Assessment: Vestibular testing techniques in adults and children

Neurologists are frequently called upon to evaluate patients with vertigo and dizziness and, in some cases, to make sense of abnormal vestibular tests. Consequently, it is useful to have some familiarity with the methods used to test vestibular function. The vestibulo-ocular reflex (VOR) is a reflex that acts at short latency to generate eye movements that compensate for head rotations in order to preserve clear vision during locomotion. The VOR is the most accessible gauge of vestibular function. Evaluating the VOR requires application of a vestibular stimulus and measurement of the resulting eye movements. This report reviews the advantages and limitations of the methods of stimulating the vestibular system: caloric irrigation, rotational chair testing, and auto-rotational testing. Vestibular testing in children is given additional consideration because of the paucity of recent reviews on the topic. This report will not address eye movement recording techniques, the neurophysiology of the VOR, which is reviewed elsewhere,1,2⇓ or interpretation of nystagmus. This evidence-based assessment was developed from a review of published articles obtained through the MEDLINE database of the National Library of Medicine. Relevant publications were rated by the strength of evidence according to a scheme approved by the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology (see Appendix 2). ### Bedside vestibular assessment. Not every dizzy patient needs quantitative vestibular testing. Clinical examination can provide some qualitative information about vestibular function ( table 1). Patients with dizziness should be examined for nystagmus in the supine and lateral head positions as well as following the Dix–Hallpike maneuver. Spontaneous and gaze-evoked nystagmus may help localize the lesion in a patient with a suspected vestibular disorder.2,3⇓ Peripheral vestibular nystagmus is often suppressed by visual fixation, but may be seen during funduscopic examination in the dark. Frenzel goggles have 10+ diopter lenses that prevent fixation, …

[1]  Bradford J McFadyen,et al.  Magnitude effects of galvanic vestibular stimulation on the trajectory of human gait , 2000, Neuroscience Letters.

[2]  Raphaël Maire,et al.  Dynamic Asymmetry of the Vestibulo‐ocular Reflex in Unilateral Peripheral Vestibular and Cochleovestibular Loss , 2000, The Laryngoscope.

[3]  D. Zee,et al.  Hyperventilation-induced nystagmus in patients with vestibular schwannoma , 1999, Neurology.

[4]  M Dieterich,et al.  Galvanic stimulation in bilateral vestibular failure: 3-D ocular motor effects. , 1999, Neuroreport.

[5]  D. Zee,et al.  The effect of hyperventilation on downbeat nystagmus in cerebellar disorders. , 1999, Neurology.

[6]  K. Hamann,et al.  Vibration-Induced Nystagmus – A Sign of Unilateral Vestibular Deficit , 1999, ORL.

[7]  Vicente Honrubia,et al.  Current Status of Electronystagmography Testing , 1999, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[8]  P. Denise,et al.  Vestibular function in children with the CHARGE association. , 1999, Archives of otolaryngology--head & neck surgery.

[9]  M Fujimoto,et al.  Significance of head-shaking nystagmus in the evaluation of the dizzy patient. , 1999, Acta oto-laryngologica. Supplementum.

[10]  A. Böhmer The subjective visual vertical as a clinical parameter for acute and chronic vestibular (otolith) disorders. , 1999, Acta oto-laryngologica.

[11]  J. Bartual,et al.  [Head-thrust test: its validity as a diagnostic clinical test]. , 1999, Anales otorrinolaringologicos ibero-americanos.

[12]  A. Safran,et al.  Subjective visual vertical in peripheral unilateral vestibular diseases. , 1999, Journal of vestibular research : equilibrium & orientation.

[13]  Hamish G. MacDougall,et al.  Maintained ocular torsion produced by bilateral and unilateral galvanic (DC) vestibular stimulation in humans , 1998, Experimental Brain Research.

[14]  M Dieterich,et al.  Effects of galvanic vestibular stimulation on otolithic and semicircular canal eye movements and perceived vertical. , 1998, Electroencephalography and Clinical Neurophysiology.

