Literature Reading

Vestibuloocular Reflex
(VOR) & Vestibulospinal
Reflex (VSR)
Presentant: Alfira Ulfa, dr
Supervisor: : Dr. dr. Wijana, Sp. T.H.T.K.L (K), FICS

DEPARTMENT OF OTORHINOLARYNGOLOGY-HEAD & NECK SURGERY

FACULTY OF MEDICINE PADJADJARAN UNIVERSITY-HASAN SADIKIN GENERAL HOSPITAL
BANDUNG
2019
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Introduction
Visual
Somatosensory /
Vestibular proprioceptive
systems

Balance

Kelly Tremblay. The Nature of Hearing in Clinical Audology and Introduction. 2n d edition. Delmar. New York. 2010 2
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PERIPHERAL VESTIBULAR
SYSTEM

Semicircular canals Otolithic organs

(superior, lateral, and posterior) (saccule and utricle)

angular accelerations linear accelerations

3 Medical publishers, Inc., New York. 2006

John Carey. Vestibular System Physiology in Otolaryngology. Thieme
CENTRAL VESTIBULAR
SYSTEM

4
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Medial VN 
Schwalbe

Superior VN 
4 main VN Bechterew
within
brainstem Lateral VN 
Deiter

Inferior VN 
Descending

Katz, J., Burkard, R. F., & Medwetsky, L. Handbook of clinical audiology (5th ed.). Philadelphia: Lippincott Williams & Wilkins.2002
Khan S, Chang R. Anatomy of the vestibular system : A review. 2013;32:437–43.
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1. VESTIBULAR NUCLEI
1. Medial VN  makes medial column
• Mediates VOR
Afferent: lateral SCC  ascends medial longitudinal fasciculus  motor
nuclei EOM
• Controlling VSR
via bilateral descending projections in medial vestibulospinal tract  to
cervical spinal cord  to allow for the coordination of head and neck
motion

2. Superior VN  makes lateral column

• Coordinate VOR
Afferent: superior & posterior SCC  ascends medial longitudinal
fasciculus  motor nuclei EOM

Khan S, Chang R. Anatomy of the vestibular system : A review. 2013;32:437–43.

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1. VESTIBULAR NUCLEI
3. Lateral VN  makes lateral column

• Functions in VSR
Afferent: crista ampulla, maculae, and the vestibulocerebellum
• Efferent: lateral vestibular tract ipsilateral spinal cord
• by coordinating  reflexive tone in trunk muscles and proximal extensors
of limbs
• to maintain posture and balance

4. Inferior VN  makes lateral column

• Afferent: maculae of both utricule and saccule

• Projection  go to the other three vestibular nuclei and to the cerebellum

Khan S, Chang R. Anatomy of the vestibular system : A review. 2013;32:437–43.

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Katz, J., Burkard, R. F., & Medwetsky, L. Handbook of clinicalaudiology (5th ed.). Philadelphia: Lippincott Williams & Wilkins.2002
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VESTIBULAR NUCLEI
Primary input  vestibular portion of cranial
nerve VIII

Other inputs  visual and proprioceptive

Outputs 3 pathways 

• Medial Vestibulospinal Tract (MVST),

• Lateral Vestibulospinal Tract (LVST),
• The Reticulospinal Pathway

Output projection to 

• contralateral VN,
• ipsilateral and contralateral abducens,
• trochlear nuclei, and
• oculomotor nuclei
• the motor spinal cord

Katz, J., Burkard, R. F., & Medwetsky, L. Handbook of clinical audiology (5th ed.). Philadelphia: Lippincott Williams & Wilkins.2002
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for perception
Cerebral cortex
of motion

VN also sends to coordinate

projection to compensatory
eye and head
movements
Cerebellum
and postural
changes

Katz, J., Burkard, R. F., & Medwetsky, L. Handbook of clinical audiology (5th ed.). Philadelphia: Lippincott Williams & Wilkins.2002
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2. CEREBELLUM

