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. 2022 Jun;42(3):287-292.
doi: 10.14639/0392-100X-N1824.

The clinical significance of direction-fixed mono-positional apogeotropic horizontal nystagmus

Mauro Gufoni  1 , Augusto Pietro Casani  1
Affiliations

The clinical significance of direction-fixed mono-positional apogeotropic horizontal nystagmus

Mauro Gufoni et al. Acta Otorhinolaryngol Ital. 2022 Jun.

Abstract
in English, Italian

Objective: A mono-positional persistent, direction-fixed apogeotropic nystagmus (MPosApoNy) is very challenging for the neuro-otologist. MPosApoNy can be found in patients suffering from a partially compensated acute unilateral vestibulopathy; with a normal caloric test, one can speculate the presence of "trapped" otolithic debris located close to the ampulla of the horizontal semicircular canal.

Methods: Among 957 patients suffering from vertigo and dizziness, we selected 53 cases of MPosApoNy.

Results: In 28 patients, caloric test showed a canal paresis on the same side of the MPosApoNy. In the remaining 25 cases, MPosApoNy was the only clinical finding. We hypothesised the presence of horizonal canal lithiasis and patients were treated with a Gufoni manoeuvre, followed by a forced prolonged position.

Conclusions: Performing bedside examination in a patient suffering from vertigo, the presence of MPosApoNy may be due to: a) facilitation of a subclinical nystagmus due to the mechanism of apogeotropic reinforcement; b) horizontal canal lithiasis with 'trapped' otoliths close to the ampulla. The disappearance of MPosApoNy following a repositioning manoeuvre or conversion in a typical form of canalolithiasis may represent the best method to confirm this hypothesis.

Il significato clinico del nistagmo monoposizionale orizzontale apogeotropo.

Obiettivo: Il riscontro di un nistagmo monoposizionale orizzontale apogeotropo (MPosApoNy) rappresenta una sfida diagnostica per il vestibologo. Tale nistagmo può indicare, in presenza di un deficit al test calorico, una labirintopatia periferica non compensata. In assenza di tale reperto, il MPosApoNy potrebbe essere riconducibile ad una forma atipica di litiasi del canale semicircolare orizzontale (CSL).

Metodi: Su 957 pazienti con vertigini, ne abbiamo selezionati 53 che presentavano MPosApoNy.

Risultati: In 28 pazienti il test calorico evidenziò un deficit ipsilaterale al MPosApoNy. Nei rimanenti 25 in cui il test calorico risultò nella norma, si ipotizzò una litiasi del CSL con otoliti intrappolati in prossimità dell’ampolla. Questi pazienti vennero trattati con manovra di Gufoni e successiva posizione coatta.

Conclusioni: Il riscontro di un MPosApoNy può riconoscere una duplice causa. Esso può essere l’espressione di un nistagmo subclinico esito di labirintopatia acuta monolaterale. Tuttavia, la presenza di otoliti intrappolati in stretta vicinanza dell’ampolla ne può spiegare la genesi. In quest’ultimo caso, le manovre liberatorie, attraverso la risoluzione del MPosApoNy o per la conversione in una forma tipica di canalolitiasi, possono confermarne l’origine litiasica.

Keywords: apogeotropic nystagmus; benign paroxysmal positional vertigo; canalolithiasis; horizontal semicircular canal; positional nystagmus.

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Figures

Figure 1.
Figure 1.
Summary of the results obtained with treatment in the 25 patients with monopositional apogeotropic horizontal nystagmus.
Figure 2.
Figure 2.
The apogeotropic monopositional nystagmus from ‘trapped’ otolithic block. (A) The patient is in sitting position: the otolithic block is close to the right ampulla. (B) When the patient lies supine with the head rotated to the right, the block does not provoke any cupular movement and no nystagmus is evident (the otolithic debris does not enter in the canal because of its dimension (=).(C) When the patient lies supine with the head rotated to the left, the movement of debris creates a persistent ampullopetal displacement of the cupula and a apogeotropic nystagmus appears (+).
See this image and copyright information in PMC

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