Physiotherapy-guided management of post-traumatic multicanal benign paroxysmal positional vertigo complicated by canalith jam and cupulolithiasis: a case report

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is the most common cause of recurrent vertigo and is typically monocanalicular, affecting a single semicircular canal at a time. Multicanalicular involvement, particularly when associated with canalith jam (CJ) or conversion to cupulolithiasis, is rare and poses significant diagnostic and therapeutic challenges. CASE PRESENTATION: A 76-year-old woman presented with acute positionally triggered vertigo following a mild traumatic brain injury (mTBI) from a road traffic accident (motorbike slip with cranial impact; transient loss of consciousness < a few minutes, no scalp or ear, nose or throat bleeding). Sequential otoneurologic examinations identified canalolithiasis of right posterior semicircular canal (PSC) and bilateral horizontal semicircular canals (HSC). A quick liberatory rotation maneuver successfully resolved right PSC canalolithiasis but precipitated a CJ in right HSC. Subsequent maneuvers confirmed bilateral HSC canalolithiasis, with later conversion of left HSC canalolithiasis to HSC cupulolithiasis. Stepwise treatment utilizing the head-shaking maneuver (HSM), Gufoni (GM), and Zuma maneuvers (ZM) resulted in complete symptom resolution. CONCLUSION: This case illustrates the dynamic nature of otoconia migration in multicanalicular BPPV following mTBI. It emphasizes the critical role of meticulous sequential otoneurologic testing, physiotherapy-guided repositioning maneuvers, and heightened awareness of CJ as a potential complication of these procedures.