This document discusses testing of vestibular function. It begins by providing statistics on dizziness complaints. The rest of the document describes various office examinations and tests that can be used to evaluate vestibular function, including cranial nerve exams, positional tests like Dix-Hallpike and Fukuda stepping, and oculomotor function tests like head thrust and head shake nystagmus. It then reviews quantitative vestibular testing methods like electronystagmography (ENG), which can test individual labyrinths, and rotational chair testing, which is considered the gold standard for identifying bilateral vestibular lesions.

1. Testing VestibularTesting Vestibular
FunctionFunction
Dr.saied alhabashDr.saied alhabash

2. Testing Vestibular FunctionTesting Vestibular Function
 Four percent of patients18-65 yo visitFour percent of patients18-65 yo visit
clinic with complaint of “dizziness”clinic with complaint of “dizziness”
 Three percent consider it “SeverelyThree percent consider it “Severely
incapacitating”incapacitating”
 Third most common complaint in elderlyThird most common complaint in elderly

3. Testing Vestibular FunctionTesting Vestibular Function
 Otolaryngologist is considered balanceOtolaryngologist is considered balance
specialistspecialist
 Private practice physicians often quotedPrivate practice physicians often quoted
“I wish I knew more about dizzy patients”“I wish I knew more about dizzy patients”

4. ObjectivesObjectives
 Describe office examinations of dizzyDescribe office examinations of dizzy
patientspatients
 Describe vestibular function studiesDescribe vestibular function studies
 Review indications for vestibular functionReview indications for vestibular function
studiesstudies
 Review efficacy of office and vestibularReview efficacy of office and vestibular
function studiesfunction studies

5. ClassificationClassification
 cranial nerve evaluationcranial nerve evaluation
 Positional testsPositional tests
 Postural control testPostural control test
 Oculomotor function testOculomotor function test

6. Cranial nerve evaluationCranial nerve evaluation
 88
 77
 3,4,6(before ENG)3,4,6(before ENG)

7. Positional testsPositional tests
 DynamicDynamic
Dix-HallpikeDix-Hallpike
visual acuity testvisual acuity test
 StaticStatic (ENG)(ENG)

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

9. Dix-Hallpike ManeuverDix-Hallpike Maneuver

10. Dix-Hallpike ManeuverDix-Hallpike Maneuver
 Positive testPositive test

Up-beating nystagmusUp-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

11. 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 andRechecked 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. Postural control testPostural control test
 Romberg testRomberg test
 Fukoda stepping testFukoda stepping test
 Tandem gait testTandem gait test
 Pastpointing testPastpointing test

13. Romberg TestRomberg Test
 Patient asked to stand with feet togetherPatient 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 closedEqual sway with eyes open and closed
suggests proprioceptive or cerebellar sitesuggests proprioceptive or cerebellar site
 More sway with eyes closed suggestsMore sway with eyes closed suggests
vestibular weaknessvestibular weakness

14. Romberg TestRomberg Test

15. Fukuda Stepping TestFukuda Stepping Test
 Originally described by Fukuda using 100 stepsOriginally described by Fukuda using 100 steps
on a marked floor.on a marked floor.
 Patients are asked to step with eyes closed andPatients 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. DysdiadochokinesiaDysdiadochokinesia
Testing(pastpointing test)Testing(pastpointing test)
 Most commonly tested with the handMost commonly tested with the hand
slapping testslapping test
 Abnormalities seen in patients withAbnormalities 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 aPatients are asked to walk heal to toe in a
straight line or in a circlestraight line or in a circle
 Complex function evaluates many aspectsComplex function evaluates many aspects
of balanceof balance
 Poor performance seen in cerebellarPoor performance seen in cerebellar
lesions, but can be seen in manylesions, but can be seen in many
disordersdisorders
 Poor sensitivity and specificityPoor sensitivity and specificity
 Normal: more than 10step withoutNormal: more than 10step without
deflectiondeflection

18. Oculomotor function testsOculomotor function tests
 Fistula testing(pneumatic otoscopy)Fistula testing(pneumatic otoscopy)
 Nonlineary testingNonlineary testing
 Nystegmus testing Head-shaking testNystegmus testing Head-shaking test
Head-thrust testHead-thrust test
spontaneous nystagmusspontaneous nystagmus
gaze nystagmusgaze nystagmus

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

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

21. 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 asShake back and forth for 30 seconds as
quickly as possiblequickly as possible
 Unilateral vestibular deficit causes slowUnilateral 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%)

22. Nonlineary testingNonlineary testing

23. Gaze nystagmusGaze nystagmus
 Central origin nystagmusCentral origin nystagmus
 Peripheral origin nystagmusPeripheral origin nystagmus

