Vestibular F TEST.pptVestibular F TEST.ppt for Vestibular Function

Vestibular F TEST.ppt for Vestibular Function

1. Testing Vestibular Testing Vestibular
FunctionFunction

2. 
Dix-Hallpike ManeuverDix-Hallpike Maneuver

Used to provoke nystagmus and vertigo Used to provoke nystagmus and vertigo
commonly associated with BPPVcommonly associated with BPPV

Head turned 45 degrees to maximally Head turned 45 degrees to maximally
stimulate posterior semicircular canalstimulate posterior semicircular canal

Head supported and rapidly placed into head Head supported and rapidly placed into head
hanging positionhanging position

Frenzel glasses eliminate visual fixation Frenzel glasses eliminate visual fixation
suppression of responsesuppression of response

3. Dix-Hallpike ManeuverDix-Hallpike Maneuver

4. VARIANT DIX HALLPIKEVARIANT DIX HALLPIKE

6. Dix-Hallpike ManeuverDix-Hallpike Maneuver

Positive testPositive test

Torsional / Up-beating nystagmusTorsional / Up-beating nystagmus

Nystagmus to the stimulated sideNystagmus to the stimulated side

Rotary component to the affected earRotary component to the affected ear

Lasts 15-45 secondsLasts 15-45 seconds

Latency of 2-15 secondsLatency of 2-15 seconds

Fatigues easilyFatigues easily

7. Pneumatic OtoscopyPneumatic Otoscopy

Positive and negative pressure applied to Positive and negative pressure applied to
middle earmiddle ear

Hennebert’s sign/symptom – nystagmus Hennebert’s sign/symptom – nystagmus
and vertigo with pressure, alternates with and vertigo with pressure, alternates with
positive and negative pressurepositive and negative pressure

Can be present in patients with Can be present in patients with
perilymphatic fistula, syphilis, Meninere’s perilymphatic fistula, syphilis, Meninere’s
disease, SCC dehiscence syndromedisease, SCC dehiscence syndrome

8. Head Shake NystagmusHead Shake Nystagmus

Evaluates unilateral vestibular weaknessEvaluates unilateral vestibular weakness

Head tilted back 30 degreesHead tilted back 30 degrees

Shake back and forth for 30 seconds as Shake back and forth for 30 seconds as
quickly as possiblequickly as possible

Unilateral vestibular deficit causes slow Unilateral vestibular deficit causes slow
phase nystagmus to the side of lesionphase nystagmus to the side of lesion

Low sensitivity (27%) Low sensitivity (27%)

Good specificity (85%)Good specificity (85%)

9. Head Thrust TestHead Thrust Test
Inhibitory response not as robust as the Inhibitory response not as robust as the
stimulatory response to stimulate VORstimulatory response to stimulate VOR
Movements that overcome the inhibitory Movements that overcome the inhibitory
response of vestibule will result in VOR lagresponse of vestibule will result in VOR lag
Head tilted 30 degrees Head tilted 30 degrees
Rapid head movements to either side with focus Rapid head movements to either side with focus
on examiner’s noseon examiner’s nose
Patients have catch-up saccade when rotated to Patients have catch-up saccade when rotated to
side of weaknessside of weakness
Sensitivity 75%, Specificity of 85% Sensitivity 75%, Specificity of 85%

10. Dynamic Visual AcuityDynamic Visual Acuity

Used for bilateral vestibular weaknessUsed for bilateral vestibular weakness

Visual acuity checked on Snellen chartVisual acuity checked on Snellen chart

Rechecked while rotating head back and Rechecked while rotating head back and
forth at 1-2 Hz.forth at 1-2 Hz.