[15]  M. Redfern,et al.  Visual-Induced Postural Sway in Children with and without Otitis Media , 1998, The Annals of otology, rhinology, and laryngology.

[16]  J. Colebatch,et al.  Vestibular-evoked electromyographic responses in soleus: a comparison between click and galvanic stimulation , 1998, Experimental Brain Research.

[17]  J M Hanson,et al.  Comparison of manual whole-body and passive and active head-on-body rotational testing with conventional rotary chair testing. , 1998, Journal of vestibular research : equilibrium & orientation.

[18]  J. Durrant,et al.  Head-only rotational testing in the elderly. , 1998, Journal of vestibular research : equilibrium & orientation.

[19]  J. Guyot,et al.  Test-Retest Reliability of Vestibular Autorotation Testing in Healthy Subjects , 1997, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[20]  W. Chao,et al.  Head-shaking nystagmus: a sensitive indicator of vestibular dysfunction. , 1997, Clinical otolaryngology and allied sciences.

[21]  T. Hirvonen,et al.  Vestibulo-ocular reflex function as measured with the head autorotation test. , 1997, Acta oto-laryngologica.

[22]  R. D'agostino,et al.  The study of optokinetic 'look' nystagmus in children: our experience. , 1997, International journal of pediatric otorhinolaryngology.

[23]  B. Blakley,et al.  Hearing, language, speech, vestibular, and dentofacial disorders in fetal alcohol syndrome. , 1997, Alcoholism, clinical and experimental research.

[24]  S. Katsuno,et al.  Vestibulo-ocular reflex and visual vestibulo-ocular reflex during sinusoidal rotation in children. , 1997, Acta oto-laryngologica. Supplementum.

[25]  Y. Melamed,et al.  Nonspecific vertigo with normal otoneurological examination. The role of vestibular laboratory tests , 1996, The Journal of Laryngology & Otology.

[26]  T Haslwanter,et al.  Three-dimensional vector analysis of the human vestibuloocular reflex in response to high-acceleration head rotations. II. responses in subjects with unilateral vestibular loss and selective semicircular canal occlusion. , 1996, Journal of neurophysiology.

[27]  Z. Dvir,et al.  Postural stability by computerized posturography in minor head trauma. , 1996, Pediatric neurology.

[28]  R. D'agostino,et al.  Study of labyrinthine function in children using the caloric test: our results. , 1996, International journal of pediatric otorhinolaryngology.

[29]  S R Wiener-Vacher,et al.  Canal and otolith vestibulo-ocular reflexes to vertical and off vertical axis rotations in children learning to walk. , 1996, Acta oto-laryngologica.

[30]  The contribution of the vertical semicircular canals to high-velocity horizontal vestibulo-ocular reflex (VOR) in normal subjects and patients with unilateral vestibular nerve section. , 1996, Acta oto-laryngologica.

[31]  Lippincott Williams Wilkins,et al.  Assessment: Electronystagmography Report of the Therapeutics and Technology Assessment Subcommittee , 1996, Neurology.

[32]  G. Michael Halmagyi,et al.  Disorders of the vestibular system , 2006, Pathy's Principles and Practice of Geriatric Medicine.

[33]  K. Money,et al.  Visual influence on head shaking using the vestibular autorotation test. , 1996, Journal of vestibular research : equilibrium & orientation.

[34]  R. A. Yavor,et al.  Tapping the head activates the vestibular system , 1995, Neurology.

[35]  E Vitte,et al.  Assessment of vestibular function by videonystagmoscopy. , 1995, Journal of vestibular research : equilibrium & orientation.

[36]  C. Bower,et al.  The spectrum of vertigo in children. , 1995, Archives of otolaryngology--head & neck surgery.

[37]  J. Furman,et al.  Effect of Otitis Media on the Vestibular System in Children , 1995, The Annals of otology, rhinology, and laryngology.

[38]  J. Furman,et al.  Head-only rotational testing: influence of volition and vision. , 1995, Journal of vestibular research : equilibrium & orientation.

