Wrong Way Nystagmus In Meniere's Disease

Timothy C. Hain, MD Page last modified: March 14, 2011

Meniere's disease often breaks the general rules of ear disease.

Hearing loss in Meniere's usually starts out with a low-frequency sensorineural pitches. Almost all other ear diseases begin with damage to the highest pitches first.

Another difference is that there can be an excitatory phase to Meniere's followed by the inhibitory phase. This results in nystagmus going the "wrong way" -- beating towards the bad ear rather than away.

Head-shaking nystagmus can also go the "wrong way", showing that the problem appears to be an increased sensitivity of the vestibular system on that side, rather than another mechanism such as bechterews.

The case and video below illustrates a patient with very well documented Meniere's, and "wrong way" spontaneous as well as head shaking nystamus.

Audiogram shows flat sensorineural hearing loss at 60 db, typical of late Meniere's disease.

DPOAE shows no responses on right side. Responses on left side are typical for age.

Caloric test shows reduced but not absent response on right side.

VEMP shows preserved responses on both sides, the left being moderately better than the right.

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Video of spontaneous and head-shaking nystagmus. This was recorded when the patient was very "active" with hearing loss, fullness, and daily dizziness. A few days after this recording, the patient had an otolithic crisis of Tumarkin attack.

Why is there "wrong way" nystagmus ? The conventional explanation is that at certain stages in Meniere's, the ear is excited rather than inhibited. Another possible explanation is recovery nystagmus, or "Bechterews". One would think that for the first explanation, head-shaking might also be reversed (as was seen here). For the second explanation, one would think that head-shaking (and vibration) would go in the opposite direction of the nystagmus. For this patient, excitation seems to be the more likely explanation.