24. Quantitative VestibularQuantitative Vestibular
Testing(static positional tests)Testing(static positional tests)
indicationsindications
 Diagnosis unclearDiagnosis unclear
 Prolonged symptoms unresponsive toProlonged symptoms unresponsive to
conservative treatmentconservative treatment
 Screen for central disordersScreen for central disorders
 Evaluate prior to surgical ablationEvaluate prior to surgical ablation
proceduresprocedures
 Documentation of vestibular deficitsDocumentation of vestibular deficits

25. Electronystagmography (ENG)Electronystagmography (ENG)
 Divided into oculomotor tests, positionalDivided into oculomotor tests, positional
and positioning tests, and caloric testsand positioning tests, and caloric tests
 Only vestibular test with the ability to testOnly vestibular test with the ability to test
individual labyrinths separatelyindividual labyrinths separately
 Relies on the vestibulo-ocular reflexRelies on the vestibulo-ocular reflex
(VOR) to test the peripheral vestibular(VOR) to test the peripheral vestibular
functionfunction

26. Electronystagmography (ENG)Electronystagmography (ENG)

27. Electronystagmography (ENG)Electronystagmography (ENG)

28. Electronystagmography (ENG)Electronystagmography (ENG)
 Oculomotor testsOculomotor tests
 Positional testsPositional tests
 Caloric testsCaloric tests

29. Electronystagmography (ENG)Electronystagmography (ENG)
 Oculomotor testsOculomotor tests

All test eye movements that originate in theAll test eye movements that originate in the
cerebellumcerebellum

Saccadic trackingSaccadic tracking

Smooth pursuit trackingSmooth pursuit tracking

Optokinetic testingOptokinetic testing

30. Oculomotor TestsOculomotor Tests
 Saccadic trackingSaccadic tracking

Patients concentrates on a randomly movingPatients concentrates on a randomly moving
targettarget

Latency – difference in time betweenLatency – difference in time between
movement of object and eye (150-250 ms)movement of object and eye (150-250 ms)

Velocity – speed of saccade 200-400Velocity – speed of saccade 200-400
degrees/second low end of normaldegrees/second low end of normal

Accuracy – amount of undershoot/overshootAccuracy – amount of undershoot/overshoot
of target (75-120%)of target (75-120%)

31. Saccadic TrackingSaccadic Tracking

32. Saccadic TrackingSaccadic Tracking

33. Saccadic TrackingSaccadic Tracking

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

35. Optokinetic TestsOptokinetic Tests
 Vestibular system and optokineticVestibular system and optokinetic
nystagmus allow steady focus on objectsnystagmus allow steady focus on objects
 Target is rapidly passed in front of subjectTarget is rapidly passed in front of subject
in one direction, then the otherin one direction, then the other
 Eye movements are recorded andEye 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

36. Smooth Pursuit andSmooth Pursuit and
Optokinetic TestsOptokinetic Tests

37. Smooth Pursuit TestSmooth Pursuit Test

38. Smooth Pursuit andSmooth Pursuit and
Optokinetic TestsOptokinetic Tests

39. Positional and Positioning TestingPositional and Positioning Testing
 Positional testPositional test

Insults to vestibular system are compensated byInsults to vestibular system are compensated by
stimulationstimulation

Maximal compensation in head up positionMaximal compensation in head up position

Tests for nystagmus in static head positionsTests for nystagmus in static head positions

Vertical or direction changing nystagmus suggestsVertical or direction changing nystagmus suggests
central disordercentral disorder
 Positioning testPositioning test

Used to determine presence of BPPVUsed to determine presence of BPPV

Quantitative Dix-Hallpike maneuverQuantitative Dix-Hallpike maneuver

40. Caloric TestingCaloric Testing
 Established and widely accepted methodEstablished and widely accepted method
of vestibular testingof vestibular testing
 Most sensitive test of unilateral vestibularMost sensitive test of unilateral vestibular
weaknessweakness
 Patient positioned 30 degrees from pronePatient 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

41. Caloric TestingCaloric 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 rangeStimulation in 0.002-0.004 Hz range
(Head movements in 1-6 Hz range)(Head movements in 1-6 Hz range)
 Visual fixation should reduce strength ofVisual fixation should reduce strength of
caloric responses 50-70%caloric responses 50-70%
 % caloric paresis = 100 * [(LC + LW) –% caloric paresis = 100 * [(LC + LW) –
(RC + RW)/(LC + LW + RC + RW)](RC + RW)/(LC + LW + RC + RW)]

42. Rotational Chair TestingRotational Chair Testing
 ““Gold standard” in identifying bilateral vestibularGold standard” in identifying bilateral vestibular
lesionslesions
 Used to monitor for progressive bilateralUsed 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 allowUseful in testing children that will not allow
caloric irrigationscaloric irrigations
 Used with borderline caloric tests when waterUsed with borderline caloric tests when water
calorics cannot be usedcalorics cannot be used