[39]  Head-shake vestibulo-ocular reflex testing: comparison of results with rotational chair testing. , 1995, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[40]  J. Demer Evaluation of Vestibular and Visual Oculomotor Function , 1995, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[41]  H. Kingma,et al.  Quantitative evaluation of the Vestibular Autorotation Test (VAT) in normal subjects. , 1995, Acta oto-laryngologica. Supplementum.

[42]  A quantitative analysis of head-shaking nystagmus of peripheral vestibular origin. , 1995, Acta oto-laryngologica. Supplementum.

[43]  I. Koizuka,et al.  Time course of vestibular function in patients with menière's disease following vestibular nerve section. , 1995, Acta oto-laryngologica. Supplementum.

[44]  Evaluation of the human vestibulo-ocular reflex at high frequencies with a helmet, driven by reactive torque. , 1995, Acta oto-laryngologica. Supplementum.

[45]  I. Curthoys,et al.  New tests of vestibular function. , 1994, Bailliere's clinical neurology.

[46]  Murphy Tp Vestibular autorotation and electronystagmography testing in patients with dizziness. , 1994 .

[47]  L. Eviatar Dizziness in children. , 1994, Otolaryngologic clinics of North America.

[48]  D. O'leary,et al.  Autorotation Test Abnormalities of the Horizontal and Vertical Vestibulo-Ocular Reflexes in Panic Disorder , 1994, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[49]  B Hoshowsky,et al.  The horizontal vestibulo‐ocular reflex gain during active and passive high‐frequency head movements , 1994, The Laryngoscope.

[50]  G M Halmagyi,et al.  Myogenic potentials generated by a click-evoked vestibulocollic reflex. , 1994, Journal of neurology, neurosurgery, and psychiatry.

[51]  T. P. Murphy Vestibular autorotation and electronystagmography testing in patients with dizziness. , 1994, The American journal of otology.

[52]  R. Leigh,et al.  The cervico-ocular reflex of normal human subjects in response to transient and sinusoidal trunk rotations. , 1994, Journal of vestibular research : equilibrium & orientation.

[53]  David F. Henry,et al.  Closed-Loop Caloric, Harmonic Acceleration and Active Head Rotation Tests: Norms and Reliability , 1993, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[54]  R W Baloh,et al.  Disequilibrium of unknown cause in older people , 1993, Annals of neurology.

[55]  D. Faraggi,et al.  Is the Vestibular System Affected by Middle Ear Effusion? , 1993, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[56]  D. O'leary,et al.  Autorotation Test of the Horizontal Vestibulo-Ocular Reflex in Meniere's Disease , 1993, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[57]  R. Leigh,et al.  A reevaluation of the vestibulo‐ocular reflex , 1993, Neurology.

[58]  Craig W. Newman,et al.  Handbook of Balance Function Testing , 1993 .

[59]  Hall Sf,et al.  Is head-shaking nystagmus a sign of vestibular dysfunction? , 1992 .

[60]  K. Kaga,et al.  Delayed motor function and results of vestibular function tests in children with inner ear anomalies. , 1992, International journal of pediatric otorhinolaryngology.

[61]  J A Goebel,et al.  Utility of headshake versus whole-body VOR evaluation during routine electronystagmography. , 1992, The American journal of otology.

[62]  R. Leigh,et al.  High‐Frequency Vestibuloocular Reflex as a Diagnostic Tool a , 1992, Annals of the New York Academy of Sciences.

[63]  M. Laird,et al.  Is head-shaking nystagmus a sign of vestibular dysfunction? , 1992, The Journal of otolaryngology.

[64]  The high-frequency oscillopsia test. , 1992, Journal of vestibular research : equilibrium & orientation.

[65]  G. Paige,et al.  Headshake versus whole‐body rotation testing of the vestibulo‐ocular reflex , 1991, The Laryngoscope.

[66]  J. Masdeu,et al.  Monocular elevation weakness and ptosis: an oculomotor fascicular syndrome? , 1991, Journal of clinical neuro-ophthalmology.

[67]  A. Bronstein,et al.  The neck-eye reflex in patients with reduced vestibular and optokinetic function. , 1991, Brain : a journal of neurology.

