title: Importance of spontaneous nystagmus detection in the differential diagnosis of acute vertigo.
abstract: Vertigo is a common cause of emergency department attendance. Detection of spontaneous nystagmus may be a useful sign in distinguishing vestibular neuritis from other vestibular diagnoses. We aimed to assess the contribution of spontaneous nystagmus in the diagnosis of acute vertigo. We enrolled consecutive consenting patients arriving at a single emergency department with acute vertigo. There was no declared protocol for the emergency department staff. A standardized history and examination was conducted by the investigators. Observation for spontaneous nystagmus, its response to visual fixation, and testing the vestibulo-ocular reflex with the horizontal head impulse test were the chief examination components. MRI was obtained within 24 hours. Clinical criteria and MRI were used to reach the final diagnosis. The investigators' physical findings and final neurological diagnosis were compared with the initial emergency department examination findings and the referral diagnosis. There were 28 patients, 15 with vestibular neuritis, six with benign paroxysmal positional vertigo, one with stroke, suspected clinically, and three with migraine. In three the diagnosis remained uncertain. Spontaneous nystagmus was seen in all 15 patients with vestibular neuritis, fixation-suppressed in eight of 11 tested for this. The head impulse test was positive in 12 of 15 with vestibular neuritis. The emergency department referral diagnosis was correct in six of 23 patients. The ability to detect spontaneous nystagmus is useful in vestibular diagnosis, both in support of a diagnosis of vestibular neuritis and in avoiding false positive diagnoses of benign paroxysmal positional vertigo.
authors.affiliation: Department of Medicine, Monash University, Clayton, VIC, Australia.
authors.forename: Davor
authors.initials: D
authors.lastname: Pavlin-Premrl
authors.affiliation: Department of Medicine, Monash University, Clayton, VIC, Australia; Neurology Department, Alfred Hospital, Melbourne, VIC, Australia.
authors.forename: John
authors.initials: J
authors.lastname: Waterston
authors.affiliation: Department of Medicine, Monash University, Clayton, VIC, Australia; Clinical Trials and Research Centre, Epworth HealthCare, Richmond, VIC, Australia.
authors.forename: Sean
authors.initials: S
authors.lastname: McGuigan
authors.affiliation: Neurosciences Institute, Epworth HealthCare, Richmond, VIC, Australia.
authors.forename: Bernard
authors.initials: B
authors.lastname: Infeld
authors.affiliation: Emergency Department, Epworth HealthCare, Richmond, VIC, Australia.
authors.forename: Ron
authors.initials: R
authors.lastname: Sultana
authors.affiliation: Department of Medicine, Monash University, Clayton, VIC, Australia; Healthcare Imaging Services, Epworth HealthCare, Richmond, VIC, Australia.
authors.forename: Richard
authors.initials: R
authors.lastname: O'Sullivan
authors.affiliation: Department of Medicine, Monash University, Clayton, VIC, Australia; Neurology Department, Alfred Hospital, Melbourne, VIC, Australia; Neurosciences Institute, Epworth HealthCare, Richmond, VIC, Australia; Victor Smorgon Epworth Education and Research Institute, Epworth HealthCare, Richmond, VIC, Australia. Electronic address: richard.gerraty@monash.edu.
authors.forename: Richard P
authors.initials: RP
authors.lastname: Gerraty
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D065635:Benign Paroxysmal Positional Vertigo / Q000175:diagnosis* / Q000503:physiopathology; D003937:Diagnosis, Differential; D005260:Female; D064087:Head Impulse Test; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D009759:Nystagmus, Pathologic / Q000175:diagnosis* / Q000503:physiopathology; D010808:Physical Examination; D011237:Predictive Value of Tests; D012027:Reflex, Vestibulo-Ocular; D020521:Stroke / Q000175:diagnosis; D014717:Vertigo / Q000175:diagnosis* / Q000503:physiopathology; D020338:Vestibular Neuronitis / Q000175:diagnosis* / Q000503:physiopathology
keywords: Acute vestibular neuritis; Spontaneous ocular nystagmus; Vestibular diseases