Electronystagmography in a 74-year-old woman with vertigo. (Vestibulology Clinic).

A 74-year-old woman came to the office with a 5-month history of dizziness. Her symptoms began as she was writing one morning before breakfast. She said that suddenly "everything was spinning" and "everything was draining from my body." She fell to the floor and experienced nausea and vomiting, but she did not lose consciousness. She was hospitalized, but the spinning feeling persisted for 3 more days. It was eventually alleviated by meclizine. Upon discharge, she noted an occasional lack of balance, but the spinning feeling did not return.

She came to the author's office for evaluation because she continued to experience an occasional lack of balance while standing and because she was unable to walk a straight line. Her unsteadiness became worse when she was fatigued. She experienced no such feeling when she was sitting or lying down.

She reported no subjective hearing loss and no tinnitus, but she had noticed occasional aural fullness in her left ear. The episodes of aural fullness had begun 5 months earlier upon the onset of her first attack of dizziness. At that time, she had also experienced a heavy head, neck pain, and difficulty moving her neck. During her previous hospitalization, she was found to be hypertriglyceridemic. She was prescribed lorazepam following her hospitalization, and she was also taking tamoxifen following a lumpectomy and quinine for leg cramps. She had a family history of hearing loss.

On examination, she was found to have a 3[degrees] rotary gaze nystagmus. She was unable to perform the sharpened tandem Romberg's test, and she had bilateral nuchal tenderness. Electronystagmography detected nystagmus in the left lateral position. The alternate binaural bithermal caloric test elicited a 42% reduced vestibular response (RVR) left with no directional preponderance. The simultaneous binaural bithermal test elicited a type 2 response, which confirmed the RVR left. Audiometric testing revealed adequate hearing in the normal range of speech frequencies, but a mild decline in the high frequencies. Evaluation of her acoustic stapedial reflexes revealed a cochlear or inner-ear-sensation level response. Ultrathinsection computed tomography of the temporal bones detected sclerotic plaque at the poles of the oval window. The pericochlear lucency was questionable, and the right footplate was thickened at the anterior pole. A 5-hour glucose tolerance test resulted in a normal fasting blood sugar level fol lowed by diabetic levels through the third hour as well as evidence of hyperinsulinemia through the third hour. Her triglyceride level was still elevated.

The patient was prescribed a bisphosphonate and a calcium supplement to address her otosclerosis and placed on a diet to address her metabolic factors. After 3 months, she reported that she felt steadier on her feet and did not weave as much, and that she experienced less fatigue. She continued to experience occasional tinnitus and aural fullness in her left ear. A follow-up sinusoidal verticalaxis rotation test elicited phase responses consistent with a peripheral vestibular disorder as well as a mild asymmetry. A 2-hour postprandial blood test revealed that her blood glucose and insulin levels were normal.

She was encouraged to discontinue the lorazepam, and her symptoms gradually diminished. Sodium fluoride was added to her regimen. She tried vestibular rehabilitation therapy, but she felt that it was of limited benefit. Three years after her initial visit, she remained free of symptoms.

From Neurotologic Associates., P.C., New York City.