[68]  D. O'leary,et al.  Vestibular autorotation test asymmetry analysis of acoustic neuromas , 1991, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[69]  D. Zee Adaptation to vestibular disturbances: some clinical implications. , 1991, Acta neurologica Belgica.

[70]  G M Gauthier,et al.  Eye-head movement coordination: vestibulo-ocular reflex suppression with head-fixed target fixation. , 1991, Journal of vestibular research : equilibrium & orientation.

[71]  D. O'leary,et al.  Vestibular Autorotation Testing of Meniere's Disease , 1990, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[72]  C. Newman,et al.  Sensitivity and Specificity of the Head-Shaking Test for Detecting Vestibular System Abnormalities , 1990, The Annals of otology, rhinology, and laryngology.

[73]  A Kasteel-van Linge,et al.  Quantification of visuo-vestibular interaction up to 5.0 Hz in normal subjects. , 1990, Acta oto-laryngologica.

[74]  R. Leigh,et al.  Instability of gaze during locomotion in patients with deficient vestibular function , 1990, Annals of neurology.

[75]  D. O'leary,et al.  High-frequency autorotational testing of the vestibulo-ocular reflex. , 1990, Neurologic clinics.

[76]  I. Curthoys,et al.  Head impulses after unilateral vestibular deafferentation validate Ewald's second law. , 1990, Journal of vestibular research : equilibrium & orientation.

[77]  J. Furman,et al.  Rotational responses in patients with bilateral caloric reduction. , 1989, Acta oto-laryngologica.

[78]  Robert J. Peterka,et al.  Effects of Unilateral Loss of Vestibular Function on the Vestibulo-Ocular Reflex and Postural Control , 1989, The Annals of otology, rhinology, and laryngology.

[79]  R. Leigh,et al.  Maturation of the vestibulo‐ocular reflex in normal infants during the first 2 months of life , 1989, Neurology.

[80]  M. Takahashi,et al.  Failure of gaze stabilization under high-frequency head oscillation. , 1989, Acta oto-laryngologica.

[81]  R. Baloh,et al.  Idiopathic bilateral vestibulopathy , 1989, Neurology.

[82]  G. Kenyon Neuro-Otological Findings in Normal Children , 1988, Journal of the Royal Society of Medicine.

[83]  M. Graham,et al.  The Vestibular system : neurophysiologic and clinical research , 1988 .

[84]  I S Curthoys,et al.  A clinical sign of canal paresis. , 1988, Archives of neurology.

[85]  D. O'leary,et al.  Analysis of vestibulo-ocular reflex using sweep frequency active head movements. , 1988, Advances in oto-rhino-laryngology.

[86]  F. Linthicum,et al.  Infrared/Video Eng Recording of Eye Movements to Evaluate the Inferior Vestibular Nerve Using the Minimal Caloric Test , 1988, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[87]  R. Tomlinson,et al.  Vestibulo-Ocular (VOR) Abnormalities at High Rotational Frequencies in Patients with Meniere' Disease , 1988, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[88]  S. L. Levens Electronystagmography in normal children. , 1988, British journal of audiology.

[89]  Active Head-Movement Analysis of Cisplatin-Induced Vestibulotoxicity , 1988, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[90]  D. O'leary,et al.  Use of active head movements for computerized vestibular testing. , 1987, Archives of otolaryngology--head & neck surgery.

[91]  M Fetter,et al.  Head-shaking nystagmus in patients with unilateral peripheral vestibular lesions. , 1987, American journal of otolaryngology.

[92]  S. Staller,et al.  Pediatric Vestibular Evaluation with Harmonic Acceleration , 1986, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[93]  R. Yee,et al.  Vestibulo-ocular reflexes in peripheral labyrinthine lesions: III. Bilateral dysfunction. , 1985, American journal of otolaryngology.

[94]  P. Brookhouser,et al.  Vestibular evaluation of infants and preschool children. , 1985, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery.

