Woman 66yr with symptoms of acute vestibular syndrome comes three weeks later to our office with complaints of slight instability, oscillopsia and vertigo with abrupt head movements.
No spont Ny, head-impulse neg. positional tests neg.
VHIT, calotic test and cVEMP didn’t show any pathological finding
BUT oVEMP showed left utricular deficit. SVV also confirmed it: -2.7
VNG and MRI excluded any central pathology.
In this patient acute vestibular syndrome can be ascribed to isolated acute utricular lesion. Lesion of the left utriculus is proven by pathological oVEMP and SVV while other tests showed good function of the semicircular canals and sacculus. Central pathology was excluded by VNG and MRI showing normal findings. We regret we didn’t have an opportunity to record ocular fundus for cyclotorsion.
Patients with acute vestibular syndrome but with good results on VHIT and caloric test should be tested by VEMPs for otolithic function also. Isolated acute utricular lesion might not be so rare cause of acute vestibular syndrome, as it is probably often unrecognized.
Except looking for oculomotor signs in patient with acute vestibular syndrome the attention should be payed to head position as lateropulsion might be a sign of utricular lesion.
Something on this topic:
1. Magliulo G, Iannella G, Gagliardi S, Re M. A 1-year follow-up study with C-VEMPs, O-VEMPs and video head impulse testing in vestibular neuritis. Eur Arch Otorhinolaryngol. 2015;272(11):3277-81.
2. Blödow A, Helbig R, Bloching M, Walther LE. Isolated functional loss of the lateral semicircular canal in vestibular neuritis. HNO. 2013;61(1):46-51.
3. Manzari L, Burgess AM, Curthoys IS. Does unilateral utricular dysfunction cause horizontal spontaneous nystagmus? Eur Arch Otorhinolaryngol. 2012;269(11):2441-5.
4. Manzari L, Burgess AM, MacDougall HG, Curthoys IS. Superior canal dehiscence reveals concomitant unilateral utricular loss (UUL). Acta Otolaryngol. 2015;135(6):557-64.
5. Manzari L, MacDougall HG, Burgess AM, Curthoys IS. Selective otolith dysfunctions objectively verified. J Vestib Res. 2014;24(5-6):365-73.
Patient in late 50thies feels one week slight instability from time to time, and describes it as difficulty walking straight and also has a short vertigo spells (discomfort in the head) when moving head, especially quick turns. Also, he complains to have left-sided tinnitus (pulsating hissing) since this instability problems has started. He had no nausea or other symptoms.
This history doesn’t sound like a vestibular neuritis.
He had no spontaneous Ny and head-impulse test was normal, but Fukuda step test showed marked turning to the right.
VHIT showed normal gains in all canals expect left posterior, where gain was markedly reduced. cVEMP showed vestibulo-infraocular reflex bilaterally but significantly lower amplitude at the left side.
Caloric test was normal, no asymmetry at all and audiometry showed bilateral mild hearing loss at high frequencies.
VHIT (6 canals) and cVEMP allowed us to diagnose acute lesion of inferior vestibular nerve branch in this patient.
Link with interesting videos of pt with inferior vestibular neuritis, showing spontaneous torsional nystagmus and positive head impulse test in the plane of the affected posterior canal.
Hyperventilation nystagmus can be induced at about 50% vestibular neuritis patients, but 7 weeks later at about 20%.
The direction of the nystagmus in the acute phase can be to the lesional side or to healthy side, but after the acute phase it’s to healthy side. Hyperventilation nystagmus to the lesional side is usualy very strong, SPV > 25deg/sec.
Here’s what colleagues from Korea got at patients with vestibular neuritis:
Hyperventilation-induced nystagmus in patients with vestibular neuritis in the acute and follow-up stages
HIN (hyperventilation induced nystagmus) to lesional side in the acute phase of vestibular neuritis or persistent HIN are acompained with persistend dizziness.
Hyperventilation-induced nystagmus in vestibular neuritis: pattern and clinical implication
When you see nystagmus to changes direction, you know that’s a central vestibular lesion. However, can peripheral vestibular lesions have a clinical presentation with alternating nystagmus? It seems to be. This is a more recent work, which describes alternating nystagmus in several patients with peripheral vestibular lesion (Mb Meniere, neuritis, vestibular schwannoma); however in all described cases alternating nystagmus was present for short period, nystagmus was suppressed by fixation (which is not characteristic of central Ny) and all tests for central vestibular pathways were fine.
Periodic alternating nystagmus of peripheral vestibular origin