43. Rotational Chair TestingRotational Chair Testing

44. Rotational Chair TestingRotational Chair Testing
 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 phaseUnilateral lesions have gain and phase
asymmetries to the affected sideasymmetries to the affected side

Reduced gain across all frequencies or phaseReduced gain across all frequencies or phase
leads suggests bilateral vestibular lesionsleads suggests bilateral vestibular lesions

45. Rotational Chair TestingRotational Chair Testing
 Kaplan et al.Kaplan et al.

198 adults tested198 adults tested

29 patients with bilateral loss by chair testing29 patients with bilateral loss by chair testing

25/29 with bilateral caloric weakness by ENG25/29 with bilateral caloric weakness by ENG

3/29 with unilateral caloric weakness by ENG3/29 with unilateral caloric weakness by ENG

3/45 patients with unilateral caloric weakness3/45 patients with unilateral caloric weakness
by ENG had abnormal chair testsby ENG had abnormal chair tests

46. PosturographyPosturography
 Used to tests integration of balanceUsed 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

47. PosturographyPosturography

48. PosturographyPosturography
 5/6 – Vestibular dysfunction5/6 – Vestibular dysfunction
 2,3,5,6 – somatosensory and vestibular dysfunction2,3,5,6 – somatosensory and vestibular dysfunction
 3,6 – visual preference3,6 – visual preference
 1,2,3,4 or any combination with normal 5/6 - aphysiologic1,2,3,4 or any combination with normal 5/6 - aphysiologic

49. Vestibular Evoked MyogenicVestibular Evoked Myogenic
Potentials (VEMP’s)Potentials (VEMP’s)
 Utricle and saccule detect linearUtricle and saccule detect linear
accelerationacceleration
 Saccule slightly responsive to sound do toSaccule slightly responsive to sound do to
its position near the oval windowits position near the oval window
 VEMP’s stimulate the saccule and recordVEMP’s stimulate the saccule and record
EMG output in the SCMEMG output in the SCM

50. Vestibular Evoked MyogenicVestibular Evoked Myogenic
Potentials (VEMP’s)Potentials (VEMP’s)
 Clicks or tones presentedClicks or tones presented
to the ear stimulateto the ear stimulate
saccule, inferiorsaccule, inferior
vestibular nerve,vestibular nerve,
vestibular nucleus, medialvestibular nucleus, medial
vestibulospinal tract,vestibulospinal tract,
accessory nucleus,accessory nucleus,
cranial nerve XIcranial nerve XI
 EMG of SCM recordsEMG of SCM records
output after clickoutput after click
stimulation of earstimulation of ear
 Allows unilateral testingAllows unilateral testing

51. Vestibular Evoked MyogenicVestibular Evoked Myogenic
Potentials (VEMP’s)Potentials (VEMP’s)
 VEMP’s may be absent in patients withVEMP’s may be absent in patients with
vestibular neuritisvestibular neuritis
 Patients with lower threshold VEMP’s and aPatients with lower threshold VEMP’s and a
conductive hearing loss same side may haveconductive hearing loss same side may have
SCC dehiscence syndromeSCC dehiscence syndrome
 Absent in bilateral vestibular loss inAbsent in bilateral vestibular loss in
aminoglycoside ototoxicityaminoglycoside ototoxicity
 VEMP‘s show higher thresholds and are absentVEMP‘s show higher thresholds and are absent
in patients with Meniere’s diseasein patients with Meniere’s disease
 Absent in acoustic neuromasAbsent in acoustic neuromas
 May be used in failed vestibular nerve sectionMay be used in failed vestibular nerve section

52. Dr. Peltier’s Dizzy EvaluationDr. Peltier’s Dizzy Evaluation
 History – will give diagnosis in majority of disordersHistory – will give diagnosis in majority of disorders
 PhysicalPhysical

Head and Neck ExamHead and Neck Exam

Spontaneous nystagmus on trackingSpontaneous nystagmus on tracking
• Vertical or direction changing nystagmus =Vertical or direction changing nystagmus =
MRI and neurology referralMRI and neurology referral

Pneumatic OtoscopyPneumatic Otoscopy
• If positiveIf positive considerconsider diagnosis of fistula, Meninere’s, syphilisdiagnosis of fistula, Meninere’s, syphilis

Dix HallpikeDix Hallpike
• If positive, Eply maneuver twice, if still dizzy, ENGIf positive, Eply maneuver twice, if still dizzy, ENG

Head thrust test alone or with head shake nystagmusHead thrust test alone or with head shake nystagmus
• If positive, start vestibular exercisesIf positive, start vestibular exercises
• If no response - ENGIf no response - ENG

