An UPDATE on some of the audiovestibular tests at VERTIGO & DEAFNESS

CLINIC, CJ-189 (ground floor), Salt Lake, Kolkata 91

The BERA Test

The Brainstem Evoked Response Audiometry (BERA)Test: also called the ABR test or the BSER test
is an objective test of hearing that is traditionally used for testing the structural and functional
integrity of the auditory pathway from the inner ear to the midbrain. Many neurotological disorders
that present with vertigo or deafness have defects in this portion of the auditory pathway in the
brain. This is hence one of the basic investigations in patients suffering from vertigo, imbalance,
hearing deficit and tinnitus. The test is also used to determine the degree of hearing loss objectivity
in pediatric patients as well as in difficult to test patients who do not respond reliably to the
subjective tests of hearing like the pure tone audiometry and allied tests.

Fig B1: The BERA graph as done in the

Interacoustics Eclipse Evoked potential
machine in our Vertigo & Deafness
Clinic at CJ-189 Salt Lake Kolkata -91

In medical parlance this test is an auditory evoked potential test. When a auditory stimulus (sound)
is presented to the ear, an electrical potential is evoked in the cochlea in response to the sound
stimulus and this electrical output called action potential traverses through the auditory pathway
to reach the higher areas in the brain where it is processed and the meaning pertaining to the sound
interpreted. The BERA test monitors and records the smooth passage of the electrical impulse
through a major part of the brain. In disorders of the brain involving the auditory pathway, the
smoothness of the passage of this electrical impulse gets affected and this abnormality can be
picked up by the BERA test. The response is identified by peaks (also called waves) that occur
typically between one and ten millisecs from the onset of the sound stimulus. The BERA peaks are
measured and marked traditionally as waves one, two, three, four, and five; each wave has an
expected latency (time in millisecs between the presentation of the sound and the occurrence of the
wave peak) which is considered as normal and any increase of the latency or absence of any of the
wave / peaks indicates an abnormality in the auditory track i.e., the nerves (neural pathways) that

transmit the electrical potential in the brain. By analyzing the morphology of the BERA graph and by
measuring different parameters of the wave peaks in the graph (as shown in Fig B1), clinicians with
sufficient knowledge and insight on the intricacies of BERA can identify disorders in the portion of
the brain through which the auditory track passes as it traverses from the ear to a portion high up in
the brain called the midbrain. Since a big portion of the neural pathway that connects the balance
organ situated deep inside the ear to the higher levels in the brain also traverses along the same
pathway as the auditory pathway, BERA though primarily a test of the hearing system, is a very
important test for patients suffering from balance disorders like vertigo / imbalance.
Tone evoked BERA for
threshold estimation at
2000Hz done in our
clinic using the
Interacoustics Eclipse
evoked potential
machine using insert
ear phones in a 3 month
old child showing
perfectly normal
hearing. Such a clean
recording even with the
pure tone sound
stimulus and not a click
with very discernable
wave peaks right upto
10dB was possible
because of using the
CHIRP BERA
technology.

The test however is a very challenging test as it depends upon a number of variables like the mental
and physical state of the patient, unknown levels of noise not only acoustic noise but also electrical
noise in the vicinity of the instrument, the experience, commitment, dedication and the medical
insight of the operator of the machine as well as that of the Doctor who interprets the test result.
Another big challenge in the BERA test is the small response amplitude of the wave peaks at
threshold. This makes identification of the BERA waves pretty difficult and results in erroneous
interpretation of the results and erroneous estimation of the hearing threshold. It is due to the same
reason that quite often small tumours in the auditory pathways in the brain remain unidentified by
the BERA test and completely normal BERA findings are obtained in spite of there being a small
tumour in the auditory pathway. Correct interpretation requires an extremely high quality of
recording that will be free from artifacts and have robust (high amplitude and easily recognizable)
wave peaks and a dedicated and committed operator of the machine as well as a knowledgeable
clinician to interpret the results . A dependable result is obtained only if all these parameters are
met which unfortunately is not usually the case.

