which may signify neuronal degenerative changes in the macula of the saccule. When an extensive neuronal damage was suspected by VEMP results such as "no response" in VEMP, the disease progress showed a chronic and resistive course. Therefore, we propose that VEMP could be a useful method to determine a clinical prognosis of patients with BPPV.

Therapeutic Efficacy and Prognostic Factors of Canalith Repositioning Maneuver in the Patients with Benign Paroxysmal Positional Vertigo

BACKGROUND AND OBJECTIVES: The purpose of this study were to evaluate the therapeutic efficacy of canalith repositioning maneuver (CRP) according to accompanying mastoid percussion and to investigate the prognostic factors that may affect successful repositioning maneuver and the recurrence of benign paroxysmal positional vertigo. MATERIALS AND METHOD: A total of 70 patients with canalith type BPPV visiting the dizziness clinic of Kangnam St. Mary's Hospital were included in this study. Variables identified for statistical analysis were patient's age, sex, maneuver method, number of involved canal, number of CRP and dizziness handicap inventory. RESULT: Overall success rate of CRP was 90%. The mean number of maneuver was 1.6 and the recurrence rate was 25.7% during the follow up period. Success rate of CRP (94.9%) was higher than maneuver without mastoid percussion (83.9%) though it was not statistically significant. Successful CRP group showed the significant less number of maneuvers at initial treatment session and less number of involved canal than failed CRP group at the time of one week-follow up visit. Patients with recurrence of BPPV had the more number of CRP during the period of previous BPPV. CONCLUSION: Therapeutic efficacy of CRP with mastoid percussion was higher than CRP without mastoid percussion though it was not statistically significant. Suggesting prognostic factors for effective CRP and recurrence were number of CRP and number of involved canal.

The Effect of Postural Restrictions in the Treatment of Benign Paroxysmal Positional Vertigo / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: The treatment of Benign Paroxysmal Positional Vertigo (BPPV) consist of repositioning maneuver in order to remove otolithic debris, and subsequent postural restrictions to prevent debris from reentering into the canal. But, it is doubtful how much postural restrictions could have an effect on the final outcomes of BPPV. The purpose of this study is to find out the effect of postural restrictions when imposed on as one of the treatment methods of BPPV, out-broken due to otolithic debris in the posterior semicircular canal, and to find out the necessity of postural restrictions. SUBJECTS AND METHOD: Seventy cases diagnosed as BPPV of the posterior semicircular canal were studied. All the patients were treated by modified Epley Maneuver. They were divided into two groups. The first group (group A, 35 patients) was instructed to sleep in a semi-sitting position and not to move their heads forward or backward, whereas the second group (group B, 35 patients) was not taught to do any specific thing. The gathered information from all the patients was analyzed by age of onset, gender, duration of the disease, and cure rates or recurrence rates. RESULTS: In group A, the average age was 54.5 years and mean duration of symptoms was 116.5 days. On the other hands, in the group B, the average age and the mean duration was 54.8 years and 86.7 days, respectively. The cure rates of the group A and B were 91.4% and 94.3%, respectively. The recurrence rates were 12.5% and 9.1% for group A and group B patients, respectively. No statistically significant difference was found between two groups regarding patient age, duration of symptoms, and cure rates or recurrence rates. CONCLUSION: From the analysis of this study, it can be said that postural restrictions imposed after the repositioning maneuver do not have a significant effect on the final outcomes of BPPV, so they are not recommendable.

Effectiveness of Cupulolith Repositioning Maneuver in the Treatment of Lateral Semicircular Canal Cupulolithiasis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: There is still a controversy surrounding lesion side differentiation and treatment of the lateral canal cupulolithiasis. The purpose of this study is to understand side differentiation, and study the treatment of this disease through analyses of clinical features, electronystagmographic (ENG) results, treatment maneuvers and its effectiveness. MATERIALS AND METHODS: Twenty three patients who showed ageotropic direction-changing horizontal positional nystagmus were included in this study. A supine head turning test was performed to induce positional nystagmus. Clinical findings and typical features of the nystagmus were recorded. Neurologic examinations, ENG tests, and MRI (6 cases) were checked to exclude the possibility of any central lesions. Cupulolith Repositioning Maneuver (CuRM) was applied on the patients and these patients were instructed to keep the healthy side at the lateral decubitus position while sleeping. RESULTS: The nystagmus had a short latency, no fatigability, and persistency in character. In one patient, nystagmus was resolved spontaneously, so we could not decide the lesion side. However, seventeen out of 22 patients showed significant differences between the intensity of each side nystagmus, and all of them showed stronger nystagmus when the head was rotated to the unaffected side. In five patients who showed no significant difference between the intensity of each side nystagmus, two cases showed same results and three cases showed opposite results. Typical nystagmus and spinning sensation in the supine head-turning test had completely subsided after physical therapy. CONCLUSION: In the cupulolithiasis of lateral semicircular canal, ageotropic nystagmus was stronger when the pathological ear was at the uppermost position, and this excitatory nystagmus beat to the lesion side. But, if there was no significant difference between the intensity of each side nystagmus, associated canal paresis, other types of BPPV, past history of acute vestibuloneuritis, and Meniere's disease, etc. might be helpful to localize the lesion side. CuRM and post- treatment lateral decubitus position kept during the night (while sleeping on the day of treatment) were effective in treating the cupulolithiasis of lateral semicircular canal.