title: Refractory Positional Vertigo With Apogeotropic Horizontal Nystagmus After Labyrinthitis: Surgical Treatment and Identification of Dysmorphic Ampullae.
abstract: OBJECTIVE
  To describe the rationale, intraoperative details, and histopathologic findings discovered when treating an unusual case of apogeotropic horizontal canal positional vertigo with a transmastoid labyrinthectomy.
  
  
  METHODS
  A single case report.
  
  
  METHODS
  Therapeutic.
  
  
  METHODS
  Resolution of apogeotropic nystagmus and improvement of positional vertigo.
  
  
  RESULTS
  The apogeotropic variant of horizontal canal positional vertigo can be a difficult entity to treat. This report describes a patient who developed profound sensorineural hearing loss and vertigo after an acute left labyrinthitis. Ten months later, she developed vertigo with apogeotropic positional nystagmus involving the left horizontal semicircular canal. Particle repositioning maneuvers and vestibular physical therapy were unsuccessful. In addition, she developed intermittent positional vertigo affecting the ipsilateral vertical semicircular canals. Given the persistence of her vertigo, multiple canal involvement, and patient preference for definitive treatment, a transmastoid labyrinthectomy was performed. Intraoperatively, the ampulla of the horizontal canal as well as that of the other canals was grossly abnormal as later confirmed on histology. After surgery, her apogeotropic nystagmus and vertigo resolved, and her balance ability gradually improved to a highly functional level.
  
  
  CONCLUSIONS
  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.
authors.affiliation: *Division of Otology-Neurotology, Department of Otolaryngology-Head and Neck Surgery; †Department of Pathology; and ‡Kresge Hearing Research Institute, Department of Otolaryngology-Head and Neck Surgery, University of Michigan Health System, Ann Arbor, Michigan, U.S.A.
authors.forename: Sameer
authors.initials: S
authors.lastname: Ahmed
authors.forename: Katherine D
authors.initials: KD
authors.lastname: Heidenreich
authors.forename: Jonathan B
authors.initials: JB
authors.lastname: McHugh
authors.forename: Richard A
authors.initials: RA
authors.lastname: Altschuler
authors.forename: Wendy J
authors.initials: WJ
authors.lastname: Carender
authors.forename: Steven A
authors.initials: SA
authors.lastname: Telian
mesh_terms: D000368:Aged; D002150:Caloric Tests; D007758:Ear, Inner / Q000601:surgery*; D005260:Female; D006801:Humans; D007762:Labyrinthitis / Q000150:complications* / Q000473:pathology / Q000601:surgery; D009759:Nystagmus, Pathologic / Q000209:etiology* / Q000473:pathology / Q000601:surgery; D013506:Otologic Surgical Procedures; D056888:Patient Positioning; D012665:Semicircular Canals / Q000473:pathology; D054776:Semicircular Ducts / Q000473:pathology*; D014717:Vertigo / Q000209:etiology* / Q000473:pathology / Q000601:surgery