Clinical Tests for Vestibular Function Dr. Vishal Sharma.
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Transcript of Clinical Tests for Vestibular Function Dr. Vishal Sharma.
![Page 1: Clinical Tests for Vestibular Function Dr. Vishal Sharma.](https://reader038.fdocuments.us/reader038/viewer/2022102616/551b1ba1550346cf5a8b5587/html5/thumbnails/1.jpg)
Clinical Tests for Vestibular Function
Dr. Vishal Sharma
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Nystagmus
• Involuntary rhythmical oscillatory movement of
eye ball
• Vestibular disorders cause jerk nystagmus with
slow & fast phases
• Direction is given by fast phase
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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
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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
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Test for gaze evoked nystagmus
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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).
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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.
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Siegalization
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Sites of labyrinthine fistula
1. Horizontal semicircular canal
Cholesteatoma destruction
Fenestration operation
2. Oval window
Post-stapedectomy
3. Round window membrane rupture
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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
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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)
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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)
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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
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Fitzgerald-Hallpike Bithermal Caloric Test
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Fitzgerald-Hallpike Bithermal Caloric Test
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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
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Normal Calorigram
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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
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Canal Paresis
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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
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Directional Preponderance
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Special cases
Same sided canal paresis + same sided
directional preponderance:
• Acoustic Neuroma
Same sided canal paresis + opposite sided
directional preponderance:
• Meniere’s disease
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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
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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
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Dix – Hallpike maneuvre
(Nylen – Barany maneuvre)
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Step 1
3
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Step 2
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Step 3
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Steps 1 to 3
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Step 4
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Step 3 to 4
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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.
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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
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Epley’s particle repositioning manoeuvre
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Step 1
3
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Step 2
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Step 3
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Step 4
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Step 5
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Step 5 to 6
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Step 6
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Step 7
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Step 8
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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
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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
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Thank You