An Approach to

vertiginous patient
and Role of Vestibular
Tests

Dr. Anurag Srivastava

Astt Prof. & Consultant
Deptt Of ENT and Head & Neck Surgery
Sri Aurobindo Medical College & PGI Indore
52 year old female with hypertension is referred to the clinic for
dizziness. Patient reports that she gets dizzy spells several
times per week.

These spells last seconds, and she describes the episodes as

feeling like the room is spinning around her. The dizziness
seems to be brought on by changes in position, specifically
turning her head to the right or rolling over in bed to her right
side. The dizzy spells seem to resolve on their own after
several seconds.

No associated neurologic symptoms.

Patient denies hearing loss, otalgia, otorrhea, aural fullness,
tinnitus.

No noise exposure, ear trauma, prior ear surgery, or family

history of hearing loss.

What is your differential diagnosis?

Neuro Otological

Consensus & Algorithm ……..

Needed !
 “I’m Dizzy”
 Non-specific term
 Vertigo and psychiatric causes make up the
majority of cases seen in clinic setting (55-
70%)
 Multicausal, presyncope, unknown,
hyperventilation
 Presyncope
 Prodromal symptom of fainting

 Usually occurs when patient is standing or

upright, not supine

 Orthostatic hypotension, cardiac arrhythmias,

vasovagal attacks most common
 Vertigo vs. presyncope
 Positional vertigo and postural presyncope
often confused

 Both can occur when someone goes from

sitting to standing
 Vertigo
 Illusion of motion
 Self-motion
 Motion of the surrouding environment
 “spinning”, “tilting”, “moving”
 All vertigo is made worse by moving the head.

 An Illusion of motion implying a disorder of the vestibular

system, either the peripheral labyrinth or its central
connections
 The History…
 Patient description (“spinning” sensation,
however is non-specific)
 Time course
 Vertigo is rarely described as continuous.
 Hearing loss? If so, duration and
progression, unilateral vs. bilateral, tinnitus,
sx of ear
High yield historical questions
 Subjective description, avoid leading
questions
 Duration/frequency of symptoms
 Triggering factors
 Associated nausea/vomiting?
 Hearing loss or tinnitus?
 Any other neurological complaints
 Recent viral illness, fever, systemic
symptoms?
 New medications?
 Peripheral causes
Hx Duration Associated Physical
symptoms
Vestibular Single prolonged Days Nausea, imbalance Peripheral
neuritis/labyri episode nystagmus, +
nthitis head thrust,
imbalance
BPV Positionally < 1 min Nausea, ask for history Positionally
triggered episodes of trauma triggered burst of
nystagmus
Ménière May be triggered hours Unilateral ear fullness, Unilateral low
disease by salty food tinnitus, hearing loss, frequency
nausea hearing loss
Vestibular Abrupt onset, spont seconds Tinnitus, hearing loss normal
paroxysmia or positionally
triggered

Perilymphatic Triggered by sound seconds Hearing loss, Nystagmus with

fistula or pressure change hyperacusis, ask for change in
or physical strain history of trauma pressure
 Central Causes
Hx Duration Associated Physical exam
symptoms
Stroke/Tia Abrupt onset >24hrs vs Brainstem, Central nystagmus, focal
minutes cerebellar neuro signs
Multiple Subacute Min-wks Unilateral Central, peripheral or
sclerosis onset vision loss, positional nystagmus
diplopia
ataxia
Neurodegen Spontaneous Min-hours ataxia Central/ peripheral
erative or positionally nystagmus, cerebellar,
disorder triggered extrapyramidal, frontal signs
Basilar Onset with Seconds Headache, Peripheral/ central/ positional
migraine typical to days visual aura, nystagmus
migraine photo/phonop
triggers hobia
Familial Acute- hours ataxia Central/ positional
ataxia subacute,
syndromes episodic type
with stress,
exercise
 On Exam:
 Postural vitals
 General physical exam
 General neuro exam
 Neuro-otological exam
 Neuro-otological Exam
 Ocular motor function testing
 Look for spontaneous nystagmus or saccadic intrusions
 Nystagmus suggests that the dizziness is vertigo

 Gaze testing
 Look for gaze-evoked nystagmus
 Normal to have non-sustained nystagmus with gaze
greater than 30 degrees
 Vertical nystagmus that increases with lateral gaze
localizes to craniocervical junction and midline cerebellum
Nystagmus – Diagnostics
 Nystagmus
Feature Central Peripheral