Loss of 2-3 lines considered abnormalLoss of 2-3 lines considered abnormal

12. Romberg TestRomberg Test

Patient asked to stand with feet together Patient asked to stand with feet together
and eyes closedand eyes closed

Fall or step is positive testFall or step is positive test

Equal sway with eyes open and closed Equal sway with eyes open and closed
suggests proprioceptive or cerebellar sitesuggests proprioceptive or cerebellar site

More sway with eyes closed suggests More sway with eyes closed suggests
vestibular weaknessvestibular weakness

13. Romberg TestRomberg Test

14. Sharpened romberg testSharpened romberg test

15. Fukuda Stepping TestFukuda Stepping Test

Originally described by Fukuda using 100 steps Originally described by Fukuda using 100 steps
on a marked floor.on a marked floor.

Patients are asked to step with eyes closed and Patients are asked to step with eyes closed and
hands out in fronthands out in front

Rotation by more than 45 degrees is abnormalRotation by more than 45 degrees is abnormal

Rotation usually occurs to the side of the lesionRotation usually occurs to the side of the lesion

Rotation often found in asymptomatic patientsRotation often found in asymptomatic patients

16. Dysdiadochokinesia TestingDysdiadochokinesia Testing

Most commonly tested with the hand Most commonly tested with the hand
slapping testslapping test

Abnormalities seen in patients with Abnormalities seen in patients with
cerebellar dysfunctioncerebellar dysfunction

Poor sensitivity and specificityPoor sensitivity and specificity

17. Tandem Gait TestTandem Gait Test

Patients are asked to walk heal to toe in a Patients are asked to walk heal to toe in a
straight line or in a circlestraight line or in a circle

Complex function evaluates many aspects Complex function evaluates many aspects
of balanceof balance

Poor performance seen in cerebellar Poor performance seen in cerebellar
lesions, but can be seen in many disorderslesions, but can be seen in many disorders

Poor sensitivity and specificityPoor sensitivity and specificity

18. Orthostatic HypotensionOrthostatic Hypotension

Most often in patients on BP meds with Most often in patients on BP meds with
“light headedness” on sitting to standing“light headedness” on sitting to standing

Defined as drop of SBP 20mm HG or DPB Defined as drop of SBP 20mm HG or DPB
10mm HG within 3 minutes of standing10mm HG within 3 minutes of standing

Tilt exams offer objective measurements Tilt exams offer objective measurements
with well established normswith well established norms

Patients with no symptoms will often “Tilt”Patients with no symptoms will often “Tilt”

19. Electronystagmography (ENG)Electronystagmography (ENG)

It test vestibular & occulomotar system.It test vestibular & occulomotar system.

Only vestibular test with the ability to test Only vestibular test with the ability to test
individual labyrinths separatelyindividual labyrinths separately

Relies on the vestibulo-ocular reflex (VOR) to Relies on the vestibulo-ocular reflex (VOR) to
test the peripheral vestibular functiontest the peripheral vestibular function

Movement of head causes stimulation of Movement of head causes stimulation of
labyrinth which in turn produces compensatory labyrinth which in turn produces compensatory
eye movement. It is recorded as change in cor-eye movement. It is recorded as change in cor-
ret potential diff.ret potential diff.

21. Electronystagmography (ENG)Electronystagmography (ENG)

22. Electronystagmography (ENG)Electronystagmography (ENG)

23. videonystagmographyvideonystagmography

24. Saccadic eye movementSaccadic eye movement

It is the fast movement of eye (200-500 It is the fast movement of eye (200-500
degree/sec)degree/sec)which allow us to shift gaze which allow us to shift gaze
from one object of interest to other.from one object of interest to other.

