This case description may be the first well documented case of Anterior Canal Cupulolithiasis:

70 year old female, new patient, presents today for a vertigo evaluation and possible ear infection.

She notes that symptoms began on the 21st of April(it is now June 2020). She notes that her symptoms were continuous for over a week. She notes that when she would sit up she would feel like her eyes would roll around in her head. She notes that she would feel fine if she would lie down.

Audiogram performed 6/15/2020 demonstrates :
Right: Mild SNHL 48 kHz WRS 100%
Left: Mild to moderate SNHL 48 kHz WRS 100%
Tymps: BL type A

She notes that the intensity of her spinning decreased daily over the period of a week. She notes that she felt 50% better at 14 days.
She notes at by 21 days she felt about 80% better.

She notes that she is going to Physical Therapy. She denies any long lasting negative response to physical therapy sessions.

She notes that the manifest dizziness has since resolved but she still feels off balance.

She notes that with onset of symptoms she would feel "room spinning" dizziness when lying back in bed and rolling over in bed especially to the right.

She notes that she has tinnitus in the right ear.

She notes that she gets headaches 4 days a week at the base of her head. She denies any history of migraine.

She denies any nausea with her headaches or visual changes. She denies taking anything for her headaches, but does note that they can be triggered by stress.

She notes neck pain from a MVA which can sometimes trigger her headaches.

She denies aural fullness or pressure.

EXAM:
Right Ear: canal is clear, no retraction or effusion

Left Ear: canal is clear, no retraction or effusion. No nystagmus in neutral gaze

Right Hallpike: Downbeat and rotatory nystagmus, persistent. Lightheadedness in this position.

Left Hallpike: Downbeat nystagmus, asymptomatic

Suggests left anterior canalithiasis or right posterior canalithiasis, however due to persistent nystagmus, I suspect possible anterior cupulolithiasis.

Sitting upright, she has no downbeat nystagmus. She has a low grade right beat nystagmus. In particular, she has no upbeat nystagmus as would be expected from utriculopetal inhibitory deflection of the cupula. The best explanation for absence of nystagmus in the upright position is habituation of the response. Even habituation of a response in the inhibitory direction, however, allows for stimulatory responses with head hanging. These are seen in this exam. The origin of the response in the left anterior canal is confirmed with gaze dissection of the response.

Null point for posterior and anterior canalithiasis are with the head tipped forward at a 30 degree angle. She does not have a reversed nystagmus when tipped forward of this position.

The above scenario suggests anterior cupulolithiasis of the left ear.

Impression: Note Probable Left Anterior cupulolithiasis on vestibular examination today.
BL SNHL
BL constant tinnitus

Plan:
Start vertical headshake for 2 minutes followed by Yacovino maneuver, twice daily.