Assessment of Vestibular System
Dr. Diwash Sunar
MBBS (Manipal, KU)
MS – ENT Head & Neck Surgery ( AIIMS, New
Delhi )
Lecturer – BMCTH, KU
Learning Objectives
• Understand the Anatomy of the Vestibular System
• Perform a Clinical Examination of the Vestibular System
• Interpret the Results of Vestibular Function Tests
• Develop a Differential Diagnosis for Vertigo and Dizziness
• Understand the Management of Common Vestibular Disorders
• Apply Knowledge in Clinical Scenarios
• Pre-Test
1. Which of the following is not a test for the evaluation of peripheral vertigo?
a. Romberg test b. Dix-Hallpike test
c. Fukuda stepping test d. Chimani-Moos test
2. True for Peripheral Nystagmus is-
a. Lasts >1min b. Direction fixed
c. No latency d. Vertigo absent
3. In case of BPPV, which SCC is affected
b. Lateral SCC b. Posterior SCC
c. Anterior SCC d. Superior SCC
4. All of the following will have positive fistula test, except –
d. Dead ear b. Labyrinthine fistula
c. Hypermobile stapes footplate d. following fenestration surgery
5. In Fitzgerald hallpike caloric test, left ear is irrigated with 30 degree celcius in normal person. Response will be –
a. Nystagmus to right ear b. Nystagmus to left ear
c. Direction changing nystagmus d. positional nystagmus
• The vestibular system is present within the bony labyrinth.
• peripheral vestibular organ consists of three Semicircular canals (SCCs),
utricle and saccule, cochlear duct and endolymphatic sac, and its duct
• utricle and saccule are together called otolith organs (macula)
• The macula of the utricle is present in the horizontal plane, and the
macula of the saccule is situated in the vertical plane.
• The semicircular canals of both temporal bones are synergistic. Horizontal canals
are synergistic, but the superior canal on one side is synergic with the posterior
canal on the opposite side.
• Crus commune is the junction of posterior and superior SCC.
• All canals opened into the utricle of the vestibule
• SCCs have smaller non-ampullated (1 mm) and larger ampullated ends (2 mm).
Ampullated ends contain crista ampullaris (contain sensory hair cells) and a
cupula that receives input from the head position (angular acceleration).
• Utricle and saccule are responsible for the assessment of linear
acceleration of the head.
• Otoconia is the gelatinous matrix around vestibular hair cells.
• Perilymph surrounds the membranous labyrinth, and endolymph is
present within the membranous labyrinth.
• Sensory hair cells are of two types
Type I and type II.
Type I cells are a flask-shaped single layer of cells.
Type II cells are cylindrical and multilayer cells.
• Kinocilium is the thicker projection presented at the
sensory cells end, and stereocilia is the thinner
projection.
• Sensory cells are fenced by supporting cells
• Potassium channels open up by ciliary bundle movement toward the kinocilium,
generating depolarization potential in the active ear (ampullopetal flow).
• The movement of endolymph in the opposite direction suppresses the generation
of potential (ampullofugal flow).
• Utricle, superior SCC and horizontal SCC received afferent fibres from a superior
vestibular nerve.
• Saccule and posterior SCC received afferent fibres from an inferior vestibular nerve.
• The vestibular nerve (25,000 nerve fibres) transmits information to the central
vestibular system.
• The four vestibular nuclei (lateral, medial, superior, and inferior) receive input from a
peripheral organ. Vestibular nuclei with various central connections (vestibulo-ocular,
vestibulospinal, vestibulothalamic, vestibulocerebellar, and vestibulocortical pathway)
comes under the central vestibular system.
• What is Vertigo ???
VERTIGO
It is the false perception of motion
It is defined as an illusion of movement
It is defined as a hallucination of movement
The disagreeable sensation of instability or disordered orientation in space is Vertigo.
Vertigo is defined as a perception of movement when there is none.
Vertigo is defined as an illusion of either oneself or the environment rotating.
• Assessment of vestibular functions can be divided into two groups:
Clinical tests
Laboratory tests
Clinical Tests
It includes -
• Detailed clinical history
• Complete Neuro-otological evaluation
• Cerebellar function tests
• Test of nystagmus
• Cranial nerve examination
Detailed clinical history
• The guided questions are very helpful in reaching the diagnosis
• Ask if It is vertigo, imbalance, and light-headedness
• Approximate duration of each episode (seconds, minutes, or hours) with a detailed description of the first
episode
• Continue or episodic
• Aggravating (head movement, specific head position, loud noise, pressure, etc.) and relieving factors
• Associated symptoms (hearing loss, tinnitus, ear fullness, ear discharge, otalgia, diplopia, blurring of vision,
dysphagia, dyspnea, palpitation, etc.)
• Family history, history of trauma
• Chronic medical illness (diabetes, anemia, hypothyroidism, central nervous system disorders, cardiac
diseases, postural hypotension, etc.) and history of surgery.
• History of psychological disorders (anxiety, depression, etc.)
• History of drug abuse and chronic medication
Aggravating factors for Vertigo
Head and neck movements BPPV
Cervical vertigo
Pressure and Superior SCC dehiscence syndrome
Loud sounds/Noise
Pressure Perilymph fistula
Labyrinthine fistula
Meniere’s disease
Otosyphilis
Superior SCC Dehiscence syndrome
Stress Psychological illnesses
Standing up from sitting Orthostatic Hypotension
position
Nystagmus
• involuntary, rhythmical, oscillatory movement of eyes.
