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A physically active 62-year-old man experienced the gradual onset of intermittent positional dizziness, occurring primarily on inclining his head upwards or downwards. Dizziness also appeared less commonly with abrupt turns of the head or while bearing down during a bowel movement. He denied tinnitus. He had no significant family history, he had never sustained head or neck trauma, and he was on no medications. Treatment with meclizine had not alleviated his symptoms.
On physical examination with video Frenzel goggles (Micromedical Technology, Chatham, IL), there was a primary position torsional nystagmus, of approximately 1 Hz. There was also a low-amplitude downbeating nystagmus, greater on lateral gaze, and with no positional modulation. By watching the nystagmus while palpating the pulse, it was appreciated that the torsional nystagmus was pulse-synchronous, with the clockwise component corresponding to the pulse upswing. The torsional nystagmus was present when the patient was sitting or standing, but was suppressible in those positions with the Valsalva maneuver, and was absent when supine (see video on the Neurology® Web site at www.neurology.org).
Laboratory investigation revealed vestibular evoked myogenic potentials to be fourfold enlarged on the right, and the responses could be obtained at a lower threshold on the …
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