Does the video head impulse test replace caloric testing in the assessment of patients with chronic dizziness? A systematic review and meta-analysis

A Preliminary Data Visualization Approach to Vestibulocochlear Diseases Based on Multiple Scalar Dimensions

For vestibulocochlear diseases, traditional clinical history-taking, and the terminology of widely taught nosologic taxonomy, have misleading implications that can lead to errors in diagnosis and therefore in treatment. In the interest of facilitating differential diagnosis while simultaneously recognizing that many of these diseases may not be as discrete as textbooks suggest, we propose a data visualization approach focusing on several continuous scalar dimensions in the domains of anatomy, physiology, and chronology. We illustrate the application of this approach to several categories of clinical presentation.

Evaluation of Semicircular Canal Function Using Video Head Impulse Test in Patients With Peripheral Vestibular Disorders Without Nystagmus

Objectives This study aims to evaluate semicircular canal function using video head impulse test (vHIT) in patients with peripheral vestibular disorders without nystagmus. Methods Patients who underwent vHIT were enrolled in this study, and the proportion of abnormal findings on vHIT in patients without nystagmus was investigated. In addition, the results of vestibular testing were investigated in cases in which both vHIT and caloric testing were performed in patients without nystagmus. Results Forty-six patients (23.4%) of 197 patients who had no abnormal findings on the nystagmus tests, including the gaze nystagmus test, positional nystagmus test, and positioning nystagmus test, showed dysfunction in at least one semicircular canal on vHIT. The most frequent diagnosis was vestibular schwannoma (14/46, 30.4%), and cases with bilateral vestibular dysfunction were also included (12/46, 26.1%). A disorganized pattern of catch-up saccade was observed more frequently in patients with subjective symptoms of dizziness/vertigo compared to those without subjective symptoms. Although the sensitivity of vHIT was low compared to caloric testing, vHIT could detect isolated vertical canal dysfunction not detected by caloric testing. Conclusions vHIT is considered to be a useful test for patients without nystagmus, as vHIT could detect abnormalities in approximately one-quarter of patients without nystagmus. vHIT is considered to be one of the first tests to be performed following nystagmus testing, including the gaze nystagmus test, the positional nystagmus test, and the positioning nystagmus test. On the other hand, there are some cases in which vHIT shows no abnormality while caloric testing shows canal paresis. It is necessary to perform vHIT, bearing in mind that there are abnormalities that cannot be detected by vHIT alone.

Comparative utility of vestibular function tests in patients with peripheral and central vestibular dysfunction

Background

Bithermal caloric irrigation, video head impulse test (vHIT), and rotational testing are commonly used to assess peripheral vestibular function, but the relative clinical utility of each test in differentiating patients with peripheral vestibulopathy is debated.

Objectives

To determine whether (1) the combination of two or more vestibular tests enhances diagnostic utility over a single test; (2) abnormal test results on vestibular tests correlate with one another.

Methods

Retrospective analysis of data collected from multidisciplinary vestibular clinics at two academic medical centers from 2016 to 2022.

Results

150 patients (54.10 ± 15.09 years, 88 females) were included. No individual test was significantly better at predicting the presence of peripheral vestibular damage (p > 0.05). vHIT test results improved significantly when combined with either the caloric test (p = 0.007) or rotary chair test (p = 0.039). Caloric and rotational testing had high sensitivity (74.65% and 76.06%, respectively) and specificity (83.54% and 78.48%, respectively). vHIT demonstrated excellent specificity (89.87%) but poor sensitivity (47.89%). Caloric, vHIT, and rotary chair tests results did not correlate with one another (p > 0.05).

Conclusions

Vestibular function tests have comparable diagnostic utility, yet each offers unique advantages. Caloric and rotational testing may be best suited for screening peripheral damage and vHIT may function ideally as a confirmatory test.

Dissociation between video head impulse test and caloric test: a marker of menière's disease? - A systematic review and meta-analysis

OBJECTIVE

To analyze, by means of a systematic review and meta-analysis, the proportion of patients with Meniere's disease who have altered caloric test and vHIT, as well as to determine the prevalence of altered caloric test and normal vHIT dissociation in the diagnosis of Meniere's disease.

METHODS

The literature search had no restriction regarding the period of publication on the following indexed data platforms: PubMed, PubMed PMC, BVS-Bireme, Web of Science, Embase and Cochrane Library. Articles that evaluated patients with Meniere's disease who underwent caloric test and vHIT were included. Two researchers independently conducted the analysis of the articles, promoting the selection and capture of data, following the recommendations of the PRISMA method, and complying with the criteria for articles inclusion and exclusion defined in the research protocol. In case of disagreement during the selection process, a third researcher was included for analysis.