• It can be spontaneous or induced (generated by a test).
• Nystagmus of peripheral vs central disease ??
• It may be Horizontal / Vertical / Rotatory.
• Vestibular nystagmus has a slow and a fast component,
• direction of nystagmus is indicated by the direction of the fast component.
• The slow component is toward the disease side.
INDUCED NYSTAGMUS
• 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.
Nystagmus of peripheral origin
suppressed by optic fixation by looking at a fixed point
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.
• In irritative nystagmus, the fast component is toward the disease side, due
to the labyrinth's hyperfunctioning
• in paralytic nystagmus, a fast component is toward the healthy side, due to
the hypofunction of a diseased labyrinth.
Fistula Test
• Principle - to induce nystagmus by producing pressure
changes in the external canal which are then transmitted to
the labyrinth via an abnormal communicating connection.
• Pressure is induced by Siegel's speculum (pneumatic
otoscopy) or pushing the tragus against the external auditory
canal (EAC)
• The parts of the fistula test are nystagmus, vertigo, and head
movement.
• Normally, Fistula test is negative because the pressure changes in the external auditory canal cannot be
transmitted to the labyrinth.
• Positive Fistula test - when there is erosion of Horizontal SCC as in cholesteatoma or a surgically created
window in the horizontal canal (fenestration operation), abnormal opening in the oval window (post-
stapedectomy fistula) or the round window (rupture of round window membrane).
• A positive fistula test also implies that the labyrinth is still functioning.
• Negative fistula test: Normal ear and dead labyrinth
• 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 hyper-mobile 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.
Head Impulse/Head Thrust Test
• Patient is instructed to look at a central point (examiner's nose and central part of
forehead).
• The test is performed by sudden head thrush by 10-15° (rapidly turning the head
to one side ) done on both sides
• The test enhances the effect of the vestibulo-ocular reflex
Head Shake Test
• Unequal input of the disease side
generates nystagmus when the head
is shacked 20 times (20-30 cycles)
and is stopped suddenly.
• Nystagmus is induced in both central
and peripheral vestibular
dysfunction.
• Positional Tests/Maneuvers
Dix-Hallpike Test
most commonly used maneuver in ENT practice
• patient is asked to fix their gaze on the examiner's nose.
• patient's face is turned 45° toward the diseased side in an upright position.
• Then the patient is quickly brought to the supine head-hanging position. (head hangs 30° below
the horizontal )
• Vertigo and nystagmus are checked
• Presence of Nystagmus and/or Vertigo is Test positive.
• The latency for induced nystagmus is approximately 10-20 seconds, and the duration of
nystagmus is <1 minute.
• patient is brought back to a sitting position.
• similar procedure is done on another side.
• presence of nystagmus and vertigo is documented as a positive test for posterior canal benign
paroxysmal positional vertigo (BPPV).
• This test is particularly useful when patient complains of vertigo in certain head positions.
• For Horizontal SCC BPPV Supine roll test
The patient is made supine with head 30° elevated in central position first.
Then the head is turned to 90° on one side and the position is maintained for 30
seconds and
then head is turned to opposite side again keeping the position for 30 seconds.
A positive test is the appearance of nystagmus and Vertigo
Romberg Test
• Patient is asked to stand with feet together and arms
by the side with eyes first open and then closed.
• when the patient is asked to stand straight with
closed eyes with feet together for a minute
• 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.
• Sharpened Romberg test:
Patient stands with feet one behind
the other and arms folded in an "X"
to let the hands touch the opposite
shoulder.
Presence of sway is checked,
which indicates an ipsilateral
vestibular or cerebellar lesion
Fukuda Stepping Test/Unterberger Test
Caloric Test
• Basis of this test - to induce nystagmus by thermal stimulation of the
vestibular system
• Advantage -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.
Caloric Test
• 1. MODIFIED KOBRAK TEST.
• 2. FITZGERALD-HALLPIKE TEST (BITHERMAL CALORIC TEST).
• 3. COLD-AIR CALORIC TEsT.
1. MODIFIED KOBRAK TEST.
It is a quick office procedure.
• Patient is seated with head tilted 30° forward / 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
2. FITZGERALD-HALLPIKE TEST
(Bithermal Caloric Test)
• In this test, patient lies supine with head tilted 30° forward so that horizontal canal is vertical
• The diseased ear followed by a healthy ear is irrigated
• first with warm water (44°C) and then cold water (30°C) i.e. 7° below and above normal body
temperature
• 250 cc is rinsed in 40 seconds.
• The sequence is right 44°C, left 44°C, right 30°C, and left 30°C.
• The nystagmus appears in a 30-second interval. It reaches its peak in 30-45 seconds.
• 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
(@ 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.
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
Ro and L44.
• If the nystagmus is 25-30% or more on one side than the other, it is called directional preponderance to
that side.
• 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
• canal paresis with directional preponderance to ipsilateral side is seen in acoustic neuroma.
3. 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.
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.
• Videographic recording of responses is known as Videonystagmography (VNG)
• Posturography: It records the effect of balance disturbance generated by moving
platforms with movable visual input.