Latency none 2-15 sec

Duration > 30 sec 5-30 sec

Fatiguability +/- ++

Vertigo Usually absent Usually present

Fixation No suppression suppression

Direction Vertical or horizontal, Unidirectional,

direction may change Horizontal or rotatory,
with head position fast phase toward
normal ear, increased
with gaze in direction of
fast phase
Types of Nystagmus
 Neuro-otological Exam

 Smooth pursuit
 Voluntary mvt of of the eyes used to track
a target moving at a low velocity
 Look for saccadic pursuit
 May occur with early/mild cerebellar
degenerative disorders as the only finding
with minimal ataxia
 Neuro-otological Exam
 Saccades
 Fast eye mvts used to quickly bring the image of an object
on the fovea
 Shift gaze from one object to another under voluntary
control
Interpretation :
 Slowing of saccades = lesion in pons/midbrain,
oculomotor neuron or extra-ocular muscles
 Overshooting saccades = ocular dysmetria, sign of
cerebellar lesion
 Undershooting saccades less specific and occur in normal
people
 Neuro-otological Exam
 Optokinetic nystagmus

 Combination of fast saccadic and slow smooth pursuit

observed in people observing a moving object.

 Patients with severe slowing of saccades will not be able to

generate OKN and will have their eyes pinned on one side
 Vestibular nerve exam
 Head thrust test

 When quickly unpredictably turn head of patient by 30

degree on side, eyes will go on opposite direction (vestibulo-
ocular reflex) to continue to fixate target.
 Abnormal vestibulo-ocular reflex if observe corrective
saccade bringing eyes back to target after head thrust
 Sensitivity 71% and specificity 82%
 Positional testing
 Dix-Hall-Pike
 Burst of upbeat, torsional nystagmus triggered in patients
with BPPV by rapid change from erect sitting to supine
head-hanging right or left

 Epley maneuvre
 More than 80% effective in treating patients with posterior
canal BPPV
 Auditory examination
 Otoscopy

 Whisper test (stand behind to prevent lip reading and

occlude/mask the non-tested ear by finger rub or occluding
external auditory canal)
 Whisper 3-6 numbers or letters
 Normal if can repeat 50%
 Weber: lateralizes to ipsi conductive impairment or
contralateral sensorineural

 Rinne: if bone conduction > air conduction = ipsi conductive

hearing loss
 Common Audiometric Findings in Selected
Disorders Causing Dizziness

◆ Ménière disease: unilateral low-frequency

sensorineural loss at the onset of disease

◆ Vestibular schwannoma: unilateral progressive high-

frequency sensorineural loss

◆ Superior canal dehiscence (conductive hyperacusis):

bone conduction better than air conduction at 500 H
 Diagnostic matrix

Episodic Vestibular
vertigo crisis

Hearing loss - Meniere’s

- Perilymph Labyrinthitis
present fistula

Hearing loss
BPPV Vestibular
absent
neuronitis

28
 Pneumatic Otoscopy

 Positive and negative pressure applied to middle

ear.
 Hennebert’s sign/symptom ––nystagmus and
vertigo with pressure, alternates with positive and
negative pressure.

 Can be present - perilymphatic fistula, syphilis,

Meniere’s disease, SCC dehiscence syndrome.
 Warning signs
 Suggestions of central vestibular
disease or brainstem lesions
 Persistent vertigo
 Ataxia
 Nausea/vomiting
 Headache
 Vision loss, diplopia
 Slurred speech
 Nystagmus due to Central Acute
Vestibular Syndrome
 Change direction
 Not altered by visual fixation
(Failure of suppression of the VOR by
fixation)
 Impaired saccades and smooth pursuit
 Bilateral Peripheral Vestibulopathy
 Positive bilateral head thrust test
 “Negative” Romberg test
 “Vestibular ataxia”
 Ototoxicity, idiopathic, presbistasis,
autoimmune disease of the inner ear

Treatment: Vestibular rehabilitation

 Bilateral Peripheral Vestibulopathy
 Bilateral vestibular hypofunction (BVH) heterogeneous
condition results from defects - vestibular organs, eighth
cranial nerves, or a combination of the two.