RESULTS

From a total of 427 initial studies, the researchers selected 12 articles, published between 2014 and 2021, with a total of 708 patients evaluated, with a mean age of 52.72 years old. The prevalence of patients with Meniere's disease with altered caloric reflex test was 64% (95% CI 57%‒71%), while the prevalence of altered vHIT was only 28% (95% CI 16%-40%). The prevalence of the altered caloric test + normal vHIT dissociation was 47% (95% CI 37%-57%).

CONCLUSION

The video head impulse test and the caloric test are valuable tools for vestibular assessment. The dissociation of findings between these two tests in patients with Meniere's disease was more prevalent in this meta-analysis and may be a result of the tonotopy of specialized hair cells in the ampullary crest. The prevalence of altered caloric test was 64% and anormal vHIT was 28%. The dissociation caloric asymmetry and normal vHIT was observed in 47% of the patients.

LEVEL OF EVIDENCE: 1

Clinical features of persistent postural-perceptual dizziness with isolated otolith dysfunction as revealed by VEMP and vHIT findings

Background

Persistent postural-perceptual dizziness (PPPD) is a relatively new disease entity, with diagnostic criteria published by the Bárány Society. PPPD is often preceded by a peripheral or central vestibular disorder. It is not clear how coexisting deficits due to preceding vestibular disorders affect PPPD symptoms.

Objective

This study aimed to characterize the clinical features of PPPD with or without isolated otolith dysfunction using vestibular function tests.

Methods

The study included 43 patients (12 males and 31 females) who were diagnosed with PPPD and completed oculomotor-vestibular function tests. The Dizziness Handicap Inventory (DHI), Hospital Anxiety and Depression Scale (HADS), Niigata PPPD Questionnaire (NPQ), and Romberg test for stabilometry were examined. The 43 patients with PPPD were classified into four categories based on vestibular evoked myogenic potential (VEMP) and video head impulse test (vHIT) results: normal function for both semicircular canals and otoliths (normal), isolated otolith dysfunction (iOtoDys), isolated semicircular canal dysfunction (iCanalDys), and dysfunction of both otoliths and semicircular canals (OtoCanalDys).

Results

Among the 43 patients with PPPD, the iOtoDys group was the largest (44.2%), followed by the normal group (37.2%), iCanalDys group (9.3%), and OtoCanalDys group (9.3%). Eight of the 19 iOtoDys patients showed both abnormal cVEMP and oVEMP responses unilaterally or bilaterally (both sacculus and utriculus damage type), whereas 11 showed either an abnormal cVEMP or an abnormal oVEMP response (either sacculus or utriculus damage type). In a three-group comparison of the both sacculus and utriculus damage type, the either sacculus or utriculus damage type, and the normal group, the mean total, functional, and emotional DHI scores were significantly higher for the both sacculus and utriculus damage type than for the either sacculus or utriculus damage type. The Romberg ratio, a measure of stabilometry, was significantly higher for the normal group than for the both sacculus and utriculus damage type and the sacculus or utriculus damage type in the iOtoDys group.

Conclusions

The coexistence of sacculus and utriculus damage may exacerbate dizziness symptoms in patients with PPPD. Determining the presence and extent of otolith damage in PPPD may provide useful information on the pathophysiology and treatment strategies of PPPD.

Accelerated Cognitive Decline Associated With Hearing Loss and Bilateral Vestibulopathy: Insights From a Prospective Cross-Sectional Study Using the Repeatable Battery for the Assessment of Neuropsychological Status Adjusted for the Hearing Impaired in the DFNA9 Population

BACKGROUND

DeaFNess Autosomal dominant 9 (DFNA9) is a hereditary disorder known to affect both hearing and vestibular function in its carriers. Its phenotype is characterized by progressive sensorineural hearing loss (SNHL) and vestibular dysfunction evolving towards bilateral vestibulopathy (BV) by the 3rd to 5th life decade. Recent studies have identified the impact of hearing loss and vestibular dysfunction on cognitive functioning.

OBJECTIVE

The main objective of this study was to investigate how the cognitive functioning of carriers of the p.Pro51Ser variant in the COCH gene is affected by the disease and compare these results with a matched healthy control group.

STUDY DESIGN

Forty-six carriers of the pathogenic p.Pro51Ser variant in the COCH gene were included in this study, of which 38 met the Bárány Society criteria and were thus diagnosed with BV. All subjects were between the age of 22 and 72 years old. Each control was individually matched based on age, gender, and education level. A cognitive, vestibular, and hearing assessment was performed in all subjects. All participants completed the Repeatable Battery for the Assessment of Neuropsychological Status, adjusted for the Hearing Impaired (RBANS-H), a cognitive test battery that includes subtests probing Immediate and Delayed Memory, Visuospatial/Constructional, Language, and Attention.