VESTIBUL
EFFERENT
OCEREBE
=
AFFERENT LLAR
= NUCLEI=
extends terminates
from the on the
from medial flocculus,
vermis, lateral VN.
& inferior nodulus,
flocculus,
VN uvula, and
and fastigial
fastigial
nuclei
nucleus

Katz, J., Burkard, R. F., & Medwetsky, L. Handbook of clinical audiology (5th ed.). Philadelphia: Lippincott Williams & Wilkins.2002
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2. Cerebellar nodulus
1. Cerebellar flocculus  adjusts duration of the
 adjusts the gain of the VOR and  involved in

‘’
VOR processing afferent
activity from maculae
The
Vestibulo- 3. Anterior superior
vermis  regulating the
cerebellum VSR  by encoding
composed of the
flocconodular lobe and
vestibular signals and
the vermian cortex proprioceptive input from
axial muscles

Khan S, Chang R. Anatomy of the vestibular system : A review. 2013;32:437–43.

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‘’

VERMIS
Lateral

The Cerebellum

Vestibulo-
cerebellum Nodulus
Floculus

composed of the
flocconodular lobe and
the vermian cortex

Khan S, Chang R. Anatomy of the vestibular system : A review. 2013;32:437–43.

  monitors vestibular 14
Role of the cerebellum performance  readjust
 functions as adaptive vestibular input 
processor through inhibitory input
as necessary

The
Vestibulo-
‘’ Ipsilateral cerebellum 
send efferent information
to bilateral vestibular
nuclei 
1. Projection fibers
directly to  2.
Ipsilateral vestibular
nuclei and to  3.
Ipsilateral fastigial
nucleus

cerebellum
composed of the The juxarestiform body
flocconodular lobe and Fastigial nucleus project  role in the generation
the vermian cortex to  4. Contralateral of postural reflexes
vestibular nuclei via  and orienting
behaviors

Khan S, Chang R. Anatomy of the vestibular system : A review. 2013;32:437–43.

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Cortex Area Complex

cortical -
 not clearly
vestibular
understood
connectio
ns
Thalamus
• ascending vestibular fibers
make connections in  Main area 
ventral posterior nucleus of In studies
parietoinsular
thalamus  prior to vestbular cortex
of
reaching the cortex primates
(PIVC)

Hippocampus  most likely in or

Studies near the parietal or
• play a critical role in the of insular cortex
processing of spatial humans  “temporo-peri-
orientation and spatial sylvian vestibular
memory cortex”
corresponds to
PIVC
Khan S, Chang R. Anatomy of the vestibular system : A review. 2013;32:437–43.
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Vestibular Reflex
Vestibuloocular reflex (VOR)
• generates eye movements that enable clear vision while the head is in
motion
Vestibulocollic reflex (VCR)
• acts on the neck musculature to stabilize the head

Vestibulospinal reflex (VSR)

• generates compensatory body movement in order to maintain head
and postural stability and thereby prevent falls
Timothy CH, Janet OH. Anatomy and Physiology of the Normal Vestibular System in Vestibular Rehabilitation. 3 rd edition. F. A. Davis
16
Company. Philadelphia 2007
VOR
Vestibuloocular
Reflex

17
 Function of VOR
VOR contributes to ocular stability when the head is in
motion

coordinates eye movement in order to stabilize retinal

images during head rotation

Effector organs of VOR  Extraocular Muscles

Katz, J., Burkard, R. F., & Medwetsky, L. Handbook of clinical audiology (5th ed.). Philadelphia: Lippincott Williams & Wilkins.2002
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Khan S, Chang R. Anatomy of the vestibular system : A review. 2013;32:437–43.
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Angular Rotation
from the resting
Head turns  The subsequent
level of the afferent
increases or
movement of the decreases in
fibers signal to the
endolymph brain that the head
discharge rate
is moving

Deflection of the Activating synapses

cupula  bend the between the hair
stereocilia and cells and  afferent
kinocilia of the hair nerve fibers in the
cells vestibular CN VIII

Ion channels at the

tips of stereocilia 
Raise or lower the
open or close 
resting potential of
generating K+ and
the hair cells
Ca++ currents in the
hair cells
Bernard Cohen , Theodore Raphan. The Physiology of the Vestibuloocular Reflex (VOR) in The Vestibular System. Springer.
19
NewYork. 2004
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For Instance
Head turns to the right

endolymph flow in ampulla of SCC  deflect

the cupula to the left

This causes depolarization of the hair cells on

the right

and hyperpolarization of the left hair cells

Khan S, Chang R. Anatomy of the vestibular system : A review. 2013;32:437–43.

