Clinical Tests for Vestibular Function

Dr. Vishal Sharma

Nystagmus

• Involuntary rhythmical oscillatory movement of

eye ball

• Vestibular disorders cause jerk nystagmus with

slow & fast phases

• Direction is given by fast phase

Nystagmus

Intensity grading (Alexander’s law):

1° only present when looking

towards fast phase

2° also seen when looking straight

3° also seen when looking

towards slow phase

Nystagmus

• Vestibular lesion nystagmus gets suppressed

by optic fixation & enhanced with its removal

with Frenzel glasses

• Irritative vestibular labyrinthine lesion:

Ipsilateral nystagmus

• Paralytic vestibular labyrinthine lesion:

Contralateral nystagmus

Test for gaze evoked nystagmus

Test for gaze evoked nystagmus

Examiner’s finger kept 30 cm from pt's eyes in

centre. Moved in horizontal & vertical planes. Pt

is asked to follow it with his eyes. Keep

displacement from midline to maximum of 30°

(to avoid physiological end-point nystagmus).

Fistula test

Transmission of increased air pressure in

E.A.C., via middle ear, into inner ear through a

labyrinthine fistula causes vertigo + nystagmus

towards affected ear. E.A.C. pressure is by

intermittent tragal pressure or Siegelization.

Siegalization

Sites of labyrinthine fistula

1. Horizontal semicircular canal

Cholesteatoma destruction

Fenestration operation

2. Oval window

Post-stapedectomy

3. Round window membrane rupture

Hennebert’s sign

False positive fistula sign in absence of

labyrinthine fistula.

1. Meniere's disease (fibrosis b/w

stapes footplate & utricle)

2. Hyper mobile stapes footplate

Congenital syphilis

Idiopathic

False negative fistula sign

Negative fistula sign in presence of

labyrinthine fistula.

1. Cholesteatoma / granulation covering

the labyrinthine fistula

2. Dead Labyrinth

3. Total E.A.C. obstruction (impacted wax)

Fitzgerald-Hallpike Bithermal Caloric Test

Contraindications:

1. E.A.C. obstruction

2. Ear infection

3. T.M. perforation

4. Bradyarrythmias

5. Labyrinthine sedatives (for 24 hrs)

Mechanism

Convection current formation in endo-lymph

due to temperature gradient → ampullo-petal

flow or ampullo-fugal flow due to warm or cold

water activation of Vestibulo-Ocular Reflex →

vertigo + horizontal nystagmus

Fitzgerald-Hallpike Bithermal Caloric Test

Fitzgerald-Hallpike Bithermal Caloric Test

Procedure

Pt supine + 30° head elevation. Each ear irrigated

in turn for 40 sec with warm water at 44°C & then

cold water at 30°C.

Duration of nystagmus is from start of irrigation

to end point of nystagmus. Normal = 90–140 sec

Direction of fast component:

Cold → Opposite ear; Warm → Same ear

Normal Calorigram

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

Canal Paresis

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

Directional Preponderance

Special cases

Same sided canal paresis + same sided

directional preponderance:

• Acoustic Neuroma

Same sided canal paresis + opposite sided

directional preponderance:

• Meniere’s disease

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 (40 ml) = Dead labyrinth

Dundas Grant Cold Air Caloric Test

• Done in T.M. perforation as water syringing is

contraindicated

• Air in coiled copper tube is cooled by pouring

ethyl chloride in it

• Effluent cool air is blown into E.A.C. to

produce vertigo + nystagmus

Dix – Hallpike maneuvre

(Nylen – Barany maneuvre)

Step 1

3

Step 2

Step 3

Steps 1 to 3

Step 4

Step 3 to 4

Dix-Hallpike Manoeuvre

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. Pt’s eyes

observed for nystagmus for 1 minute.

4. Pt moved rapidly back into sitting position.

5. Manoeuvre repeated for opposite ear.

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 sit position

Fatiguing on repeating Hallpike maneuver

Associated vertigo & autonomic symptoms

Epley’s particle repositioning manoeuvre

Step 1

3

Step 2

Step 3

Step 4

Step 5

Step 5 to 6

Step 6

Step 7

Step 8

Epley’s Manoeuvre

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

Epley’s Manoeuvre

7. Pt’s head brought in midline

8. Slight flexion of pt’s head

Cervical collar given to pt 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 manoeuvre if it is done properly

Thank You