RESULTS

Overall, the DFNA9 patients demonstrated significantly lower scores on the Immediate Memory subscale and lower Total Scale scores than their healthy matched controls. The total sample was divided into two groups: age <55 years old and age ≥55 years old. The DFNA9 group aged ≥55 years old obtained significantly lower scores on the Attention subscale and lower Total Scale scores than their matched controls. Cognition of DFNA9 patients aged <55 years old no longer differed significantly from their matched controls.

CONCLUSION

This cross-sectional study found that DFNA9 patients demonstrated cognitive deficits in comparison with their healthy matched controls. The DFNA9 group aged ≥ 55 years old obtained significantly lower scores on the Total Scale and Attention subscale. This finding; however, was not observed for the age group younger than 55 years old. Further research is needed on the individual trajectory of SNHL and vestibular function, and how hearing rehabilitation affects cognitive functioning.

What does the video head impulse test tell us about post-caloric vestibular recruitment?

OBJECTIVE

The vestibular recruitment observed in caloric testing is a new tool in the study of the vestibulo-ocular reflex. This study aimed to determine the sensitivity and specificity of the video head impulse test to detect post-caloric vestibular recruitment.

METHOD

In this cross-sectional study, all participants underwent the standard otoneurological assessment of the service, caloric test, and video head impulse test. A non-linear mixed model was used to test for associations.

RESULTS

The study group consisted of 250 (89 male and 161 female) patients, with a mean age of 54.84 years. The control group comprised 35 participants, 18 men and 17 women, with a mean age of 40.42 years. Sex and age had no effect on group responses. There was no difference between the study and control groups regarding the interaction between recruitment and gain (p = 0.7487); recruitment and overt (p = 0.7002) and covert saccades (p = 1.0000); and recruitment and anti-compensatory saccades in the contralateral ear (p = 0.3050). The video head impulse test had a sensitivity of 51% and a specificity of 50% as a predictor of post-caloric recruitment.

CONCLUSION

The video head impulse test results showed no relevance in predicting post-caloric vestibular recruitment.

Caloric and video head impulse test dissociated results in dizzy patients

Introduction

We are now able to detect abnormalities for any semicircular canal with the use of the video head impulse test (vHIT). Prior to the vHIT, the gold standard for unilateral canal paresis of the lateral canal was considered the caloric test. Clinical cases where the caloric test and vHIT are discordant are not uncommon.

Methods

Retrospective study. All consecutive cases of dizziness seen from 11/2020 to 12/2021 for which the patient underwent both caloric and vHIT tests performed within 10 days, were reviewed. Patients with discordant results were included. We evaluated the caloric response, vHIT gains for all canals and saccades, with and without gain abnormalities.

Results

We included 74 cases of dizziness with dissociated results. The most common finding was a normal caloric response with abnormal vHIT results (60.8%); the main abnormal finding on vHIT was the presence of saccades. In this group, 37.7% of patients had normal gains and refixation saccades. In addition, the most found low gain was for the posterior canal. The main diagnosis in this group was vestibular migraine. For the group with unilateral caloric paresis and normal vHIT gain in the lateral canal, the main diagnosis was Ménière's disease.

Discussion

The most common disorders with discordant results were Ménière's disease and vestibular migraine. The caloric test and vHIT are complementary and combining both tests provide greater clinical information. Further research is needed to understand refixation saccades with normal gains.

[The occurrence and evaluation methods of horizontal semicircular canal dysfunction in patients with common vestibular diseases]

Objective:To understand the occurrence of horizontal semicircular canal functional impairment in patients with common vestibular diseases and to explore the characteristics and clinical value of different evaluation methods of horizontal semicircular canal. Methods:From July 2013 to December 2016, patients who attended the vertigo clinic of the First Affiliated Hospital of Dalian Medical University and completed more than three horizontal semicircular canal function tests were retrospectively analyzed. A total of 396 patients diagnosed as vestibular migraine （VM）, Ménière's disease （MD）, benign paroxysmal positional vertigo （BPPV）, vestibular neuritis （VN） and 104 patients with unknown diagnosis were enrolled. The results of caloric test （CT）, rotation test （RT）, head-shaking nystagmus test （HSN） and video head impulse test （vHIT） were collected and the abnormal detection rates of different detection methods were calculated. The sensitivity, specificity and coincidence rate of various detection methods were statistically analyzed using CT as the gold standard. Results:①The abnormal rates of the four evaluation methods from high to low were HSN, CT, RT, vHIT （51.20%, 50.80%, 25.76%, 19.74%, respectively）; ②Taking CT as the gold standard, among these four common vestibular diseases, the sensitivity and specificity of vHIT were 0.13-0.41 and 0.69-1.00, the sensitivity and specificity of HSN were 0.44-0.76 and 0.29-0.69, and the sensitivity and specificity of RT were 0.25-0.45 and 0.50-0.84;③According to statistical analysis, only HSN and CT results showed no statistically significant difference in the 4 diseases. There was no significant difference between RT and CT in VM and BPPV, and vHIT and CT in BPPV. Conclusion:The abnormal rate of HSN results in common vestibular diseases is highest, and it could be recommended as a routine vestibular function screening item. The specificity of vHIT is highest and worthy of promotion. CT is still an irreplaceable method to evaluate the function of horizontal semicircular canal.