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For Instance
results  increase firing frequency in afferent
fibers of right VN

impulses sent to  ipsilateral superior and

medial VN and cerebellum

Excitatory impulses  transmitted in medial

longitudinal fasciculus  to right oculomotor
nuclei

Khan S, Chang R. Anatomy of the vestibular system : A review. 2013;32:437–43.

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For Instance
and in the ascending tract of Deiters  to
the left abducens nuclei

This results  ipsilateral medial rectus and

contralateral lateral rectus contraction

which produces eye movement to the left

(opposite to head turning)

Khan S, Chang R. Anatomy of the vestibular system : A review. 2013;32:437–43.

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 VOR related to oVEMP 26

oVEMPs evaluate  functional integrity of utricle and superior branch of the vestibular
nerve

The non-invasive oVEMP test can quantitatively measure the VOR system 
essentially by “sound-evoked VOR”

A brief intense 110 dB nHL (normalized hearing level) click  delivered in the affected
ear  evokes a vertical upward and contraversive (ie. the upper pole of the eye torting
away from the stimulus) torsional eye movement in the plane of the affected canal.

OVEMP is not an electro retinal potential. Instead, it represents part of the muscle
action potential that leads to sound-evoked eye movement conducted by VOR

Welgampola, M. S., Migliaccio, A. A., Myrie, O. A., Minor, L. B., & Carey, J. P. (2009). The human sound-evoked vestibulo-ocular
reflex and its electromyographic correlate. Clinical Neurophysiology, 120(1), 158–166. doi:10.1016/j.clinph.2008.06.020
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VSR
Vestibulospinal
Reflex

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 Function of VSR
31

to produce transitory contractions of muscles

to maintain posture, equilibrium during movement,

and muscular tone

Effector organs of VSR  the extensors of the neck,

trunk, and extremities

Katz, J., Burkard, R. F., & Medwetsky, L. Handbook of clinical audiology (5th ed.). Philadelphia: Lippincott Williams & Wilkins.2002
 Function of VSR
32

VSR requires  coordinated action of both extensor and flexor

muscles to respond to postural disturbances

Afferent: this reflex integrates many complex connections 

integrate input from macula, crista ampullaris, visual system, and axial & limb
muscles
•  by the brainstem and cerebellum

Katz, J., Burkard, R. F., & Medwetsky, L. Handbook of clinical audiology (5th ed.). Philadelphia: Lippincott Williams & Wilkins.2002
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Direct connections  to
neck motorneurons
MVST

‘’
Indirect connections 
through spinal interneurons

Direct connections  to
Connection VN to neck motorneurons
spinal cord LVST
Indirect connections 
through spinal interneurons

Indirect connections 
Reticulospinal
through the reticular
Tract
formation

Katz, J., Burkard, R. F., & Medwetsky, L. Handbook of clinical audiology (5th ed.). Philadelphia: Lippincott Williams & Wilkins.2002
 Medial Vestibulospinal Tract 35

Input from  both saccule (dominant)

& utricle via medial VN

Other input  lateral and superior

SCCs

MVST pathway descends bilaterally

 through MLF into spinal cord

Katz, J., Burkard, R. F., & Medwetsky, L. Handbook of clinical audiology (5th ed.). Philadelphia: Lippincott Williams & Wilkins.2002
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Angular rotation of the head  sensed by SCC

transmitted to the medial VN

where the MVST originates

This tract projects bilaterally to motor neurons in the cervical spinal

cord

It activates  cervical axial muscles that coordinate head and

neck motion

Khan S, Chang R. Anatomy of the vestibular system : A review. 2013;32:437–43.

