Assessment of vestibular functions

Clinical tests Laboratory tests

A. SPONTANEOUS NYSTAGMUS A. CALORIC TEST
B. FISTULA TEST 1. Modified Kobrak test
C. ROMBERG TEST 2. Fitzgerald–Hallpike test
(bithermal caloric test)
D. GAIT
3. Cold-air caloric test.
E. PAST-POINTING AND
B. ELECTRONYSTAGMOGRAPHY
FALLING
C. OPTOKINETIC TEST
F. HALLPIKE MANOEUVRE
(POSITIONAL TEST) E. ROTATION TEST
G. TEST OF CEREBELLAR F. GALVANIC TEST
DYSFUNCTION G. POSTUROGRAPHY
 A. SPONTANEOUS NYSTAGMUS
 Nystagmus is an important sign in the evaluation of
vestibular system.
 It is defined as involuntary, rhythmical, oscillatory
movement of eyes.
 It may be horizontal, vertical or rotatory.
 Vestibular nystagmus has a slow and a fast component,
and by convention, the direction of nystagmus is
indicated by the direction of the fast component.
 Intensity of nystagmus is indicated by its degree
 To elicit nystagmus, patient is seated in front of the
examiner or lies supine on the bed.
 The examiner keeps his finger about 30 cm from the
patient’s eye in the central position and moves it to the right
or left, up or down, but not moving at any time more than
30° from the central position to avoid gaze nystagmus.
 Presence of spontaneous nystagmus always indicates an
organic lesion.
 Vestibular nystagmus is called peripheral, when it is due to
lesion of labyrinth or VIIIth nerve and central, when lesion
is in the central neural pathways (vestibular nuclei,
brainstem, cerebellum).
 Irritative lesions of the labyrinth (serous labyrinthitis) cause
nystagmus to the side of lesion.
 Paretic lesions (purulent labyrinthitis, trauma to labyrinth,
section of VIIIth nerve) cause nystagmus to the healthy
side.
 Nystagmus of peripheral origin can be suppressed by optic
fixation by looking at a fixed point, and enhanced in
darkness or by the use of Frenzel glasses (+20 dioptre
glasses) both of which abolish optic fixation.
 Nystagmus of central origin cannot be suppressed by optic
fixation.
 B. FISTULA TEST
 The basis of this test is to induce nystagmus by producing
pressure changes in the external canal which are then
transmitted to the labyrinth.
 Stimulation of labyrinth results in nystagmus and vertigo.
 The test is performed by applying intermittent pressure on
the tragus or by using Siegel’s speculum.
 Normally, the test is negative because the pressure changes
in the external auditory canal cannot be transmitted to the
labyrinth.
 It is positive when there is erosion of horizontal
semicircular canal as in cholesteatoma or a surgically
created window in the horizontal canal (fenestration
operation), abnormal opening in the oval window
(poststapedectomy fistula) or the round window
(rupture of round window membrane).
 A positive fistula also implies that the labyrinth is still
functioning; it is absent when labyrinth is dead.
 A false negative fistula test is also seen when
cholesteatoma covers the site of fistula and does not
allow pressure changes to be transmitted to the
labyrinth.
 A false positive fistula test (i.e. positive fistula test
without the presence of a fistula) is seen in Congenital
syphilis and in about 25% cases of Ménière’s disease
(Hennebert’s sign).
 In congenital syphilis, stapes footplate is hypermobile
while in Ménière’s disease it is due to the fibrous bands
connecting utricular macula to the stapes footplate. In
both these conditions, movements of stapes result in
stimulation of the utricular macula.
 C. ROMBERG TEST
 The patient is asked to stand with feet together and arms by the
side with eyes first open and then closed.
 With the eyes open, patient can still compensate the imbalance
but with eyes closed, vestibular system is at more disadvantage.
 In peripheral vestibular lesions, the patient sways to the side of
lesion.
 In central vestibular disorder, patient shows instability.
 If patient can perform this test without sway, “sharpened
Romberg test” is performed.
 In this the patient stands with one heel in front of toes and arms
folded across the chest.
 Inability to perform the sharpened Romberg test indicates
vestibular impairment.
 D. GAIT
 The patient is asked to walk along a straight line to a fixed
point, first with eyes open and then closed.
 In case of uncompensated lesion of peripheral vestibular
system, with eyes closed, the patient deviates to the
affected side.
 E. PAST-POINTING AND FALLING
 The past-pointing, falling and the slow component of
nystagmus are all in the same direction.
 If there is acute vestibular failure, say on the right side,
nystagmus is to the left but the past-pointing and falling
will be towards the right, i.e. towards side of the slow
component.
F. HALLPIKE MANOEUVRE
(POSITIONAL TEST)
 This test is particularly useful when patient complains
of vertigo in certain head positions.
 It also helps to differentiate a peripheral from a central
lesion.
 METHOD
 Patient sits on a couch. Examiner holds the patient’s
head, turns it 45° to the right and then places the patient
in a supine position so that his head hangs 30° below the
horizontal
 Patient’s eyes are observed for nystagmus.
 The test is repeated with head turned to left and then
again in straight head-hanging position.
 Four parameters of nystagmus are observed: latency,
duration, direction and fatiguability.
 In benign paroxysmal positional vertigo, nystagmus
appears after a latent period of 2–20 s, lasts for less than
a minute and is always in one direction, i.e. towards the
ear that is undermost.
 On repetition of the test, nystagmus may still be elicited
but lasts for a shorter period.
 On subsequent repetitions it disappears altogether, i.e.
nystagmus is fatiguable.
 Patient also complains of vertigo when the head is in
critical position.
 In central lesions nystagmus is produced immediately, as
soon as the head is in critical position without any latency
and lasts as long as head is in that critical position.
(tumours of IVth ventricle, cerebellum, temporal lobe,
multiple sclerosis, vertebrobasilar insufficiency or raised
intracranial tension)
 Direction of nystagmus also varies in different test
positions (direction changing) and is non-fatiguable on
repetition of test.
G. TEST OF CEREBELLAR DYSFUNCTION
 All cases of giddiness should be tested for cerebellar
disorders.
 Disease of the cerebellar hemisphere causes:
 1. Asynergia (abnormal finger-nose test)
 2. Dysmetria (inability to control range of motion)
 3. Adiadochokinesia (inability to perform rapid alternating
movements)
 4. Rebound phenomenon (inability to control movement of
extremity when opposing forceful restraint is suddenly
released)
Midline disease of cerebellum causes:
 1. Wide base gait
 2. Falling in any direction
 3. Inability to make sudden turns while walking
 4. Truncal ataxia

