Refractory Positional Vertigo With Apogeotropic Horizontal Nystagmus After Labyrinthitis

Abstract

This case illustrates a unique form of positional vertigo that developed and persisted after acute labyrinthitis. Conservative measures were unsuccessful and a transmastoid labyrinthectomy documented dense inflammatory tissue involving all three ampullae. We postulate that the post-labyrinthitic inflammatory changes resulted in mass loading of the membranous ampullae, causing abnormal nystagmus patterns and positional vertigo, which resolved after the labyrinthectomy.

Neuro-otology- some recent clinical advances

“…With BPV after vestibular neuritis, there can be impaired ocular VEMPs (oVEMPs) from the utricle and horizontal plus anterior SCCs vHITs but normal cervical VEMPs (cVEMPs) from the saccule [31]. In contrast, with BPV after labyrinthitis or labyrinthine infarct, there is sudden hearing loss, and there can be prolonged geotropic or apogeotropic horizontal positional nystagmus (as in cupulolithiasis) refractory to treatment, and also abnormal posterior SCC vHIT [32, 33]. Apogeotropic horizontal nystagmus could be due to post-labyrinthitis inflammation within the ampulla [34] and geotropic nystagmus to a light, “floating” cupula [25].…”

Pearls & Oy-sters: Cogan syndrome

“…Of interest, the positional nystagmus was refractory to repeated CRMs, which is inconsistent with BPPV due to canalithiasis. Indeed, persistent geotropic or apogeotropic nystagmus may be observed in labyrinthitis 8,9 and has been ascribed to heavy or light cupula due to changes in the specific gravity of the endolymph from inflammation. Otherwise, given the paroxysmal nature of the positional nystagmus during Dix-Hallpike maneuver, it may be ascribed to secondary BPPV due to labyrinthine inflammation.…”