 Impairments - vestibulo-ocular reflex (VOR) and the

major functions of the vestibular organs

BVH has four clinical subtypes:

1. Recurrent vertigo and BVH
2. Rapidly progressive BVH
3. Slowly progressive BVH
4. BVH with neurological deficits
 Bilateral Peripheral Vestibulopathy
 Vestibular tests performed to help
diagnose BVH:

• Caloric Test
• Rotatory Chair Test
• Head Impulse Test (HIT)
• Vesitbular-Evoked Myogenic Potentials
(VEMP)Dynamic Visual Acuity Test (DVA)
 Romberg Test

 Patient asked to stand with feet together and

eyes closed.
 Fall or step is positive test.
 Equal sway with eyes open and closed
suggests proprioceptive or cerebellar site
 More sway with eyes closed suggests
vestibular weakness.
 FUKUDA TEST
Measurements of vestibulospinal function

March – 30 secs

Calibrated Mat - Angle Of Rotation

Crude Test but Indicative despite variations

 Head Shake Test
 Evaluates unilateral vestibular weakness.
 Head tilted back 30 degrees
 Shake back and forth for 30 seconds as quickly as
possible.
 Unilateral vestibular deficit causes slow phase
nystagmus to the side of lesion.
 Low sensitivity (27%)
 Good specificity (85%)
 Head Thrust /Impulse Test
 Inhibitory response not as robust as the stimulatory
response to stimulate VOR.
 Movements that overcome the inhibitory response of
vestibule - result in VOR lag

 Head tilted 30 degrees

 Rapid head movements to either side with focus on
examiner’s nose.
 Patients have catch-up saccade when rotated to side of
weakness
 Sensitivity 75%, Specificity of 85%
 Dynamic Visual Acuity
 Used for bilateral vestibular weakness.

 Visual acuity checked on Snellen chart.

 Rechecked while rotating head back
and forth at 1-2 Hz.
 Loss of 2-3 lines considered abnormal
 Cerebellar Examination
 Coordinates Range, velocity and strength of contractions to
produce steady volitional movements and steady volitional
postures.

 Incoordination (ataxia) - main feature.

Easy way
Imagine a Drunken person
- cannot coordinate any volitional movement.
- Sways when standing, Reels when walking
- Slurs words when talking, Jerky eye movements when looking.
 Cerebellar examination
 Ataxia, Dysarthria, Nystagmus and Hypotonia -
Four major clinical signs of the cerebellar syndrome.

 Incoordinated speech - Dysartrhia.

 Oscillations eye movements - nystagmus.
 Floppiness of the extremities is – Hypotonia.
 Cerebellar examination
Clinical examination for Arm ataxia
 Finger-to-nose test: Inspect for intention or ataxic
tremor, accuracy to reach the nose. Patient
undershoots or overshoots the target because of
incoordination of agonist- antagonist muscles, called
dysmetria.

 The rapid alternating movements tests (for

dysdiadochokinesia)
 Cerebellar examination
 Clinical examination for leg ataxia
 The heel to shin test
 The heel-tapping test

 Clinical examination for hypotonia

 Pendulous or hypotonic muscle stretch reflexes
 “Titubation”: a rhythmic “nodding” tremor of the head

 Clinical examination for postural or position

“overshooting”
 The arm-pulling test
 Tandem Gait Test
 Patients are asked to walk heal to toe in a straight
line or in a circles
 Complex function evaluates many aspects of balance
 Poor performance seen in cerebellar lesions, but can
be seen in many disorders.
 Poor sensitivity and specificity.
 Cerebellar Eye movements
abnormalities
 Incoordination of different eye movements :
Jerky or saccadic rather than smooth pursuit, slowness in initiating
eye movements - ocular dysmetria

 Different types of nystagmus reflecting

vestibulocerebellum dysfunction:
 Gaze evoked nystagmus - change direction in accordance to
gaze direction).
 “rebound nystagmus”
 Downbeat nystagmus, opsoclonus and ocular flutter
 Quantitative Vestibular
Testing
 When -
 Diagnosis unclear
 Prolonged symptoms unresponsive to conservative
treatment.

 Screen for central disorders

 Evaluate prior to surgical ablation procedures
 Documentation of vestibular deficits
 VNG(VideoNystagmography)
Only vestibular test with ability to test individual labyrinths separately.

