From the Guidelines
Peripheral nystagmus is an involuntary rhythmic eye movement disorder caused by dysfunction in the vestibular system of the inner ear, and the most effective treatment depends on the underlying cause, with canalith repositioning maneuvers like the Epley maneuver being highly effective for benign paroxysmal positional vertigo (BPPV) 1.
Causes and Diagnosis
Peripheral nystagmus typically presents as horizontal or rotatory eye movements that are more pronounced when looking away from the affected side. Common causes include vestibular neuritis, Ménière's disease, BPPV, and labyrinthitis. The diagnosis of peripheral nystagmus involves a thorough physical examination, including the Dix-Hallpike maneuver, which is considered the gold standard test for the diagnosis of posterior canal BPPV 1.
Treatment
Treatment depends on the underlying cause but often includes vestibular suppressant medications like meclizine (25-50mg every 4-6 hours as needed) or diazepam (2-5mg every 6-8 hours) for acute symptoms. These medications should be used short-term (3-5 days) as prolonged use can delay central compensation. For BPPV specifically, canalith repositioning maneuvers like the Epley maneuver are highly effective 1. Vestibular rehabilitation therapy is recommended for most patients with peripheral nystagmus to promote central compensation and improve balance.
Key Considerations
Patients should be advised that associated symptoms like vertigo, nausea, and imbalance typically improve within days to weeks as the brain compensates for the vestibular imbalance. Unlike central nystagmus, peripheral nystagmus is usually temporary and improves as the underlying condition resolves or as central compensation occurs. It is essential to differentiate peripheral nystagmus from central causes of vertigo, such as vestibular migraine, brainstem and cerebellar stroke or transient ischemic attacks, and intracranial tumors or disorders, such as multiple sclerosis 1.
Management
The management of peripheral nystagmus involves a multidisciplinary approach, including education, counseling, and physical therapy. Clinicians should provide patients with clear and comprehensible information on the benefits of treatment and promote shared decision-making to facilitate patient understanding and adherence to treatment plans 1.
From the Research
Peripheral Nystagmus
- Peripheral nystagmus is associated with benign paroxysmal positional vertigo (BPPV), which is the most common peripheral vertigo 2
- BPPV is characterized by brief attacks of rotatory vertigo associated with positional and/or positioning nystagmus, which are elicited by specific head positions or changes in head position relative to gravity 2
- The pathophysiology of BPPV is canalolithiasis comprising free-floating otoconial debris within the endolymph of a semicircular canal, or cupulolithiasis comprising otoconial debris adherent to the cupula 2
- The observation of positional and/or positioning nystagmus is essential for the diagnosis of BPPV 2
Diagnosis and Treatment
- BPPV can be diagnosed from associated positional torsional or direction-changing horizontal nystagmus and can be treated with canalith repositioning procedures 3
- Evaluation of nystagmus is essential for the diagnosis of peripheral vestibular disorders 3
- Experienced physical therapists demonstrated strong agreement in diagnosing common forms of BPPV 4
Comparison with Central Positional Nystagmus
- Central positional nystagmus (CPN) is often suspected when atypical forms of its peripheral counterpart, i.e., BPPV, are observed 5
- CPN is caused by cerebellar and/or brainstem dysfunction, whereas BPPV is caused by peripheral vestibular disorders 5
- CPN may account for up to 12% of patients with positional nystagmus, and its natural course remains largely unknown 5