Rhomberg TestRhomberg Test
• If equal sway with eyes closed and open neurology referral, ENGIf equal sway with eyes closed and open neurology referral, ENG

53. Dr. Peltier’s Dizzy EvaluationDr. Peltier’s Dizzy Evaluation
• Fukuda stepping test if suspected vestibularFukuda stepping test if suspected vestibular
dysfunction and normal head shake/head thrustdysfunction and normal head shake/head thrust
tests, or proceed to ENGtests, or proceed to ENG
• Orthostatic measurements if directed by historyOrthostatic measurements if directed by history
• Dynamic visual acuity if possibility of bilateral lossDynamic visual acuity if possibility of bilateral loss

AudiogramAudiogram
• Obtain in every dizzy patient. Cost effective examObtain in every dizzy patient. Cost effective exam
for acoustic neuroma, useful in other diagnosisfor acoustic neuroma, useful in other diagnosis

54. Dr. Peltier’s Dizzy EvaluationDr. Peltier’s Dizzy Evaluation

ENGENG
• Patients unresponsive to conservative treatmentPatients unresponsive to conservative treatment
• Severe symptoms and not suspicious of acute vestibularSevere symptoms and not suspicious of acute vestibular
infectioninfection
• Diagnosis uncertain and chronic symptomsDiagnosis uncertain and chronic symptoms
• Pre-op when vestibular ablation procedure consideredPre-op when vestibular ablation procedure considered
• When documentation of vestibular function is necessaryWhen documentation of vestibular function is necessary
• When referred from neurology for evaluationWhen referred from neurology for evaluation

MRIMRI
• Any suspicion of central lesions by physicial, or objectiveAny suspicion of central lesions by physicial, or objective
testingtesting

Posturography/Chair testing/VEMPPosturography/Chair testing/VEMP
• Not available at UTMBNot available at UTMB
• Of questionable clinical utilityOf questionable clinical utility

55. ReferencesReferences
 Kroenke, Lucas, Rosenberg et al.Kroenke, Lucas, Rosenberg et al. Causes of persistent dizziness: a prospectiveCauses of persistent dizziness: a prospective
study of 100 patients in ambulatory care.study of 100 patients in ambulatory care. Ann Intern Med, 117Ann Intern Med, 117 (11), 898-905.(11), 898-905.
 Allum, H.J., & Shepard, N. T. (1999), An overview of the clinical use of dynamicAllum, H.J., & Shepard, N. T. (1999), An overview of the clinical use of dynamic
posturography in the differential diagnosis of balance disorders. J Vestib Res, 9, 223-posturography in the differential diagnosis of balance disorders. J Vestib Res, 9, 223-
252252
 Kaplan, Marais et. al. (2001), Does High-Frequency Pseudo-random Rotational ChairKaplan, Marais et. al. (2001), Does High-Frequency Pseudo-random Rotational Chair
Testing Increase the Diagnostic Yield of the ENG Caloric Test in Detecting BilateralTesting Increase the Diagnostic Yield of the ENG Caloric Test in Detecting Bilateral
Vestibular Loss in the Dizzy Patient? Laryngoscope, 111: 959-963Vestibular Loss in the Dizzy Patient? Laryngoscope, 111: 959-963
 Hain, Timothy, Vestibular Evoked Myogenic Potential (VEMP) TestingHain, Timothy, Vestibular Evoked Myogenic Potential (VEMP) Testing
http://www.dizziness-and-balance.com/testing/vemp.htmlhttp://www.dizziness-and-balance.com/testing/vemp.html
 Hajioff, D et. al. Is electronystagmography of diagnostic value in the elderly? ClinicalHajioff, D et. al. Is electronystagmography of diagnostic value in the elderly? Clinical
Otolaryngology, 27(1) Feb. 2002 pp 27-31Otolaryngology, 27(1) Feb. 2002 pp 27-31
 Desmond, Alan. Vestibular Function: Evaluation and Treatment. Thieme MedicalDesmond, Alan. Vestibular Function: Evaluation and Treatment. Thieme Medical
Publishers, INC New York, NY 2004. pp 65-111.Publishers, INC New York, NY 2004. pp 65-111.
 Stockwell, Charles. Introduction to ENG. ICS Medical, Schaumburg, Illinois, 2001,Stockwell, Charles. Introduction to ENG. ICS Medical, Schaumburg, Illinois, 2001,
multiple pages.multiple pages.
 Stockwell, Charles. Catalog of ENG abnormalities.Stockwell, Charles. Catalog of ENG abnormalities. ICS Medical, Schaumburg,ICS Medical, Schaumburg,
Illinois, 2001, multiple pages.Illinois, 2001, multiple pages.