Relies on the vestibulo-ocular reflex (VOR) to Test the peripheral vestibular

function

Mostly a test of HSCC function

False-positive interpretations : “Bilateral vestibular weakness,” are common if

the person performing the air caloric testing.

Identify vestibular asymmetry - vestibular neuritis, documents spontaneous or

positional nystagmus, such as that caused by BPPV.
 Spontaneous nystagmus
 Peripheral lesion
 Examples:
1- Acute labyrinthitis
2- Vestibular neuronitis
3- Meniere’s disease

 Usually unilateral
 Suppressed by visual fixation
 Associated otologic symptoms
 Oculomotor tests

 All test eye movements that originate in

the cerebellum

 Saccadic tracking
 Smooth pursuit tracking
 Optokinetic testing
 Saccadic tracking
 Patients concentrates on a randomly moving
target

 Latency ––difference in time between

movement of object and eye (150-250 ms)
 Velocity ––speed of saccade 200-400
degrees/second.
 Accuracy ––amount of undershoot/overshoot
of target ( 75-120%)
 Smooth Pursuit Test

 Tests ability to accurately and smoothly

pursue a target
 Gain of eyes compared to movement of
target
 Saccade movements eliminated from
calculations
 Asymmetrical pursuit highly suggestive of
central disorders.
 Optokinetic Tests
 Vestibular system and optokinetic nystagmus
allow steady focus on objects

 Target is rapidly passed in front of subject in

one direction, then the other
 Eye movements are recorded and compared in
each direction
 Asymmetry suggestive of CNS lesion
 High rate of false positive results.
 Positional and Positioning Testing
 Positional test
 Insults to vestibular system are compensated by
stimulations
 Maximal compensation in head up position
 Tests for nystagmus in static head positions
 Vertical or direction changing nystagmus suggests
central disorder.
 Positioning test:
 Used to determine presence of BPPV
 Quantitative Dix-Hallpike maneuver
Posterior canal BPPV
 Voluntary Hyperventilation

 Patients asked to over breathe for 90

seconds to 3 minutes
 Hyperventilation causes symptoms in
some anxiety disorder
 May provoke symptoms in normal
 Poor test for vestibular diagnosis.
 SVV (SUBJECTIVE VISUAL VERTICAL TEST )

 Otolithic function: Orientation of the vertical and horizontal is a

function of the utricle and saccule

 Peripheral vestibular lesion that has not yet been compensated

 Dynamic visual vertical test : uncompensated unilateral peripheral

vestibular lesions.
 VHIT
 Quickly diagnose both severe bilateral vestibular loss
and complete unilateral vestibular loss
 VNG testing is more accurate.
 VHIT is more resistant to false-positive findings in
patients with functional symptoms than tests of
nystagmus such as VNG and the rotary chair
Vestibular Evoked Myogenic
Potentials ( VEMP’s)

 Utricle and saccule detect linear

acceleration

 Saccule slightly responsive to

sound due to its position near
the oval window

 VEMP stimulate the saccule and

record EMG output in the SCM.
 Vestibular Evoked Myogenic Potentials ( VEMP )
 C VEMP
 Clicks or tones presented to ear stimulate saccule,
inferior vestibular nerve, vestibular nucleus, medial
vestibulospinal tract, accessory nucleus, cranial nerve
XI.

 EMG of SCM records output after click stimulation of

ear.

 Allows unilateral testing.

 VEMP
VEMP’s may be absent - vestibular neuritis- •
Lower threshold VEMP’s and conductive hearing loss same side -- -
.SCC dehiscence syndrome

Absent in bilateral vestibular loss in aminoglycoside oto-toxicity-

VEMP‘s show higher thresholds and absent in Meniere’s disease-

Absent in acoustic neuromas-

May be used in failed vestibular nerve section

 oVEMP
 The oVEMP is recorded from the tonically active contralateral inferior
oblique muscle
 Records function from the utricle (mainly), superior vestibular nerve,
vestibular nuclear complex, medial longitudinal fasciculus, oculomotor
nucleus, III CN, inferior oblique muscle
 Rotational Chair Testing
 “Gold standard” in identifying bilateral vestibular lesions better than
VNG
 Monitor for progressive bilateral vestibular loss (gentamicin toxicity)
 Quantify bilateral vestibular loss ––vestibular rehab vs. balance training
 Testing children that will not allow caloric irrigation
 Measures vestibular function of both inner ears together.
 Indication For Rotational Chair
Testing
 Assesment of peripheral system dysfunction& status of
compensation.