These challenges in BERA have however been largely overcome by modern technology and
sophisticated high-end evoked potential machines like the InteracousticsEclipse have in-built
systems that enhance the sensitivity of the BERA test and increases the accuracy of identification of
the hearing threshold. This particular model implements the use of a system called chirp. Research
has shown that the use of the chirp technology results in very significantly increasing the
amplitude(approx 1.5 to 2 times) of the wave peaks ( as shown in Fig B2). This results in increasing
the sensitivity of the BERA test so that not only small tumours can be identified more easily but also
helps in identifying the hearing threshold much more accurately. This reduces the test time and also
increases the confidence of the operator. The doctor interpreting the test also finds it much easier
and more comfortable. The chirp system uses a technology that manipulates the timing issues of the
sound stimulus within the cochlea. The low-frequency sounds are presented to the cochlea a
fraction of a millisecond earlier than the high-frequency sounds thereby ensuring that the entire
cochlea is stimulated together and as one unit thereby giving a very robust response. In traditional
BERA the high-frequency component of the sound stimulus stimulates the cochlea much earlier than
the low-frequency sounds which results in temporal distortion of the sound in the cochlea that in
turn leads to small wave peaks which are quite un-identifiable at threshold. Details and design of the
chirp technology may be had from the publications of C. Elberling (2007), Don (2008) etc. Other
modern technologies Incorporated in the sophisticated models are monitoring of residual
background noise during the recording and having systems by which the quality of the recording can
be evaluated online by calculating the evoked response to residual noise ratio while the recording is
going on . These technologies have immensely enhanced the sensitivity of the BERA test.
Instruments like the Interacoustics Eclipse that have these systems built in are much more sensitive
than traditional BERA machines.

Electrocochleography ECochG
Although Electrocochleography has been around for many years, for much of that time it was an
invasive procedure. With the advent of a peritympanic electrode it no longer is invasive and it is now
a fast and simple test. Since the invasive technique is no longer necessary the ECochG should become
routine within the Neurotologic clinic. The diagnosis of endolymphatic hydrops, through EcochG
utilizing a peritympanic electrode rather than the invasive electrode on the promontory, gives us
results that have large amplitudes and good morphology.

We also have other audiological tests like Pure Tone

audiometry with all localizing tests like ABLB, SISI,
TDT and speech audiometry, High frequency
audiometry(9000 to 20000Hz) which is essential for
tinnitus patients and in some SN deafness patients
like ototoxicity, tympanometry with full range of
acoustic reflex tests and Eustachian tube function
tests, ASSR test, Automated BERA (ABRIS) for hearing
screening of infants and neonates and even adults
and all types of Otoacoustic Emission tests (DPOAE
and TEOAE)

VESTIBULOMETRY at Vertigo and Deafness Clinic

CJ-15 Salt Lake Kolkata -91
Oculography
Oculography:-the eyes are said to be the windows of the vestibular system. The vestibular system is
anatomically scattered in discrete difficult to reach areas in different parts of the brain and deep
inside the ears. Disorders in a major part of the vestibular system are physically manifested by
abnormal eye movements. Documenting and analysing the eye movements is an easy way of
understanding the functioning of the vestibular system in health and disease. The eye movements
can be recorded by different ways. The process of recording eye movements is called oculography.
Oculography evaluates the vestibulo-ocular reflex system which is the part of the vestibular system
that facilitates and carries out the function of GAZE-STABILISATION. Gaze stabilization -the faculty
by which our surroundings and the objects in the surroundings appear stable is one of the important
functions of the vestibular system. The most popular methods of oculography in clinical practice are
electronystagmography (ENG) and video nystagmography (VNG) . In our clinic we have both ENG
and VNG systems. Though ENG still holds its pride of place in terms of usage yet VNG is now the in
thing and is replacing ENG in most modern clinics. We use ENG and VNG in our clinic depending on
the patient. A lot of patients have small narrow eyes and some patients have a habit of blinking too
much. In such patients it is difficult to carry out a video nystagmography (VNG) test and ENG is a
better choice in these patients. Moreover some vertigo patients are extremely claustrophobic and
do not tolerate the eye masks at all. In these patients too ENG is more convenient than VNG. The
main advantage of ENG is that it is much cheaper and hence more affordable for most clinics than
the top of the line Video nystagmography systems which cost 10 to 15 times the cost of an ENG
machine. VNG of course has its own advantages and does yield a lot of clinically relevant
neurotological information that helps in pinpointing the lesion in patients suffering from vertigo/
imbalance. The resolution of video nystagmography (VNG) is much higher than that of
electronystagmography. Moreover the oculomotor tests are much more informative with VNG than
with ENG. Most central vestibular lesions induce abnormalities in the oculomotor system which are
easy to identify by video nystagmography (VNG). For gaze stabilization the eyes have to mone in a
very coherent and orderly manner and this process of eyemovement is carried out and controlled
by the Oculomotor system, hence evaluating the functioning of the Oculomotor system in the finest
way possible is a vital part of vestibulometry. Gaze stabilization is carried out by the vestibuloocular
reflex system in conjunction with different central nervous system mechanisms like the saccadic
system, the optokinetic system and the smooth pursuit system. The precision of eye movement
during the saccade tests need to be documented very very precisely to identify lesions in the
saccadic system. The latency of the saccades, the velocity of the saccades and the accuracy with
which the eyes fixate during the saccade test are important parameters to evaluate the functioning
of the Central vestibular system.

