Acute audiovestibular deficit with complete ocular tilt reaction and absent VEMPs

A patient presenting with vertical diplopia along with ocular tilt reaction (OTR) due to peripheral vestibular dysfunction is a rare occurrence. OTR is an eye-head postural reaction consisting of head tilt, skew deviation, conjugated eye cyclotorsion, and alteration of vertical perception, and is thought to occur with central lesions, mainly brainstem lesions. Here, we report a case of a patient who was suffering from left acute peripheral cochleovestibular loss. He had profound deafness and absence of caloric response on the left side. No central lesion was observed on magnetic resonance images. Neuro-ophthalmological examination showed OTR consisting of head tilt, skew deviation with left hypotropia, excyclotorsion, and tilt of the static visual vertical directed to the left side. Both utricular and saccular dysfunctions were identified by the absence of cervical vestibular evoked myogenic potential (cVEMP) and ocular VEMP (oVEMP) on the left side. Within a month, the OTR disappeared completely probably because of vestibular compensation. This is the first report to state that the peripheral otolith dysfunction causing reversible vertical diplopia was identified by objective examinations (VEMP).