Nystagmus is a rhythmic movement of the eyes that can have various causes. Vestibular disorders can result in nystagmus because the vestibular system and the oculomotor nuclei are interconnected. The presence of vestibular nystagmus helps identify vestibular disorders and sometimes distinguishes central from peripheral vertigo. Vestibular nystagmus has a slow component caused by the vestibular input and a quick, corrective component that causes movement in the opposite direction. The direction of the nystagmus is defined by the direction of the quick component because it is easier to see. Nystagmus may be rotary, vertical, or horizontal and may occur spontaneously, with gaze, or with head motion.

Initial inspection for nystagmus is done with the patient lying supine with unfocused gaze (+30 diopter or Frenzel lenses can be used to prevent gaze fixation). The patient is then slowly rotated to a left and then to a right lateral position. The direction and duration of nystagmus are noted. If nystagmus is not detected, then the Dix-Hallpike (or Barany) maneuver is performed. In this maneuver, the patient sits erect on a stretcher so that when lying back, the head extends beyond the end. With support, the patient is rapidly lowered to horizontal, and the head is extended back 45° below horizontal and rotated 45° to the left. Direction and duration of nystagmus and development of vertigo are noted. The patient is returned to an upright position, and the maneuver is repeated with rotation to the right. Any position or maneuver that causes nystagmus should be repeated to see if it fatigues.

Nystagmus secondary to peripheral nervous system disorders has a latency period of 3 to 10 sec and fatigues rapidly, whereas nystagmus secondary to CNS causes has no latency period and does not fatigue. During induced nystagmus, the patient is instructed to focus on an object. Nystagmus from peripheral disorders is inhibited by visual fixation. Because Frenzel lenses prevent visual fixation, they must be removed to assess visual fixation.

Caloric stimulation of the ear canal induces nystagmus in a person with an intact vestibular system. Failure to induce nystagmus or > 20% difference in duration between sides suggests a lesion on the side of the decreased response. Quantification of caloric response is best done with formal (computerized) electronystagmography. Ability of the vestibular system to respond to peripheral stimulation can be assessed at the bedside. Care should be taken not to irrigate an ear with a known tympanic membrane perforation or chronic infection. With the patient supine and the head elevated 30°, each ear is irrigated sequentially with 3 mL of ice water. Alternatively, 240 mL of warm water (40 to 44°C) may be used, taking care not to burn the patient with overly hot water. Cold water produces nystagmus to the opposite side; warm water produces nystagmus to the same side. A mnemonic device is COWS (Cold to the Opposite and Warm to the Same).