1. Clinical Tests for Vestibular Function
Dr. Vishal Sharma

2. Nystagmus Involuntary rhythmical oscillatory movement of eye ball
Vestibular disorders cause jerk nystagmus with slow & fast phases
Direction is given by fast phase

3. 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

4. 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

5. Test for gaze evoked nystagmus

6. 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).

7. 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.

8. Siegalization

9. Sites of labyrinthine fistula
1. Horizontal semicircular canal
 Cholesteatoma destruction
 Fenestration operation
2. Oval window
 Post-stapedectomy
3. Round window membrane rupture

10. 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

11. 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)

12. 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)

13. 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

14. Fitzgerald-Hallpike Bithermal Caloric Test

15. Fitzgerald-Hallpike Bithermal Caloric Test

16. 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

17. Normal Calorigram

18. 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

19. Canal Paresis

20. 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

21. Directional Preponderance

22. Special cases
Same sided canal paresis + same sided directional preponderance:
Acoustic Neuroma
Same sided canal paresis + opposite sided directional preponderance:
Meniere’s disease

23. 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

24. 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

25. Dix – Hallpike maneuvre (Nylen – Barany maneuvre)

26. Step 1 3

27. Step 2

28. Step 3

29. Steps 1 to 3

30. Step 4

31. Step 3 to 4

32. 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.

33. 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

34. Epley’s particle repositioning manoeuvre

35. Step 1 3

36. Step 2

37. Step 3

38. Step 4

39. Step 5

40. Step 5 to 6

41. Step 6

42. Step 7

43. Step 8

44. 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

45. 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

46. Thank You