What does the nystagmus in vestibular neuritis look like?

Added: 2026-05-22

[00:00:00]What does the nystagmus in vestibular neuritis look like? Or should you do the HINTS exam if the patient doesn't have spontaneous nystagmus?

[00:00:09]Hi, Peter Johns here, a retired emergency physician for the past 3 years, but still an active and passionate vertigo educator. I'll answer these questions by first giving a relatively short answer followed by a longer answer with more details.

[00:00:23]So, the short answer is that spontaneous nystagmus is nystagmus that you see when the patient is looking straight ahead, which is called primary gaze. All patients suffering from vestibular neuritis will have horizontal spontaneous nystagmus early on in their illness, and it'll look like this. This video loop is showing horizontal nystagmus with the fast component beating to the left, and this is the patient population you should certainly be performing the HINTS exam on. That's assuming you've already screened them for the central features listed here.

[00:00:53]Having focal weakness or paresthesias, new significant headache or neck pain, vertical nystagmus at rest, any of the dangerous D's, or inability to walk unaided would raise your concern for stroke enough that it should be ruled out.

[00:01:07]But can you do the HINTS exam in patients who don't have spontaneous nystagmus?

[00:01:11]This patient doesn't have obvious spontaneous nystagmus like the previous one.

[00:01:16]And the answer is yes, you can perform the HINTS exam on a patient without spontaneous nystagmus. But, and this is a big but, only if you see some nystagmus when the patient is looking left or right about 30°.

[00:01:29]This patient presented a few days into their illness, and the spontaneous nystagmus was no longer easily visible.

[00:01:35]And the nystagmus was only seen when she was asked to look to the left. I use the term nystagmus at rest to describe nystagmus that you see with the patient looking straight ahead, which is spontaneous nystagmus, or when they are looking 30° to the left or right. And by this, I don't mean nystagmus seen during positional testing like the Dix-Hallpike test. So, the short answer is, if you see a patient with nystagmus at rest, you can do the HINTS exam to determine if the patient is suffering from vestibular neuritis or from a posterior circulation stroke.

[00:02:04]If that all makes sense to you, you can stop watching now. But, keep watching if you want a more detailed explanation, including description of the typical presentation and nystagmus of vestibular neuritis, a tip on how to not miss mild nystagmus, and an explanation of why you shouldn't do the HINTS exam if you don't see any nystagmus at rest. The power of HINTS is that after screening patients for the central features we went through, HINTS can definitively diagnose vestibular neuritis in those patients with nystagmus at rest, and thereby rule out a stroke. And on the first day of their acute onset illness, vestibular neuritis patients all have dizziness, vertigo, nausea, vomiting, difficulty walking, and spontaneous horizontal nystagmus. And interestingly, about 20% of the patients who get vestibular neuritis have a prodromal episode of dizziness, vertigo that mostly occurs the day before the onset of full-blown vestibular neuritis, and last between 1 and 60 minutes. Some last longer, and about a third of patients will have two or more prodromal episodes before the big episode. I just wanted you to be aware so that if you see a typical presentation of vestibular neuritis with no central features and HINTS peripheral result, and the patient says they had a one or two short episodes before their big episode, that you don't freak out and think it that's a posterior circulation TIA.

[00:03:24]Now, let's go into more details of what the typical nystagmus of vestibular neuritis looks like.

[00:03:29]We already covered that spontaneous nystagmus is nystagmus which is seen when the patient is looking straight ahead.

[00:03:36]Like we can see in this gentleman with horizontal nystagmus beating to the left.

[00:03:41]The direction of any nystagmus is defined by the fast component. In vestibular neuritis, you can also see a torsional component in the same direction as the nystagmus. The affected ear in vestibular neuritis is the one in the opposite direction of the fast component of the nystagmus. Note that this is opposite to BPPV where the torsional component of the nystagmus is towards the affected ear. Another thing you might notice in vestibular neuritis patients who have spontaneous nystagmus is that if the patient is asked to look in the direction of the fast component of the nystagmus, the nystagmus increases in intensity and frequency.

[00:04:17]When they are asked to look away from the direction of the nystagmus, it decreases or even stops altogether. Note that the nystagmus does not change direction with gaze in the vestibular neuritis. This description of how the nystagmus increases when the patient looks in the direction of the nystagmus and decreases when you look away is called Alexander's law. In this patient, you can see horizontal nystagmus beating towards the right. If you look carefully at the red vessels on his eyes, you can see that his eyes are rotating or torsionally moving towards the right as well. Since we see that the nystagmus is to the right, his affected ear would be his left ear if he indeed has vestibular neuritis.

[00:04:56]When he's asked to look towards the right, you'll note that his nystagmus increases in amplitude and frequency a bit.