 To verify the presence & define the extent of a B/L

weakness .

 When caloric study are unreliable or unavailable.

 To asses effectiveness of particular treatment(chemical

ablation)
 Contd…
 Barany chair,Head errect, Eyes closed,chair turned in
10 circles in 20secs,suddenly stopped.

 Nystagmus : opposite to direction of rotation.

 Rotational Chair Testing
 Sinusoidal Harmonic Acceleration Test
 Most commonly performed
 Rotates patients at frequencies from 0.01-
1.28 Hz
 Unilateral lesions have gain and phase
asymmetries to the affected side.

 Reduced gain across all frequencies or phase

leads suggests bilateral vestibular lesions.
 Physiology of rotational nystagmus

 Pt.turned to Rt
 Endolymph moves away from
Rt.ampulla

Nystagmus to Lt.
 Rotary Chair Test(RCT)

 Most useful & Passive rotational test

 Pt. rotates, axis of rotation is vertical &
passes through centre of head

Stimulates LSCC
Horizontal eye movements recorded.
 Tests Performed
 Sinusoidal harmonic Acceleration
 Visual-vestibular Interaction Test
 Vestibular Ocular Reflex Suppression
Test
 Step Velocity Testing
Sinusoidal Harmonic Acceleration
 Chair oscillated in sinusoidal way in vertical
axis at freq.of 0.01Hz-1.28Hz

 Pt.undergo multiple cycle of oscillation at each

freq.
 Oscillations are gradually increased

 Stimulus level of RCT > Caloric testing(0.002-

0.004Hz)
 Components Of Rotary Chair
Testing
 Rt.beating nystagmus- Pt.moving Rt.
 Lt.beating nystagmus – Pt.moving Lt.
 Computer differentiate eye position signal
Remove fast phase of nystagmus
Compare head velocity & slow-phase eye velocity
Calculate GAIN,PHASE,SYMMETRY
 PHASE
 Measures timing relationship betw. Reflexive eye response &
head movements.
 Measured in degree.
 Greatest clinical significance.
 Out of Phase/180deg: head & eye moving same
velocity,opposite direction
 Phase lead: reflex eye movements leads head movements.
 Phase Lag: compensatory eye movements trails head
movements.
 Increased Phase: peripheral vestibular sys.dysfunct.
 Decreased Phase: Cerebellar lesion.
 Posturography

Used to test integration of balance systems

Useful in quantification of fall risk.
Most useful in following conditions:
 Chronic disequilibrium and normal exams
 Suspected malingering
 Suspected multifactorial disequilibrium
 Poorly compensated vestibular injuries
 Evaluate vestibular, proprioceptive, and visual contributions to balance
and is similar to the Romberg test.

 cooperation from the patient.

 5/6 ––Vestibular dysfunction
 2,3,5,6 ––somatosensory and vestibular dysfunction
 3,6 ––visual preference
 1,2,3,4 or any combination with normal 5/6
aphysiologic.
 End Organ Specific Diagnosis!
 Normal Caloric + Normal Cvemp + Normal oVEMP =No
Impairment .
 Abnormal Caloric + Abnormal Cvemp + Abnormal
oVEMP = Entire End Organ/ Sup and Inf Vestibular
affection
 Normal Caloric +Abnormal Cvemp + Normal oVEMP =
Saccule and Inf Vestibular affection .
 Abnormal Caloric + Normal Cvemp + Abnormal oVEMP
= Sup Vestb nerve and or lat SCC and utricle affection
 Abnormal Caloric + Normal Cvemp + Normal oVEMP =
Lat SCC impairment affection
 Normal Caloric + Normal Cvemp + Abnormal oVEMP =
Utricle affection
 Conclusion
 Vestibular testing assists diagnostic process by supplementing
the clinical history and examination.

 Identifies unilateral vestibular loss, bilateral vestibular loss, and

Superior canal dehiscence.

 Be patient as history is the most important part, physical is

confirmatory.

 Combined with hearing testing, - assist in identification of

Ménière disease.

 Orthostatic hypotension / persistent postural perceptual

dizziness have normal results on vestibular assessments
85