Vestibular Neuritis Case 1
Timothy C. Hain, MD • Page last modified: August 2, 2022
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A middle aged man was going through some paperwork with his neck inclined forward. When he raised his head, he experienced the abrupt onset of horizontal spinning that was accompanied by nausea. The sensation lasted approximately 30 minutes. The next morning, after eating breakfast, the patient sat down on the couch, and with no apparent provocative movement. He experienced the abrupt onset of similar horizontal vertigo, which was accompanied by nausea and eventually by vomiting. This episode lasted six to eight hours. He now feels "off".
Under video Frenzel’s goggles on primary position of gaze in the light, there is a spontaneous 2/10 left-beating nystagmus. In the dark, there is a 4/10 left-beating nystagmus. Vibration applied to either side of the neck increased the left beating nystagmus to a grade 5/10. Cervical testing did not change this nystagmus. In the supine position with the head to the right, there is a 6/10 left-beating nystagmus and with the head to the left, there is a 6/10 left-beating nystagmus.
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| Audiometry showed a mild high frequency sensorineural reduction |
Audiometry is symmetrical in persons with vestibular neuritis.
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| The VEMP test was reduced on the right. |
VEMP's are variable in vestibular neuritis. In severe cases, VEMP's are reduced.
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| There was a weak left-beating nystagmus in the light, much stronger in the dark. |
This is the classic appearence of a largely uncompensated vestibular imbalance. Here is what it looks like on video --
Movie of nystagmus of vestibular neuritis.
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| Vibration greatly increased the amplitude of the spontaneous nystagmus |
Vibration usually increases spontaneous nystagmus in the dark.
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| Caloric testing was dominated by the strong spontaneous nystagmus, which at first glance, makes the recording look as if there is a huge directional preponderance. However, if one looks at the traces, once can see that there is no response on the right. If the 10 deg/sec spontaneous nystagmus had been subtracted out from the traces above, there would have been no bars at all on the right, and somewhat more symmetrical bars on the left. |
Caloric testing should be reduced on the opposite to the beating direction of the spontaneus nystagmus.
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Inspection of the traces shows that on the right side, the intensity of the nystagmus is unaffected by caloric irrigation. Ice should have been done in this case too.
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| Optokinetic nystagmus was normal |
OKN is generally unaffected by vestibular neuritis.
Comment:
This is a classic presentation of the testing picture of vestibular neuritis. There is good evidence for damage to the horizontal canal (VENG), but also evidence that the inferior vestibular nerve is spared (present VEMP).
The presentation is not unusual but the abrupt and "sputtering" course also is suggestive of a circulation disturbance (to the labyrinth) rather than the usual attribution of this picture to a viral process. A more "classic" picture would be a slowly increasing dizziness (over hours).
As time goes on, the spontaneous nystagmus will resolve but the other findings will remain.
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