Diagnostic Considerations
On the basis of the patient’s history and physical findings, the examining physician should be able to formulate a differential diagnosis and determine whether the symptoms are likely to be peripheral or central (see the Table below).
Table. Features Differentiating Peripheral from Central Nystagmus (Open Table in a new window)
System or Reflex |
Peripheral Lesions |
Central Lesions |
Oculomotor |
Spontaneous nystagmus with eyes closed |
Saccades (velocity, accuracy), internuclear ophthalmoplegia, saccadic pursuit, gaze-evoked nystagmus |
Vestibulo-ocular reflex (VOR) |
Nystagmus without fixation, nystagmus after head shaking, eye-head mismatch, unilateral and bilateral vestibular loss |
Hyperactive VOR, failure of fixation suppression (FFS), positional nystagmus, bilateral vestibular loss |
Vestibulospinal reflex (VSR) |
Cautious gait; normal spontaneous movement; normal, spontaneous, and correct movement |
Wide-based gait, minimal spontaneous movement |
Differential Diagnoses
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Immune-mediated inner-ear disease
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Vestibular schwannoma
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Example of Frenzel goggles used for evaluation in neuro-otology clinic.
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Typical example of computer and headgear equipment used in neuro-otology clinic.