 Nystagmus observed in midline or hemispheral disorders of

cerebellum includes gaze evoked nystagmus, rebound
nystagmus and abnormal optokinetic nystagmus.
 A. CALORIC TEST
1. Modified Kobrak test
2. Fitzgerald–Hallpike test (bithermal caloric test)
3. Cold-air caloric test.

 The basis of this test is to induce nystagmus by thermal

stimulation of the vestibular system.
 Advantage of the test is that each labyrinth can be tested
separately.
 Patient is also asked whether vertigo induced by the caloric
test is qualitatively similar to the type experienced by him
during the episode of vertigo.
 If yes, it proves labyrinthine origin of vertigo.
 Modified Kobrak test
 It is a quick office procedure.
 Patient is seated with head tilted 60° backwards to place
horizontal canal in vertical position.
 Ear is irrigated with ice water for 60 s, first with 5 mL and if
there is no response, 10, 20 and 40 mL.
 Normally, nystagmus beating towards the opposite ear will
be seen with 5 mL of ice water.
 If response is seen with increased quantities of water
between 5 and 40 mL, labyrinth is considered hypoactive.
No response to 40mL of water indicates dead labyrinth.
 Fitzgerald–Hallpike test
(bithermal caloric test)
 In this test, patient lies supine with head tilted 30° forward so
that horizontal canal is vertical.
 Ears are irrigated for 40 s alternately with water at 30°C and at
44°C (i.e. 7° below and above normal body temperature) and eyes
observed for appearance of nystagmus till its end point.
 Time taken from the start of irrigation to the end point of
nystagmus is recorded and charted on a calorigram.
 If no nystagmus is elicited from any ear, test is repeated with
water at 20°C for 4 min before labelling the labyrinth dead. A gap
of 5 min should be allowed between two ears.
 Cold water induces nystagmus to opposite side and warm water
to the same side
 (remember mnemonic COWS: cold–opposite, warm–same).
 Depending on response to the caloric test, we can find
canal paresis or dead labyrinth, directional
preponderance, i.e. nystagmus is more in one
particular direction than in the other, or both canal
paresis and directional preponderance.
 Canal paresis
 It indicates that response (measured as duration of nystagmus)
elicited from a particular canal (labyrinth), right or left, after
stimulation with cold and warm water is less than that from the
opposite side. It can also be expressed as percentage of the total
response from both ears.