[00:05:01]And when he looks towards the left, it decreases quite a bit, but it's still beating towards the right. This is Alexander's law in action.

[00:05:10]So, it's easy to see nystagmus on day one of a bout of vestibular neuritis, and the HINTS exam can definitively make the diagnosis of vestibular neuritis and allow you to discharge most patients without imaging.

[00:05:21]Now, for the patient with vestibular neuritis, the first day or two are quite difficult. Very dizzy, nauseated, difficulty walking, but after a day or two, they are usually noticing a substantial improvement. And their nystagmus can start to settle down a bit also. And in the recovery stage, it's not hard to miss subtle nystagmus.

[00:05:42]And this can lead to confusion by the clinician, and sometimes the diagnosis of vestibular neuritis is missed.

[00:05:48]Peripheral nystagmus, as seen in vestibular neuritis, is suppressed by visual fixation, which is why I don't have the patient stare at my finger when I examine them.

[00:05:58]Ideally, you want to remove fixation to bring out subtle nystagmus. Clinicians who see a lot of dizziness in their practice often have fancy goggles to make subtle nystagmus easier to see.

[00:06:09]I've never had any access to any fixation-removing goggles, but those who use them swear by them. I find the easiest way to remove fixation is to put a blank piece of paper beside their head and ask them to keep their head straight and then look to the left and right through the paper as if it's not there.

[00:06:26]Now, eventually, in vestibular neuritis patients, in the next few days or weeks, or sometimes even months, their symptoms will resolve pretty much completely. And they'll have no discernible nystagmus even when you look carefully for it.

[00:06:41]And they'll have no difficulty walking in normal circumstances.

[00:06:45]But their nystagmus doesn't go from full-on obvious spontaneous nystagmus straight to zero nystagmus instantly.

[00:06:51]It happens in stages, and you'll see the different stages in those who present a day or two or more into their illness.

[00:06:58]Let's look at some examples. The first thing to disappear will be the weakest nystagmus. That is when the patient looks in the opposite direction of the fast component. And that looks like this.

[00:07:09]This woman has obvious left-beating horizontal spontaneous nystagmus with a torsional component beating to the left.

[00:07:15]So, her right ear is the affected ear.

[00:07:18]When she looks to the left, it increases a bit, but stops when she looks to the right. Still a great candidate you can do the HINTS exam on.

[00:07:26]After that, even the nystagmus when you're looking straight ahead will resolve. By now, I hope you realize that the name for this is spontaneous nystagmus. And you may only see nystagmus when the patient is looking away from the affected ear. And finally, there'll be a point where you don't see any nystagmus at all. However, removing fixation may bring out some nystagmus that you wouldn't see otherwise.

[00:07:50]Now, here's a case where the absence of easy-to-see nystagmus got a case a bit off the rails.

[00:07:56]At handover, I was asked to take over the care of a patient that one of my colleagues had been investigating for vertigo. She had developed dizziness 2 days before and saw her family doctor who did a Dix-Hallpike test and Epley on her, which didn't seem to help.

[00:08:10]The next day, she was slightly better and she saw her family doctor again and was referred to the emergency department for a diagnosis. She waited over 12 hours to be seen as it was quite busy in the emergency that day. And when she was, my colleague didn't see any spontaneous nystagmus.

[00:08:26]And since I had drilled into most of my local colleagues that no nystagmus, no HINTS exam for you was the way to go, he didn't do a HINTS exam. And instead, since the dizziness got worse when she moved her head, he did a Dix-Hallpike test. This reportedly showed horizontal nystagmus on one side that didn't stop even after 10 minutes. Although she had no central features, my colleagues ordered a CTA head and neck, which was completed and she was now awaiting the report. When it came back completely normal, I went to see her. By now, she had been in the emergency department for 24 hours and was sitting in a jerry chair in the hall.

[00:09:01]And this is what I saw. No rip-roaring spontaneous nystagmus, but was there a beat or two to the left? And when she was asked to look to the left, was there anything there?

[00:09:11]I wasn't sure, so I put the blank piece of paper beside her head and asked her to look through it as if it wasn't there and look to the left.

[00:09:20]Now, I'm pretty sure there is left-beating horizontal nystagmus with a torsional component to the left.

[00:09:30]And when I took the paper away, it lessened.

[00:09:41]>> And when the paper was put back, it enhanced the nystagmus again.

[00:09:46]And when I asked her to look to the right, I didn't see any nystagmus even with fixation removed. So so far, her HINTS exam showed a left horizontal torsional nystagmus which didn't change direction with gaze. She had no abnormal skew deviation.

[00:10:03]So what did her head impulse test show?

[00:10:05]If she has vestibular neuritis affecting her right ear, we should see a a catch-up saccade when her head is turned rapidly towards the right.

