A man in his 60s was referred for treatment of 12 months’ persistent motion-induced vertigo and superimposed episodes of exercise-induced vertigo. Ten years earlier he had presented with asymmetric hearing loss, and was diagnosed with a right intracanalicular vestibular schwannoma, which remained stable on repeated magnetic resonance imaging (MRI) (Figure). A computed tomographic (CT) scan of the temporal bones did not reveal superior canal dehiscence (SCD). Video head impulse testing demonstrated normal and symmetrical horizontal semicircular canal gains (left, 0.94; right, 0.92; normal range, 0.9-1.1), and mildly reduced right posterior canal gain (0.67; normal range, 0.7-0.9). Vertical canal function was otherwise preserved. Infrared video goggles revealed a weak spontaneous horizontal left beating nystagmus. After 15 seconds of hyperventilation there was a right beating nystagmus associated with vertigo followed by the reappearance of a left beating nystagmus (Video). Positional testing evoked nonspecific sustained right beating nystagmus. Audiovestibular evaluation revealed right air caloric canal paresis of 67% (mean slow phase velocities: left cold-water response, 22.6o/s; left warm-water response, 20.8°/s; right cold-water response, 2.1°/s; right warm-water response, 6.5°/s; normal range, <25%), and symmetrical down sloping hearing loss from 2 kHz to 8 kHz. Bone-conducted ocular and air-conducted tone burst cervical vestibular evoked myogenic potentials (VEMPs) were present symmetrically, and thresholds were normal.
Foster E, Chen L. Exercise-Induced Vertigo in Vestibular Schwannoma. JAMA Otolaryngol Head Neck Surg. 2017;143(9):955–956. doi:10.1001/jamaoto.2017.0993
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