The effect of cochlear implant surgery on vestibular function in adults: A meta-analysis study

Issue

The findings in literature indicate inconsistency in the complications caused by the implant of electrodes in the cochlea; vestibular alterations and balance disorders are mentioned as the most likely.

Purpose

To evaluate, in literature, through the results of multiple vestibular function tests, the effects of cochlear implant surgery on postural stability in adult patients and to analyze.

Hypothesis

From the PICO strategy, where the Population focuses on adults, Intervention is cochlear implant surgery, Comparisons are between implanted patients, and Outcomes are the results of the assessment of cochlear function, the research question was formulated: Are there deficits in vestibular function in adults undergoing cochlear implant placement?

Method

Systematic review based on cohort, case–control, and cross-sectional observational studies. Information sources: Databases between 1980 and 2021, namely, PubMed, Cinahl, Web Of Science, Cochrane, and Scopus. Search strategy using Mesh terms: “Adult,” “Cochlear Implant,” “Postural Balance,” “Posturography,” “Cochlear Implant,” “Dizziness,” “Vertigo,” “Vestibular Functional Tests,”and “Caloric Tests.” Populational inclusion criteria: studies with adult patients; intervention: cochlear implant placement surgery; comparison: analysis of a vestibular function with vestibular test results and pre- and postoperative symptoms; outcome: studies with at least one of the vestibular function tests, such as computerized vectoelectronystagmography (VENG), vestibular-evoked myogenic potentials (VEMPs), caloric test, video head impulse test (VHIT), head impulse test (HIT), videonystagmography, (VNG) and static and dynamic posturography. Exclusion criteria: studies without records of pre- and postoperative data collection and studies with populations under 18 years of age. Screening based on the reading of abstracts and titles was performed independently by two reviewers. In the end, with the intermediation of a third reviewer, manuscripts were included. Risk of bias analysis, performed by two other authors, occurred using the JBI “Critical Appraisal Checklist.”

Results

Of the 757 studies, 38 articles met the inclusion criteria. VEMP was the most commonly used test by the studies (44.7%), followed by the caloric test (36.8%) and vHIT (23.6%). Most studies performed more than one test to assess vestibular function.

Conclusion

Among all vestibular tests investigated, the deleterious effects on vestibular function after cochlear implant surgery were detected with statistical significance (P < 0.05) using VEMP and caloric test. Comparing abnormal and normal results after implant surgery, the vestibular apparatus was evaluated as having abnormal results after cochlear implant surgery only in the VEMP test. The other tests analyzed maintained a percentage mostly considered normal results.

Systematic review registration

identifier: CRD42020198872.

Agreement Between Caloric and Horizontal Video Head Impulse Testing in School-Aged Children Presenting With Dizziness

OBJECTIVE

The purpose of this investigation was to determine the relationship between the horizontal semicircular canal video head impulse test (hvHIT) and the caloric test in a sample of school-age children evaluated due to complaints of dizziness or imbalance. In adults, these two tests provide different but complementary information regarding vestibular function and/or pathology. However, the most common causes of vestibular loss in children are different than those in adults, and it is not clear how these two tests of horizontal semicircular canal function are related in a pediatric population.

METHOD

This is a retrospective study of electronic records of pediatric patients (< 18 years old) who were referred for vestibular function testing and completed both hvHIT and caloric testing. Agreement between both test results was evaluated by examining measures of sensitivity, specificity, and calculating Cohen's kappa.

RESULTS

Results from 117 patients (mean age = 13.7 years, age range: 8-17 years, 37 males) were analyzed. Most patients (97/115 [84.3%]) demonstrated both normal hvHIT and caloric test results. Compared to caloric testing, the hvHIT had poor sensitivity (38.9%) and excellent specificity (98.0%). Cohen's kappa analysis revealed moderate agreement between the methods (coefficient = 0.49 [0.24, 0.73]). Where disagreement between the two tests occurred, the final diagnosis was not contingent on either test result.

CONCLUSIONS

There is a moderate agreement between the hvHIT and the caloric test in pediatric patients presenting to a tertiary care medical center for a vestibular evaluation. Most patients in this cohort presented with normal findings. The specificity of hvHIT was excellent, although the sensitivity was low. This may be related to the low prevalence of peripheral vestibular system disease in this study cohort, and these results do not generalize to centers that serve populations of children where vestibular disorders are more prevalent (e.g., children with sensorineural hearing loss).