 Lateral Vestibulospinal Tract 37

Input from  from the utricle and posterior SCC 

via lateral VN

LVST descends into  ipsilateral central funiculus of

spinal cord

LVST results  activation of extensor motor neurons and

inhibition of flexor neurons  in the upper and lower extremities

Katz, J., Burkard, R. F., & Medwetsky, L. Handbook of clinical audiology (5th ed.). Philadelphia: Lippincott Williams & Wilkins.2002
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Main pathway  lateral vestibular spinal tracts

 originates in the lateral vestibular nucleus

Efferent: projects ipsilaterally in the spinal

cord to neurons of all spinal levels

It produces  monosynaptic activation of

ipsilateral trunk and proximal limb extensors

 and disynaptic inhibition of contralateral

proximal extensors

Khan S, Chang R. Anatomy of the vestibular system : A review. 2013;32:437–43.

VCR
Vestibulocollic
Reflex

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 VCR 40

is part of the VSR

is the focus of most clinical vestibular testing  cVEMP

cVEMP measures  the inhibition of the flexor motor

neurons  through a skin electrode over the
sternocleidomastoid muscle (SCM)

Katz, J., Burkard, R. F., & Medwetsky, L. Handbook of clinical audiology (5th ed.). Philadelphia: Lippincott Williams & Wilkins.2002
 VCR Pathway 41

Saccule sends an through the inferior to the medial

electrical signal vestibular nerve vestibular nucleus

signal is sent to the Results  increase  inhibition of flexor

spinal cord motor ipsilateral activation motor neurons in
neurons  via the of extensor motor neck and cervical
MVST neurons region

Katz, J., Burkard, R. F., & Medwetsky, L. Handbook of clinical audiology (5th ed.). Philadelphia: Lippincott Williams & Wilkins.2002
 Examination procedure for ocular motor and
vestibular systems
Type of examination Question
Inspection
Head, body, and posture Tilt or turn of head/body
Position of eyelids Ptosis
Eye position/motility Misalignment in primary position, spontaneous or
Position of eyes during straight-ahead gaze fixation nystagmus
Cover test Horizontal or vertical misalignment
Examination of eyes in 8 positions (binocular and Determination of extent of motility, gaze-evoked
monocular) nystagmus, end-position
nystagmus
Gaze-holding function: after 10–408 in the horizontal or Gaze-evoked nystagmus: horizontal and vertical,
10–208 in the rebound nystagmus
vertical and back to 08
Smooth pursuit movements: horizontal and vertical Smooth or saccadic
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Type of examination Question

Saccades: horizontal and vertical when looking around or Latency, velocity, accuracy, conjugacy
at targets

Optokinetic nystagmus (OKN): horizontal and vertical with Inducible, direction, phase (reversal or monocularly
OKN diagonal)
drum or tape

Peripheral vestibular function: clinical testing of the VOR Unilateral or bilateral, peripheral vestibular
(Halmagyi– Curthoys test): (semicircular canal) deficit
rapid turning of the head and fixation of a stationary target

Fixation suppression of the VOR:

turn of head and fixation of a target
moving at same speed Failure of fixation suppression

Examination with Frenzel’s glasses:

Straight-ahead gaze, to the right, to the left, downward,
and upward Spontaneous nystagmus
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Type of examination Question

Head-shaking test Provocation-induced nystagmus

Positioning and positional maneuver (with Frenzel’s Peripheral positional or positioning nystagmus, central
glasses): positional
to the right, left, head-hanging position, turning about nystagmus
the cephalocaudal axis

Posture and balance control:

Romberg’s test and simple and difficult posture and gait
tests:

Open-closed eyes Instability, tendency to fall

With/without reclining the head

With/without distraction (writing numbers on the skin,

doing maths Psychogenic/functional components
mentally)
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 Measurement
of head tilt
An abnormal head posture to the right or
left shoulder or a constant, abnormal tilt is
especially observed in patients
with
(a) paresis of the oblique eye muscles, e.g. in
superior oblique palsy,
the head is turned to the non-affected side to
lessen diplopia, or
(b) An ocular tilt reaction due to a vestibular tonus
imbalance of the VOR in roll.

