Pearls & Oy-sters: Vestibular neuritis or not?

Abstract

The ocular tilt reaction (OTR) is a central vestibular disorder that is characterized by the triad of head tilt, skew deviation, and ocular torsion. As the OTR frequently shows an incomplete manifestation, a head tilt can be the only apparent clinical sign of significant brainstem disorders. Hence, even a slight head tilt should be thoroughly investigated. A 48-year-old man presented after sudden onset of a severe, persistent rotatory vertigo associated with nausea, vomiting, and postural imbalance. Examination revealed a horizontal-torsional spontaneous nystagmus with the quick phases beating to the right ear. The nystagmus was attenuated by fixation as examined by Frenzel goggles. Head impulse test was positive to the left. When attempting to walk and during Romberg testing he fell to his left side. Except for a head tilt to the right (see video on the Neurology ® Web site at www.neurology.org), no other neurologic deficit was observed. The patient's medical history revealed no neurologic disorders. Quantitative caloric testing showed a canal paresis of the left vestibular organ. Taken together, the initial clinical presentation was highly suggestive of a left vestibular neuritis. However, due to the head tilt, an extended neuroophthalmologic examination was performed that revealed a discrete but complete OTR to the right with head tilt, mild skew deviation …