Tullio phenomenon with torsion of the eyes and subjective tilt of the visual surround.

A 44-year-old male patient had an acoustic trauma three years previously, after which he suffered from vertigo and tilting of the environment to the right when uttering the vowels u or e. At such times, a tonic eye torsion to the left, which lasted throughout the utterance, was observed under Frenzel's glasses along with head tilt to the left. The phenomenon could be elicited experimentally by right-ear stimulation with low-frequency noise (mean frequency, 125 Hz; 90 dB), as well as by constant pressure. The patient also reported observing the phenomenon with loud noises, nose blowing, obstruction of his right external meatus with the finger, and with altitude pressure changes in a car. This suggests that the phenomenon is elicited via the eardrum and the ossicular chain. Since lateral head tilt and counterrolling were tonic and without nystagmus, it is unlikely that one of the semicircular canals is involved as in usual Tullio cases. Rather, the otoliths may play a role in pathogenesis. Possible causative mechanisms are discussed along with the relevant literature.