Direction-Changing Positional Nystagmus in Acute Otitis Media Complicated by Serous Labyrinthitis: New Insights into Positional Nystagmus

Abstract

Objective: To demonstrate characteristic nystagmus findings in acute otitis media (AOM) complicated by serous labyrinthitis and discuss the mechanism of direction-changing positional nystagmus (DCPN) in this condition. Patients: A patient with AOM complicated by serous labyrinthitis on the left side. Intervention: Video nystagmography and 3D fluid attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI). Main Outcome Measures: Characterize positional nystagmus in a head-roll test observing the change of nystagmus direction in process of time and compare findings of temporal bone 3D FLAIR MRI. Results: A previously healthy 50-year-old man who complained of acute otalgia, hearing loss, and vertigo was diagnosed with AOM complicated by serous labyrinthitis on the left side. A head-roll test performed on the day when vertigo developed showed persistent geotropic DCPN. While pre- and postcontrast T1-weighted MRI showed no signal abnormality in both inner ears, 10-minute delay postcontrast 3D FLAIR image showed enhancement in the inner ear on the left side. Four-hour-delay postcontrast 3D FLAIR images showed more conspicuous enhancement of the whole cochlea, vestibule, and semicircular canals on the left side. Conclusions: In AOM complicated by serous labyrinthitis, density of perilymph may increase due to direct penetration of cytokines and other inflammatory mediators from the middle ear into perilymph and breakdown of blood–labyrinth barrier that causes vascular leakage of serum albumin into perilymph. The density difference between perilymph and endolymph makes the semicircular canal gravity sensitive. A buoyant force is also generated by gravity, causing indentation of endolymphatic membrane in the ampulla and cupula displacement. Thus, at the early stage of serous labyrinthitis, a head-roll test may elicit persistent geotropic DCPN, of which the direction can be changed over time.

Case Report: Could Hennebert's Sign Be Evoked Despite Global Vestibular Impairment on Video Head Impulse Test? Considerations Upon Pathomechanisms Underlying Pressure-Induced Nystagmus due to Labyrinthine Fistula

“…In the same patient, paroxysmal nystagmus could be elicited despite PSC VOR-gain loss on vHIT, strengthening the assumption of spared or recovered lowvelocity afferents (58). Similarly, in the second case, positional geotropic direction-changing horizontal nystagmus closely matched with the expected oculomotor findings resulting from a buoyancy mechanism likely due to penetration of toxic agents and/or inflammatory mediators into the affected HSC (59)(60)(61). On the other hand, positional nystagmus has been reported in patients with labyrinthine-intracranial fistula.…”

Positional Nystagmus after Acute Vertiginous Attack in Meniere’s Disease

“…Our patients showed very weak, persistent positional direction-changing nystagmus, of which the direction was geotropic in Case 1 and apogeotropic in Case 2. This type of positional nystagmus has been reported in other inner ear disorders [19][20][21][22][23][24], and it could not be clearly explained by typical BPPV [25]. The change in chemical composition and/or electrolyte concentration in the inner ear fluid, although still unclear, may underlie the production of this characteristic nystagmus in these patients.…”

An intact bony tympanic facial canal does not protect from secondary facial paresis in adult acute otitis media

“…1,3 Treatment algorithms should rely on clinical, audiological and radiological findings, and must incorporate the presence or absence of concomitant serous labyrinthitis due to bacterial toxin and inflammatory mediators in the middle ear. 12,13 In addition to conservative treatment cornerstones, there are surgical options to maximally evanish ototoxic agents due to concomitant labyrinthitis, including paracentesis or ventilation tube insertion and antrotomy. 10 In our cohort, antrotomy, the more extreme treatment, was performed in 32 out of 48 patients (66.7 per cent; 15 in the acute otitis media with facial paresis group, 17 in the acute otitis media without facial paresis group).…”