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This 70-year-old patient was referred in our hospital department for positional rotatory vertigo. The patient had a history of BPPV, with the most recent episode occurring 7 months ago (BPPV of the right posterior semicircular canal).

In the days leading up to the visit, the patient had spent several hours working with his head in extension and hyperflexion while laying a floor.

Clinical examination revealed a positive bilateral Head Roll Test (HRT) with untiring ageotropic horizontal nystagmus, more symptomatic in left HRT. The null point (disappearance of nystagmus) was in a slight rightward rotation. Surprisingly, the Bow test and Lean test were negative.

A cupulolithiasis of the right lateral semi-circular canal was suspected. The classical diagnostic tests and therapeutic maneuvers were difficult to perform because patient’s reduced mobility due to intense nausea. It was then decided to reassess the patient and perform the maneuvers the next day using the TRV chair.

On the following day, the clinical presentation remained similar. A Gufoni maneuver on the patient’s right ear were performed to convert the ageotropic horizontal positional nystagmus to a geotropic one (Fig. 1), wich would indicate the conversion from cupulolithiasis to canalolithiasis. Upon retesting, the nystagmus was indeed geotropic in bilateral HRT, and the patient was much more symptomatic in right HRT.

Diagram illustrating the therapeutic maneuvers used

We proceeded with the mechanical Baloh Lempert maneuver adapted for BPPV of the right lateral semicircular canal (Fig. 1). Following this maneuver, the patient was significant improved, without any vertigo, and no nystagmus was observed in bilateral HRT.

We instructed the patient to perform a left Vannucchi-Asprella maneuver for three nights and reviewed him one week later (Fig. 1). One week after the treatment, the patient did not complain of any vertigo and was asymptomatic in bilateral HRT (without nystagmus).