[95]  H. Polatajko A CRITICAL LOOK AT VESTIBULAR DYSFUNCTION IN LEARNING‐DISABLED CHILDREN , 1985, Developmental medicine and child neurology.

[96]  R. Yee,et al.  Rotational testing in patients with bilateral peripheral vestibular disease , 1985, The Laryngoscope.

[97]  R. Yee,et al.  Changes in the human vestibulo‐ocular reflex after loss of peripheral sensitivity , 1984, Annals of neurology.

[98]  R. Yee,et al.  Vestibulo-ocular reflexes in peripheral labyrinthine lesions , 1984 .

[99]  Vestibular Function Tests in Children , 1983, Journal of the Royal Society of Medicine.

[100]  D. Schwarz,et al.  Quantification and localization of vestibular loss in unilaterally labyrinthectomized patients using a precise rotatory test. , 1983, Acta oto-laryngologica.

[101]  L. Odkvist,et al.  Quantification of slow compensatory eye movements in patients with bilateral vestibular loss. A study with a broad frequency-band rotatory test. , 1983, Acta oto-laryngologica.

[102]  D. Galin,et al.  Dyslexic children have normal vestibular responses to rotation. , 1983, Archives of neurology.

[103]  F. Guedry,et al.  The vestibulo-ocular reflex in man during voluntary head oscillation under three visual conditions. , 1982, Aviation, space, and environmental medicine.

[104]  A. Di Carlo,et al.  Vestibular ototoxicity in children: a retrospective study of 52 cases. , 1981, International journal of pediatric otorhinolaryngology.

[105]  D. Dehesdin,et al.  Normal vestibular responses to air caloric tests in children. , 1981, International journal of pediatric otorhinolaryngology.

[106]  D. Cyr,et al.  Vestibular Testing in Children , 1980, The Annals of otology, rhinology & laryngology. Supplement.

[107]  R. Tomlinson,et al.  Analysis of human vestibulo-ocular reflex during active head movements. , 1980, Acta oto-laryngologica.

[108]  K. Ottenbacher Excessive postrotary nystagmus duration in learning-disabled children. , 1980, The American journal of occupational therapy : official publication of the American Occupational Therapy Association.

[109]  V Honrubia,et al.  Clinical Neurophysiology of the Vestibular System , 1980, Neurology.

[110]  L. Eviatar,et al.  The normal nystagmic response of infants to caloric and perrotatory stimulation. , 1979, The Laryngoscope.

[111]  R. Baloh,et al.  Impulsive and sinusoidal rotatory testing: A comparison with results of caloric testing , 1979, The Laryngoscope.

[112]  G Mulch,et al.  Influence of Age on Results of Vestibular Function Tests: Review of Literature and Presentation of Caloric Test Results , 1979, The Annals of otology, rhinology & laryngology. Supplement.

[113]  E. Hartmann,et al.  The maturation of vestibular nystagmus in infancy and childhood. , 1979, Acta oto-laryngologica.

[114]  Cummings Cw Ann Otol Rhinol Laryngol [Suppl]. , 1978 .

[115]  Takeshi Kasai,et al.  Eye-head coordination in labyrinthine-defective human beings , 1978, Brain Research.

[116]  L. Eviatar,et al.  Neurovestibular Examination of Infants and Children1 , 1978 .

[117]  L. Eviatar,et al.  Neurovestibular examination of infants and children. , 1978, Advances in oto-rhino-laryngology.

[118]  I. Rapin Hypoactive Labyrinths and Motor Development , 1974, Clinical pediatrics.

[119]  E Bizzi,et al.  The role of vestibular and neck afferents during eye-head coordination in the monkey. , 1974, Brain research.

[120]  篤 小松崎 Electronystagmography. , 1973, Archives of otolaryngology.

[121]  D. Cogan,et al.  An apparatus for grading the visual acuity of infants on the basis of opticokinetic nystagmus. , 1957, Pediatrics.

[122]  J. Stahle,et al.  Nystagmography; recording of nystagmus in clinical neuro-otological examinations. , 1956, Acta oto-laryngologica. Supplementum.