This document describes various clinical tests used to evaluate vestibular function, including nystagmus grading, caloric testing, Dix-Hallpike maneuver, and Epley's particle repositioning maneuver. Nystagmus and its characteristics help localize vestibular lesions. Caloric testing assesses each ear's function by irrigating with warm and cold water. Dix-Hallpike and Epley's maneuver are used to provoke nystagmus associated with BPPV. Epley's maneuver aims to reposition loose otoliths in the semicircular canals.

1. Routine Clinical Tests of
Vestibular Function
Dr. Krishna Koirala
2018-07-17

2. Nystagmus
• Rhythmic, involuntary, oscillatory movement of
eyeball
• Vestibular disorders cause nystagmus with slow and
fast phases
– The slow phase of the nystagmus is the direction of
flow of endolymph and is vestibular in origin
– The fast phase is most likely initiated by the
reticular formation as a compensatory mechanism

3. Intensity grading of Nystagmus
• First Degree
– Only present when gazing towards the direction of
fast phase
• Second degree
– Seen when gazing towards the fast phase and
straight gaze
• Third degree
– Seen even when looking towards the slow phase

4. • Vestibular nystagmus
– Suppressed by optic fixation
– Enhanced with use of Frenzel glasses (remove
optic fixation)
• Irritative vestibular labyrinthine lesion causes
ipsilateral nystagmus
• Paralytic vestibular labyrinthine lesion gives rise to
contralateral nystagmus

5. Frenzel’s glasses

6. Test for gaze evoked nystagmus
• Examiner’s finger / pointed objects
kept 30 cm away from pt's eyes in
centre and moved in horizontal and
vertical planes not exceeding 30°
(to avoid physiological end-point
nystagmus)
• Pt is asked to follow it with his eyes
• Examiner looks for nystagmus

7. Fistula test
• Transmission of increased air pressure into inner
ear through a labyrinthine fistula causes vertigo
and nystagmus towards the affected ear
• E.A.C. pressure is increased by intermittent tragal
pressure or Siegelization

8. Sites of labyrinthine fistula
• Horizontal semicircular canal
– Cholesteatoma destruction
– Fenestration operation
• Oval window
– Post-stapedectomy
• Round window membrane rupture

9. Hennebert’s sign
• False positive fistula sign in absence of labyrinthine
fistula
• Seen in
– Meniere's disease (fibrosis between stapes
footplate and utricle)
– Hyper mobile stapes footplate (congenital syphilis,
idiopathic)

10. False negative fistula sign
• Negative fistula sign in presence of labyrinthine
fistula
• Seen in
– Cholesteatoma / granulation covering the
labyrinthine fistula
– Dead Labyrinth
– Total E.A.C. obstruction

11. Romberg’s Test
• Test of vestibulospinal function
• Pt. is asked to stand with feet
together and arms by the side with
eyes first open ( can compensate the
balance) and then closed ( cannot
compensate the balance and sways
to side of lesion )
• Sharpened Romberg’s if Romberg is
negative

12. Fukuda Stepping Test ( Unterberger’s
stepping test)
• Patient asked to make 90
steps in one minute with eyes
closed and hands out in front
in a circle of 1 metre
• More than 30 degree
deviation is taken as positive

13. • Mechanism
– Convection current formation in endolymph due to
temperature gradient → ampullo-petal or ampullo-fugal
flow due to warm or cold water  activation of Vestibulo-
Ocular Reflex → vertigo and horizontal nystagmus
• Contraindications
– E.A.C. obstruction, Ear infection, T.M. perforation,
Bradyarrythmias, Labyrinthine sedatives (for 24 hrs)
Fitzgerald - Hallpike Bithermal Caloric Test

14. Procedure
• Pt lies supine with 30° head elevation and each ear
is irrigated in turn for 40 sec with warm water at 44°C
& then cold water at 30°C after a gap of 8 mins
• Duration of nystagmus is counted from start of
irrigation to end point of nystagmus (Normal = 90–
140 sec)
– Direction of fast component
– Cold → Opposite ear
– Warm → Same ear

15. Normal Calorigram

16. Canal Paresis
• Duration of nystagmus with both 44°C & 30°C
irrigations in one ear is 30 % less than opposite ear
• Seen in same sided peripheral vestibular lesion
• C. P. (%) = (R30 + R44) – (L30 + L44) X 100
R30 + R44 + L30 + L44

17. Canal Paresis

18. Directional Preponderance
• Duration of nystagmus in one direction is 30 % more
than opposite direction
• Seen in same sided central vestibular lesion &
opposite peripheral vestibular lesion
• D.P. (%) = (L30 + R44) – (R30 + L44) X 100
R30 + R44 + L30 + L44

19. Directional Preponderance

20. Special cases
• Ipsilateral canal paresis and ipsilateral directional
preponderance
– Acoustic Neuroma
• Ipsilateral canal paresis and contralateral directional
preponderance
– Meniere’s disease

21. Modified Kobrak's Test
• E.A.C. irrigated for 60 sec with ice cold water in
increasing quantity (5, 10, 20 & 40 ml) till nystagmus
is noticed
• Nystagmus noticed with
– 5 ml = Normal vestibular labyrinth
– 10 / 20 / 40 ml = Hypoactive labyrinth
– No nystagmus in 40 ml = Dead labyrinth

22. Dundas Grant Cold Air Caloric Test
• Performed in T.M. perforation as water syringing is
contraindicated
• Air in coiled copper tube is cooled by pouring ethyl
chloride in it
• Effluent cold air is blown into E.A.C. to produce
vertigo + nystagmus

23. Dix – Hallpike maneuver
(Nylen – Barany maneuver)

24. Used to provoke nystagmus and vertigo commonly
associated with BPPV
1. Pt in sitting position on a couch
2. Pt’s head turned 45° towards diseased ear to maximally
stimulate posterior semicircular canal
3. Pt moved rapidly into supine position with head hanging 30°
below couch. Pt’s eyes observed for nystagmus for 1 minute
(Frenzel glasses eliminate visual fixation suppression of response)
4. Pt moved rapidly back into sitting position
5. Maneuver repeated for the opposite ear

27. Nystagmus in B.P.P.V.
• Latent period (2–20 sec) before nystagmus
• Rotatory
• Fixed direction, towards ground (geotropic)
• Duration < 1 minute due to adaptation
• Direction reversal on return to sitting position
• Fatigues on repeating Hallpike maneuver
• Presence of associated vertigo and autonomic
symptoms

28. Epley’s particle repositioning
maneuver

29. Epley’s Maneuver
1. Pt in sitting position on a couch
2. Pt’s head turned 45° towards diseased ear
3. Pt moved rapidly into supine position with head
hanging 30° below couch
4. Pt’s head rotated by 90° to opposite side
5. Further 90° head + trunk rotation
6. Pt moved rapidly back into sitting position

30. Epley’s Maneuver
7. Pt’s head brought in midline
8. Slight flexion of pt’s head
– Cervical collar applied for 48 hours
– Pt to sleep in 30o
head end elevation & avoid
violent head jerks
– Pt must have nystagmus at every step of Epley’s
maneuver if it is done properly