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 Examination should include
spontaneous and gaze-evoked
nystagmus, head-shaking nystagmus
(either the examiner turns the subject’s
head or the patient is instructed to

‘’
quickly turn his head to the right and to
the left about 20–30 times; the eye
movements are observed after head
shaking), positioning and positional
nystagmus, as well as hyperventilation-
induced nystagmus

Clinical
examination
with
Frenzel’s
glasses
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Head-impulse Test
To test the horizontal VOR, the
examiner holds the patient’s
head between both hands,asks
him to fixate a target in front of
his eyes, and rapidly and
arbitrarily turns the patient’s
head horizontally to the left
and then to the right. This
rotation of the head in a
healthy subject causes rapid
compensatory eye movements
in the opposite direction

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 Positioning/
positional
maneuvers
so-called Dix-Hallpike maneuver is performed to determine
whether benign paroxysmal positioning vertigo (BPPV) is present. While
the patient is sitting, his head is turned by 458 to one side, and then he is
rapidly put in a supine position with head hanging over the end of the
examination couch 48
Electronystagmography
(ENG)
(a) Placement of the electrodes for monocular recording of
horizontal and vertical eye movements. The electrophysiological
basis of the ENG is the corneo-retinal dipole (a potential difference
of about 1 mV).

(b) Rotatory chair and rotatory drum (with vertical stripes) with an
apparatus that projects a laser spot (above the patient). This setup
allows recordings of eye movements under static conditions (e.g.
test for spontaneous or gaze-evoked nystagmus, saccades,
pursuit, and optokinetic nystagmus) and under dynamic conditions
(per- and postrotatory nystagmus, fixation suppression of the
vestibulo-ocular reflex), as well as positional and positioning
testing and caloric irrigation.

(c) Caloric testing by electronystagmography. By means of caloric testing,

the excitability of the individual horizontal canals can be determined and
thus whether or not they are functioning. After excluding the possibility of
a lesion of the eardrum, the head of the patient is tilted 308 upward, so
that the horizontal semicircular canals approach the vertical plane. This
allows optimal caloric stimulation. The outer auditory canals on each side
are separately irrigated under standard conditions with 30 8C cool and 44
8C warm water 49
 Video-oculography

‘’ ▣
▣
▣
Another non-invasive method
The eyes are first filmed by one or two video cameras
Then a computer analysis of the image of movements
of the pupils and light reflexes is performed to
represent the eye movements in two dimensions

performed with a mask attached to the head in which a camera is

integrated. An infrared headlight built into the mask also allows
measurement of eye movements in complete darkness 50
can be used to make photographs of the fundus of the eye

The rolling of the eye or eye torsion can be measured in

degrees on the fundus photographs as the angle between
the horizontal and the so-called papillofoveal meridian

Scanning Laser
Ophthalmoscope

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CONCLUSIONS
The vestibular system is a complex sensory organization which involves the communication between the peripheral
vestibular apparatus, the ocular system, postural muscles, the brainstem, cerebellum and the cortex.

Information is processed by vestibular centers in the brain to allow the body to maintain balance and proper
spatial orientation during movement, as well as the correct processing of visual images during motion.

The vestibuloocular reflex coordinates eye movement in order to stabilize retinal images during head rotation.
It involves a three neuron reflex arc from the semicircular ducts to the vestibular nuclei and then to the
extraocular muscles to cause conjugate eye motion in a direction opposite to head turning

The vestibulospinal reflex involves many complex connections which integrate input from the macula, crista
ampullaris, visual system, and axial and limb muscles by the brainstem, and cerebellum in order for the
maintenance of posture and balance.

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THANK YOU

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