Causes and characteristics of horizontal positional nystagmus

Direction changing horizontal positional nystagmus can be observed in a variety of central and peripheral vestibular disorders. We tested sixty subjects with horizontal positional nystagmus and vertigo on the Epley Omniax(®) rotator. Monocular video recordings were performed with the right or left ear down, in the supine and prone positions. Nystagmus slow-phase velocity (SPV) was plotted as a function of time. Thirty-one subjects diagnosed with horizontal canalolithiasis had paroxysmal horizontal geotropic nystagmus with the affected ear down (onset 0.8 ± 1 s, range 0-4.9 s, duration 11.7-47.9 s, peak SPV 79 ± 67°/s). The SPV peaked at 5-20 s and declined to 0 by 60 s; at 40 s from onset, the average SPV was 1.8 % of the peak. Nine subjects diagnosed with cupulolithiasis had persistent apogeotropic horizontal nystagmus (onset 0.7 ± 1.4 s, range 0-4.3 s). Peak SPV was 54.2 ± 31.8°/s and 26.6 ± 12.2°/s with unaffected and affected ears down, respectively. At 40 s, the average SPV had decayed to only 81 % (unaffected ear down) and 65 % (affected ear down) of the peak. Twenty subjects were diagnosed with disorders other than benign positional vertigo (BPV) [vestibular migraine (VM), Ménière's Disease, vestibular schwannoma, unilateral or bilateral peripheral vestibular loss]. Subjects with VM (n = 13) had persistent geotropic or apogeotropic horizontal nystagmus. On average, at 40 s from nystagmus onset, the SPV was 61 % of the peak. Two patients with Ménière's Disease had persistent apogeotropic horizontal nystagmus; the peak SPV at 40 s ranged between 28.6 and 49.5 % of the peak. Symptomatic horizontal positional nystagmus can be observed in canalolithiasis, cupulolithiasis and diverse central and peripheral vestibulopathies; its temporal and intensity profile could be helpful in the separation of these entities.