Should the clinician do the tests for benign paroxysmal positional vertigo even in the presence of spontaneous nystagmus at primary gaze?

Different balance problems may occur in the same patient simultaneously, and the other problem may be overlooked if the clinician does not pay much attention. Spontaneous nystagmus of Meniere's disease and positional nystagmus of posterior canal BPPV in the same patient is presented. Positional tests must always be considered even in the presence of spontaneous nystagmus.

Patients with benign paroxysmal positional vertigo (BPPV) frequently experience a sudden sense of vertigo with head motion due to freely floating otoconia inside the semicircular canals or those adhering to the cupula when provocative motion is accelerated with gravitational forces. Acute episodic vertigo of Meniere's disease is due to endolymphatic hydrops and is usually associated with spontaneous nystagmus. In an acute onset condition of balance problem, clinicians are usually inclined not to test any positional nystagmus if the patient has spontaneous nystagmus at primary gaze and besides if nystagmus is fixed with visual target. This is an indication of peripheral problem. Treatment of balance problem in Meniere's disease is medical or surgical. But, follow‐up of patients is required for months or years. However, patients with BPPV have quick relief of symptoms after repositioning maneuvers and they may return to work in a short time.

A 49‐year‐old man with a long‐term diagnosis of left‐sided Meniere's disease was admitted to outpatient clinic with an acute onset vertigo. He demonstrated right beating spontaneous nystagmus with optic fixation at primary gaze. However, he also had posterior canal BPPV on the right head‐hanging position which eventually got cured after Epley's maneuver (Video S1). It is also interesting to note that geotropic or apogeotropic type lateral canal BPPV would probably stay undiagnosed or would be difficult to designate the involved side due to presence of superposed spontaneous nystagmus in Meniere's disease. Two different clinical problems may present at the same time 1, 2. We recommend performing positional tests on every occasion.

Conflict of Interest

None declared.

Video S1. Counter clockwise nystagmus is seen during right‐sided head‐hanging maneuver. Right beating spontaneous nystagmus in left‐sided Meniere's disease is evident after cessation of positional provoked nystagmus of otoconial debris of the right posterior canal.

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