[00:10:14]So now, after 24 hours in the emergency department with Dix-Hallpikes and Epley's and a CT angio that was normal, it was time to see what her head impulse test showed.

[00:10:26]So here's what test to the left that was normal and then a test to the right, catch-up saccade right there.

[00:10:34]And here's a blurry catch-up saccade to the right.

[00:10:37]Big one. You can see the catch-up saccade there.

[00:10:40]And I can also tell you that she had no new hearing loss on the finger rub test, which means that her overall HINTS Plus exam was peripheral and she had vestibular neuritis.

[00:10:49]So this was a great example of how looking carefully for nystagmus unleashes the power of the HINTS exam to rule out a stroke by definitively ruling in vestibular neuritis. So is this a novel finding and did I deserve to win a Nobel Prize for discovering it? Well, no. Turns out Dr. Welgimbola and Hamalgi wrote about this 7 years ago and probably knew about it many years before that. Here's a paragraph from this paper which I lightly edited in green for clarity. The first sentence talking about errors, especially in the emergency department, lands a little hard, but well, I guess it's true. It basically states if you miss nystagmus because of poor lighting or not removing fixation and then decide to do the Dix-Hallpike test, you might nystagmus that lasts forever and think they have BPPV and torture them with the Epley maneuver instead of doing the HINTS exam and making the diagnosis. Sound familiar? Here's another quick case of a late-presenting vestibular neuritis patient that I picked up. She was really dizzy a couple days ago, getting better now, but hadn't been diagnosed and had no central features. No spontaneous nystagmus, maybe some nystagmus when she looked to the right.

[00:11:57]The blank piece of paper it seemed to enhance it.

[00:12:00]Let's have a look at her head impulse test.

[00:12:03]Slow movements to begin with and then a rapid movement to the left, right.

[00:12:08]There and a catch-up saccade. And then to the right.

[00:12:13]Normal and to the left again, catch-up saccade. So another victory for the HINTS exam when you look carefully for nystagmus.

[00:12:22]Now eventually in vestibular neuritis patients, they'll recover enough that you won't see any nystagmus even when fixation is removed.

[00:12:30]When the nystagmus has improved this much, the patient should have much less problems with dizziness and be able to walk back and forth without any gait abnormality. Now on the other hand, if you see someone in the first day or two of their dizzy episode and you look very carefully for nystagmus and you don't see any, even with fixation removed, watch them walk. If you see a new objective gait problem like this man who normally can walk just fine, you should work them up for stroke because walking that abnormally and having no nystagmus at rest is not consistent with vestibular neuritis.

[00:13:04]So be very careful with a patient who has new onset dizziness, no nystagmus, and new objective difficulty walking.

[00:13:12]Now the last category is if you see a patient who says they're still dizzy, has no central features, has no nystagmus even when you look carefully for it, and they have no objective gait difficulty, they are probably at very low risk of having a stroke.

[00:13:27]And you should look at to see if they might have BPPV because patients with BPPV often endorse a baseline dizziness and explore the possibility of vestibular migraine or general medical cause of dizziness. And don't do the HINTS exam on them as patients with BPPV or vestibular migraine or any general medical cause will have a normal head impulse test. And in the HINTS exam, a normal head impulse test will automatically give you a HINTS central result and raise unwarranted concern for stroke in these patients. Now, some very savvy people might say, "But the abnormal head impulse test is known to persist longer than the nystagmus in vestibular neuritis.

[00:14:05]Why not do the HINTS on those patients with mild dizziness for a week or more, but no nystagmus, to pick up these cases?"

[00:14:12]And the answer is yes, you could rarely pick up recovering vestibular neuritis by doing this. And if you're a vertigo specialist seeing patients in your clinic weeks down the road, it's perfectly correct to do the head impulse test on them. But the issue is that for those who are seeing dizzy patients in the first several days, the HINTS exam is about diagnosing vestibular neuritis and thus ruling out a stroke. So, all you're going to do by performing the HINTS on every patient that says they're having constant dizziness, but have no nystagmus, just to be complete, is finding normal head impulse tests in many BPPV and vestibular migraine and and patients with general medical causes leading to unwarranted investigations and referrals. When what they really need is a Dix-Hallpike test or a good migraine history or their CO level to be checked.

[00:15:01]Not every dizzy patient needs HINTS, but they would all benefit from the right diagnosis. Well, I hope you've enjoyed this video and that it'll stimulate you to learn more about vertigo. And if you are looking to learn more about vertigo, I'll let you know that Scott Weingart and I have made a new online vertigo course, which has has a couple of hundred people sign up with very good reviews and some very nice comments. I'm going to read you a few of them.

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