The Most Common Vestibular Conditions Categorized by Timing and Triggers, with Specific Ocular Motor and Vestibular Features that Should be Sought for Each

HINTS+ = Head Impulse, Nystagmus, Test of Skew, ‘Plus' bedside assessment of auditory function; HIT = head impulse test; NP = nerve palsy; BPPV = benign paroxysmal positional vertigo; SCDS = superior canal dehiscence syndrome; BVL = bilateral vestibular loss; PPPD = persistent postural perceptual dizziness; CANVAS = cerebellar ataxia, neuropathy, vestibular areflexia syndrome * If first attack of TIA, vestibular migraine or Meniere's, may be better described as the acute transient vestibular syndrome (<24 hours) ** HINTS has been studied in the acute vestibular syndrome, and should not be relied upon in the episodic or acute transient vestibular syndrome

The most common vestibular conditions categorized by timing and triggers, with specific ocular motor and vestibular features that should be sought for each Daniel R. Gold, DO, Departments of Neurology, Ophthalmology, Neurosurgery, Otolaryngology - Head & Neck Surgery, Emergency Medicine, The Johns Hopkins School of Medicine Acute Vestibular Syndrome (>24 hours) Episodic Spontaneous Vestibular Syndrome* Episodic Triggered Vestibular Syndrome Chronic Vestibular Syndrome Vestibular Conditions to Consider 1) Vestibular neuritis Targeted Ocular Motor & Vestibular Exam 1) 2) Stroke (demyelination and other central etiologies less common) 2) 3) Wernicke's 3) 1) TIA 1) 2) Vestibular migraine 2) 3) Meniere's 3) 4) Vestibular paroxysmia 4) 1) BPPV 1) 2) Central positional vertigo or nystagmus 2) 3) SCDS 3) 1) BVL 1) 2) 3) PPPD Cerebellar disease 2) 3) HINTS+: HIT abnormal (see example https://collections.lib.utah.edu/ark:/87278/s6x398q2) AND unidirectional nystagmus that obeys Alexander's law (see example - https://collections.lib.utah.edu/ark:/87278/s64205qx) AND skew deviation absent (see alternate cover testing at 1 and 3 minutes https://collections.lib.utah.edu/ark:/87278/s6tn1htv) AND no acute hearing loss; peripheral pattern of HSN HINTS+: HIT normal (see demonstration in a normal patient https://collections.lib.utah.edu/ark:/87278/s63b97tz) OR gazeevoked nystagmus (see example https://collections.lib.utah.edu/ark:/87278/s6kh4n5k) OR skew deviation present (see example https://collections.lib.utah.edu/ark:/87278/s6c0045t) OR acute hearing loss; look for central patterns of HSN (see example https://collections.lib.utah.edu/ark:/87278/s61c5vkg) Bilaterally abnormal HIT, spontaneous vertical (see example https://collections.lib.utah.edu/ark:/87278/s6h74j6d) and gazeevoked nystagmus are common, also 6th NP, ataxia Usually symptoms have resolved and eye movement exam is normal; otherwise, may use HINTS** Can see peripheral or central patterns of nystagmus (spontaneous, gaze-evoked, head-shaking-induced, positional) during the attack, often normal inter-ictally; often spontaneous, but typical migraine triggers are common too Nystagmus can be in excitatory or inhibitory patterns during the attack, often normal inter-ictally Hyperventilation-induced nystagmus (see demonstration in a normal patient https://collections.lib.utah.edu/ark:/87278/s6pz98ht) Dix-Hallpike (see example https://collections.lib.utah.edu/ark:/87278/s6s79d1w) and supine roll test (with bow and lean to localize, see example https://collections.lib.utah.edu/ark:/87278/s68h2wk9) Consider this diagnosis when history/exam features are atypical for BPPV, including an unexpected nystagmus vector; downbeat (see video example https://collections.lib.utah.edu/ark:/87278/s66t3w9k) and apogeotropic nystagmus patterns are most common Valsalva and pinched-nose Valsalva (see example https://collections.lib.utah.edu/details?id=1213443), tragal compression, loud sounds Bilaterally abnormal HIT (see example https://collections.lib.utah.edu/ark:/87278/s62z4z8g), additional cerebellar signs can narrow differential and loss of 4 or more lines with dynamic visual acuity (see example of how to perform this maneuver - https://collections.lib.utah.edu/ark:/87278/s6tn19w8) No typical ocular motor/vestibular findings Flocculus/paraflocculus: Gaze-evoked nystagmus, spontaneous downbeat nystagmus, saccadic pursuit and VORS (when VOR is 4) Acoustic neuroma 4) 5) Oculopalatal tremor 5) present), saccadic dysmetria (see example https://collections.lib.utah.edu/ark:/87278/s6dj8q9h), alternating skew deviation (see example https://collections.lib.utah.edu/ark:/87278/s6d83n91) while additional vestibular loss can narrow differential (e.g., CANVAS, see example https://collections.lib.utah.edu/ark:/87278/s6s50fth) Nodulus/uvula: periodic alternating nystagmus (see example https://collections.lib.utah.edu/ark:/87278/s62k013r) Hyperventilation-induced nystagmus (see example https://collections.lib.utah.edu/ark:/87278/s63f8cgs), and Bruns nystagmus (see example https://collections.lib.utah.edu/ark:/87278/s60p4p3j) Vertical or vertical-torsional pendular nystagmus with palatal tremor (see example https://collections.lib.utah.edu/ark:/87278/s6mh1mnm) HINTS+ = Head Impulse, Nystagmus, Test of Skew, ‘Plus' bedside assessment of auditory function; HIT = head impulse test; NP = nerve palsy; BPPV = benign paroxysmal positional vertigo; SCDS = superior canal dehiscence syndrome; BVL = bilateral vestibular loss; PPPD = persistent postural perceptual dizziness; CANVAS = cerebellar ataxia, neuropathy, vestibular areflexia syndrome * If first attack of TIA, vestibular migraine or Meniere's, may be better described as the acute transient vestibular syndrome (<24 hours) ** HINTS has been studied in the acute vestibular syndrome, and should not be relied upon in the episodic or acute transient vestibular syndrome