47 years old, female , Italy
Development of symptoms of persistent vertigo since September 2008, for which the patient was evaluated on several occasions at the ENT department of the Pordenone hospital, for example:
- on September 2008: “otoscope examination negative, clinical signs of left vestibular deficit (II-III° nystagmus to the right, tonic deviation of the limbs to the left, Romberg's negative and Hallpike negative overall)" with instructions to take Plasil, Vertiserc and rest for several days;
- on September 2008: “evidence of rapid III° nystagmus to the right, unsteady gait, no clear tonic deviations. Finger-nose test and heel-knee test: negative. Mingazzini I: negative. No signs of cranial nerve deficits. Diagnosis of peripheral Vertigo” with instructions to rest with the use of levosulpiride 25 mg x 3 in consideration of the ineffectiveness of the other drugs taken.
- On September 2008: ENT re-evaluation: “ II° - III° spontaneous nystagmus to the right persists, Head thrust test positive to the left, gait still unsteady with deviation to the right. Suggestion: CT scan of the brain.” CT scan of the brain: within normal limits in relation to age, ventricular system and subarachnoid cavity. No particular supra and subtentorial sensitometric alterations are determined. Midline structures aligned.
- On September 2008: “left peripheral vestibular deficit persists, with initial signs of compensation (no more gait deviations with eyes closed, II° spontaneous nystagmus to the right and positive head thrust test to the left persist). Vestibulo-ocular reflex rehabilitation exercises are assigned (rotation of the head with visual fixation for 1? – 2? Several times a day)”. On October 2008: “at the current check-up PPV (Paroxysmal Positional Vertigo) of the left PSC (posterior semicircular canal). The Epley maneuver is performed to the right.”
- On November 2009, specialist visit “Findings are negative. The audiometric exam shows a minimal neurosensory component for acute tones to the left and the head shaking test is clearly positive for nystagmus to the right. This finding is compatible with left peripheral vestibular deficit, probably ascribable (based on clinical history) to viral labyrinthitis. The persistence of symptoms can be attributed to the fact that the vestibular deficit is unstable and therefore establishment of compensation is delayed. Today I do not detect paroxysmal positional vertigo, for which reason I am not performing any maneuvers. I advise performing auditory brainstem response (ABR) and MRI scan of the brain with contrast medium. I suggest resuming treatment with microsr 24 mg 1 tablet 2 times a day for 30 days. I also advise paying attention to posture in the workplace and ruling out any accompanying head and neck disturbance components.”
- ABR of December 2008: “bilateral traces negative for retrocochlear pathological conditions.”
- Audiometric exam dated October 2008: “ minor neurosensory deafness more noticeable on the left side at around 1000 Hz, pantonal.”
- MRI of the brain and brainstem with and without contrast medium of December 2008: “CSF spaces of normal width. No signs of masses. Median structures in axis. No supra and subtentorial parenchymal sign alterations or pathological permeation foci after contrast. Regular appearance of the acoustic nerves; no expansive formations are seen in their proximity."
- Follow-up visit on January 2009: “left posterior vestibular deficit persists. Cracking with passive movement of the head. I advise cervical spine x-ray and rehabilitation physician visit to exclude possible muscle tension component. Vestibular adaptation exercises are given.”