26. 3 parameter3 parameter
Saccadic velocitySaccadic velocity
100-500 degree/sec100-500 degree/sec
sac.slowing i/c/o nd disordersac.slowing i/c/o nd disorder
>saccadic accuracy >saccadic accuracy
½ small corrective saccade½ small corrective saccade
s.hypo/hypermetrias.hypo/hypermetria
> saccadic conjugacy> saccadic conjugacy
both eye travel with same speedboth eye travel with same speed
inoino

27. Smooth Pursuit TestSmooth Pursuit Test

Tests ability to accurately and smoothly Tests ability to accurately and smoothly
pursue a targetpursue a target

Gain of eyes compared to movement of Gain of eyes compared to movement of
targettarget

Saccade movements eliminated from Saccade movements eliminated from
calculationscalculations

Asymmetrical pursuit highly suggestive of Asymmetrical pursuit highly suggestive of
central disorderscentral disorders

28. Optokinetic TestsOptokinetic Tests

Vestibular system and optokinetic Vestibular system and optokinetic
nystagmus allow steady focus on objectsnystagmus allow steady focus on objects

Target is rapidly passed in front of subject Target is rapidly passed in front of subject
in one direction, then the otherin one direction, then the other

Eye movements are recorded and Eye movements are recorded and
compared in each directioncompared in each direction

Asymmetry suggestive of CNS lesionAsymmetry suggestive of CNS lesion

High rate of false positive resultsHigh rate of false positive results

30. Caloric TestingCaloric Testing

Established and widely accepted method Established and widely accepted method
of vestibular testingof vestibular testing

Most sensitive test of unilateral vestibular Most sensitive test of unilateral vestibular
weaknessweakness

Patient positioned 30 degrees from prone Patient positioned 30 degrees from prone
(HSCC vertical allowing max stim)(HSCC vertical allowing max stim)

Cold and warm water/air flushed into EACCold and warm water/air flushed into EAC

31. Caloric Testing Caloric Testing

COWS (cold opposite, warm same) – COWS (cold opposite, warm same) –
direction of the nystagmusdirection of the nystagmus

Stimulation in 0.002-0.004 Hz range Stimulation in 0.002-0.004 Hz range
(Head movements in 1-6 Hz range)(Head movements in 1-6 Hz range)

% caloric paresis = 100 * [(LC + LW) – % caloric paresis = 100 * [(LC + LW) –
(RC + RW)/(LC + LW + RC + RW)](RC + RW)/(LC + LW + RC + RW)]

32. Caloric TestingCaloric Testing

33. Caloric TestingCaloric Testing

34. Rotational Chair TestingRotational Chair Testing
““Gold standard” in identifying bilateral vestibular Gold standard” in identifying bilateral vestibular
lesionslesions
Used to monitor for progressive bilateral Used to monitor for progressive bilateral
vestibular loss (gentamicin toxicity)vestibular loss (gentamicin toxicity)
Used to quantify bilateral vestibular loss – Used to quantify bilateral vestibular loss –
vestibular rehab vs. balance trainingvestibular rehab vs. balance training
Useful in testing children that will not allow Useful in testing children that will not allow
caloric irrigationscaloric irrigations
Used with borderline caloric tests when water Used with borderline caloric tests when water
calorics cannot be used calorics cannot be used

35. Rotational Chair TestingRotational Chair Testing

36. Rotational Chair Testing(barany’s Rotational Chair Testing(barany’s
rc)rc)

Sinusoidal Harmonic Acceleration TestSinusoidal Harmonic Acceleration Test

Most commonly performedMost commonly performed

Rotates patients at frequencies from 0.01-Rotates patients at frequencies from 0.01-
1.28 Hz1.28 Hz

Unilateral lesions have gain and phase Unilateral lesions have gain and phase
asymmetries to the affected sideasymmetries to the affected side

Reduced gain across all frequencies or phase Reduced gain across all frequencies or phase
leads suggests bilateral vestibular lesionsleads suggests bilateral vestibular lesions

37. PosturographyPosturography

Used to tests integration of balance Used to tests integration of balance
systemssystems

Useful in quantification of fall riskUseful in quantification of fall risk

Most useful in following conditions:Most useful in following conditions:

Chronic disequilibrium and normal examsChronic disequilibrium and normal exams

Suspected malingeringSuspected malingering

Suspected multifactorial disequilibriumSuspected multifactorial disequilibrium

Poorly compensated vestibular injuriesPoorly compensated vestibular injuries

38. PosturographyPosturography

39. PosturographyPosturography

5/6 – Vestibular dysfunction5/6 – Vestibular dysfunction

2,3,5,6 – somatosensory and vestibular 2,3,5,6 – somatosensory and vestibular
dysfunctiondysfunction

40. CALORIC TESTCALORIC TEST

Basis of this test is temp.changes in EAC Basis of this test is temp.changes in EAC
causes convection current in horizental causes convection current in horizental
ssc which in turn stimulate cupula.ssc which in turn stimulate cupula.
> >
advantage- each labyrinth can be tested advantage- each labyrinth can be tested
separately.separately.

41. MODIFIED KOBRAK TESTMODIFIED KOBRAK TEST

IT IS A QUICK OFFICE PROCEDURE.IT IS A QUICK OFFICE PROCEDURE.
>pt, is seated with head tilted 60* >pt, is seated with head tilted 60*
backward to place hssc vertical.backward to place hssc vertical.
>ear is irrigated with ice water>ear is irrigated with ice water for 60 for 60
sec.sec.
5/10/20/40ml5/10/20/40ml

42. Fitzgerald hallpike testFitzgerald hallpike test

Pt lies supine with head tilted 30* forward to make hssc Pt lies supine with head tilted 30* forward to make hssc
vertical.vertical.
>ear is irrigated for 40 sec>ear is irrigated for 40 sec
cool-30*ccool-30*c
warm-42*cwarm-42*c
> 5 min gap > 5 min gap

> eyes are observed for nystagmus till its end > eyes are observed for nystagmus till its end
point.point.
>time taken from the start of irrigation to end >time taken from the start of irrigation to end
nystagmus nystagmus
>calorigram.>calorigram.
> dead labyrinth -20*c for 4 min > dead labyrinth -20*c for 4 min

43. 
COWS (cold opposite, warm same) – COWS (cold opposite, warm same) –
direction of the nystagmusdirection of the nystagmus

44. Canal paresisCanal paresis

If duration of nustagmus of either side If duration of nustagmus of either side
after stimulation with cold/ warm water is after stimulation with cold/ warm water is
less than normal .less than normal .
> seen i/c/o meinere’s > seen i/c/o meinere’s
disease/acoustic neuroma/post disease/acoustic neuroma/post
labyrinthectomylabyrinthectomy

45. Directional preponderanceDirectional preponderance

Right beating nystagmus –L30 & R44Right beating nystagmus –L30 & R44
>left beating nystagmus- R30 & L44>left beating nystagmus- R30 & L44
> IF NYSTAGMUS IS 25-30 % > IF NYSTAGMUS IS 25-30 %
MORE MORE

46. SIGNIFICANCESIGNIFICANCE

directional preponderance nystagmus directional preponderance nystagmus
occur toward the side of central lesion & occur toward the side of central lesion &
away from side in c/o peripheral lesion.away from side in c/o peripheral lesion.
> >
canal paresis on one side/ d pto other canal paresis on one side/ d pto other
side---MDside---MD > >
canal paresis on one side/ d p to same canal paresis on one side/ d p to same
side-acoustic neuromaside-acoustic neuroma

47. Cold air caloric testCold air caloric test

In case of perforated tmIn case of perforated tm
>this test employs dundas grant tube >this test employs dundas grant tube
which is acoiled copper tube wrapped in which is acoiled copper tube wrapped in
cloth. The air in tube is cooled by pouring cloth. The air in tube is cooled by pouring
ethyl chloride then blown into air. ethyl chloride then blown into air.

48. ReferencesReferences

1.scott-1.scott-
browns 7browns 7
thth
edition edition
2.B.J.Bailey 2.B.J.Bailey

3.Shambaugh3.Shambaugh