 where L30 is the response from left side with water at 30°C and
L44 is response from left ear after stimulation with warm water at
44°C. Less or no response from a particular side is indicative of
depressed function of the ipsilateral labyrinth, vestibular nerve
or vestibular nuclei and is seen in Ménière’s disease, acoustic
neuroma, postlabyrinthectomy or vestibular nerve section.
 Directional preponderance
 It takes into consideration the duration of nystagmus to the right
or left irrespective of whether it is elicited from the right or left
labyrinth.
 We know that right beating nystagmus is caused by L30 and R44
and left
 beating nystagmus is caused by R30 and L44. Therefore,

 If the nystagmus is 25–30% or more on one side than the other, it is

called directional preponderance to that side.
 It is believed that directional preponderance occurs towards the side of
a central lesion, away from the side in a peripheral lesion; however, it
does not help to localize the lesion in central vestibular pathways.
 Canal paresis and directional preponderance can also
be seen together.
 Canal paresis on one side with directional
preponderance to the opposite side is seen in
unilateral Ménière’s disease while canal paresis with
directional preponderance to ipsilateral side is seen in
acoustic neuroma.
Cold-air caloric test
 This test is done when there is perforation of tympanic
membrane because irrigation with water in such a case
with perforation is contraindicated.
 The test employs Dundas Grant tube, which is a coiled
copper tube wrapped in cloth.
 The air in the tube is cooled by pouring ethyl chloride
and then blown into the ear.
 It is only a rough qualitative test.
B. ELECTRONYSTAGMOGRAPHY
 It is a method of detecting and recording of
nystagmus, which is spontaneous or induced by
caloric, positional, rotational or optokinetic stimulus.
 The test depends on the presence of corneoretinal
potentials which are recorded by placing electrodes at
suitable places round the eyes.
 The test is also useful to detect nystagmus, which is
not seen with the naked eye.
 It also permits to keep a permanent record of
nystagmus.
C. OPTOKINETIC TEST
 Patient is asked to follow a series of vertical stripes on
a drum moving first from right to left and then from
left to right.
 Normally it produces nystagmus with slow component
in the direction of moving stripes and fast component
in the opposite direction.
 Optokinetic abnormalities are seen in brainstem and
cerebral hemisphere lesions.
 Thus this test is useful to diagnose a central lesion.
 E. ROTATION TEST
 Patient is seated in Barany’s revolving chair with his head tilted
30° forward and then rotated 10 turns in 20 s.
 The chair is stopped abruptly and nystagmus observed.
 Normally there is nystagmus for 25–40 s.
 The test is useful as it can be performed in cases of congenital
abnormalities where ear canal has failed to develop and it is not
possible to perform the caloric test.
 Disadvantage of the test is that both the labyrinths are
simultaneously stimulated during the rotation process and
cannot be tested individually.
 The test has now been made more sophisticated by the use of
torsion swings, electronystagmography and computer analysis of
the results.
F. GALVANIC TEST
 It is the only vestibular test which helps in
differentiating an end organ lesion from that of
vestibular nerve.
 Patient stands with his feet together, eyes closed and
arms outstretched and then a current of 1 mA is passed
to one ear.
 Normally, person sways towards the side of anodal
current.
 Body sway can be studied by a special platform.
G. POSTUROGRAPHY
 It is a method to evaluate vestibular function by measuring
postural stability and is based on the fact that
maintenance of posture depends on three sensory
inputs—visual, vestibular and somatosensory.
 It uses either a fixed or a moving platform.
 Visual cues can also be varied.
 The clinical application of posturography is still under
investigation.
 Final Thought
Tests are not infallible.
They are only as good as those taking,
administering and interpreting them…