Electronystagmography in a 13-year-old boy with dizziness and hyperacusis. (Vestibulology Clinic).

A 13-year-old boy was brought to the office with a 4month history of dizziness. He had trouble with his balance while walking, and he also felt dizzy while sitting and lying down, more so while sitting. He said his vision was blurred and that he had been sleeping a great deal. In addition, he said he had difficulty concentrating and focusing his thoughts. He also had difficulty describing his symptoms, but he agreed that there was an element of rotation that occurred during his spells. He experienced as many as 10 or 15 spells per day, and their duration ranged from 5 minutes to 3 hours. His symptoms fluctuated in their severity. Another physician had prescribed meclizine, an antihistamine, and a decongestant, but they had failed to provide symptomatic relief. The boy's parents also noted that he would hyperventilate four or five times a day, usually while eating. The boy reported no subjective hearing loss, tinnitus, or aural fullness, but he did complain of binaural hyperacusis. During these episodes, he sa id he was not able to remain in certain rooms where the ambient noise was particularly bothersome; his school's cafeteria was especially problematic.

On clinical examination, the patient experienced marked difficulty performing the sharpened tandem Romberg's test with either foot forward. He also exhibited bilateral nuchal spasm and tenderness. Findings on magnetic resonance imaging with enhancement were negative for any abnormality. Electronystagmography performed elsewhere had detected no spontaneous or positional nystagmus, and the alternate binaural bithermal stimulus had elicited a 10% reduced vestibular response (RVR) right, which is within normal limits. A subsequent simultaneous binaural bithermal test elicited a type 2 response, indicating an RVR right.

Ultrathin, small-pixel computed tomography of the temporal bones detected evidence consistent with a diagnosis of otosclerosis. A 5-hour glucose tolerance test yielded an exaggerated response, with markedly elevated simultaneous insulin levels. These metabolic findings are consistent with a diet that is too high in carbohydrates. The patient was placed on a diet to address his metabolic factors and low doses of sodium monofluorophosphate and calcium carbonate to address his otosclerosis.

Three months later, the patient reported that his dizzy spells were less frequent, less severe, and of shorter duration. His 2-hour postprandial insulin level had fallen to within the normal range. However, his hyperacusis persisted.

Nine months after he had begun treatment, the patient said that his dizziness-free periods were becoming longer, although they were exacerbated whenever his allergies flared up. His hyperacusis was still present, but it was less severe. Fifteen months into treatment, he reported only a few episodes of dizziness, and they were associated with a bout of influenza and an upper respiratory infection. Hyperacusis occurred only when he was dizzy.

At 21 months after the initiation of treatment, the patient was symptom-free and able to liberalize his diet without triggering a recurrence. Three years into treatment, the sodium monofluorophosphate and calcium carbonate were discontinued.

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