Saccade test as recorded by VNG:The green line is the target and the red
line is the movement of the right eye and
the blue line that of the left eye. The top
box records the movement of the eyes in
the horizontal axis and the bottom box
that in the vertical axis. The latency,
velocity and precision of eye movements
are calculated and documented
automatically by the high end VNG
machines

Similarly, very precise and high resolution recording is necessary for evaluating the smooth pursuit
system and the optokinetic system and a lot of parameters need to be measured and compared
during these tests to know about the functionality of these very important neural mechanisms of the
brain that facilitate gaze stabilization. This preciseness and accuracy is not possible by ENG. In
cooperative patients, carrying out a VNG test is less cumbersome than the ENG test. All these factors
have added to the increasing popularity of video nystagmography. Our clinic has an ENG system
manufactured by Recorders and Medicare system of India and high end models of two of the best
VNG systems available in the world one by Interacoustics of Denmark (www.interacoustics.com )
and the other one manufactured by Synapsys of France (www.synapsys.fr ) . Unlike most other
clinics which have incomplete systems (i.e., monocular cameras and without Oculomotor testing
systems) we have the complete VNG systems which includes the Oculomotor tests with LCD
projectors and binocular cameras.ENG and VNG tests are done in our clinics by very dedicated and
experienced technicians who have been working for over 2 decades on vestibulometry and always
under the physical supervision of neurotologist Dr Anirban Biswas.

The VEMP test

The VEMP test is a much touted neurotological investigation and is the being marketed by
unscrupulous clinics and unethical paramedicals as the most modern test of the balance system and
as a replacement of age-old tests like ENG, VNG etc. The VEMP test just evaluates a very small
portion of the balance system and is in no way a replacement of the other neurotological tests like
video nystagmography (VNG), video head impulse test, subjective visual vertical test,
craniocorpography and stabilometry . The main reasons for it being marketed so very much is
because this test is very easy to carry out, does not require much time, is non-invasive, not too costly

to purchase and can be carried out by anybody with a little bit of training. It is a good money earner
for most clinics without requiring much of infrastructural or financial investment or specialised
manpower. Moreover as most clinics have a evoked potential system, installing VEMP as an add-on
in it is easy. Most audiology clinics will have a VEMP system (a cheap model with unrectified VEMP in
most cases) and have a technician to press a couple of switches and dole out a computerised
semblance of a VEMP report in a few minutes. Nave doctors who are not adequately updated are
fooled into accepting them as actual VEMPs and believe in the marketing gimmicks that VEMP is a
modern test of the vestibular system and a replacement of all other age-old vestibulometric tests.
The VEMP test is but overhyped and it does not give us a comprehensive idea of the functioning of
the balance system. It definitely has its role to play as a part of the neurotological test battery but is
definitely not a stand-alone test. Moreover this being an Auditory Evoked Potential test, it is not at
all to be believed or accepted by the clinician only if it is not done by a person with sufficient clinical
insight and knowledge of the vestibular system. The test is extremely prone to errors and the
integrity of the man behind the machine, the quality of the machine and the place from where it is
done is of vital importance before giving it any clinical relevance . This of course applies for most
neurotological tests but it is much more important in VEMP. The VEMP test evaluates a portion of
the balance system which is not tested by the other common tests like ENG or VNG and should
undoubtedly be part of the neurotologists diagnostic armamentarium. Different types of VEMP tests
are done but the cervical VEMP is more popular than the ocular VEMP or bone cond VEMP which
have not caught the neurotologists fancy as yet . An example of the results of the VEMP test are as
below:-

A recording of cervical VEMP test done in our clinic. This however is an unrectified VEMP

An ocular VEMP test

The vestibular evoked myogenic potential (VEMP) test is a evoked potential that is used to test the
structural and functional integrity of the saccule and its afferent connections. The VEMP test is the
only test in the vestibulometry test battery that can evaluate the function of the saccule and the
inferior vestibular nerve. The test works on the principle that when a high-intensity sound stimulus is
presented to the ear the energy transmitted into the cochlea through the stapes also stimulates the
saccule which is a part of the vestibular labyrinth is stimulated. This stimulation generates an action
potential that passes through the inferior vestibular nerve to the vestibular nucleus and from there
through the median longitudinal fasciculus to the motor root of the 11th cranial nerve (that is the
accessory nerve) and from there through the nerve to sternomastoid up to the sternomastoid
muscle. The VEMP response is actually a electromyography (EMG) recording of the contraction of
the sternomastoid muscle brought about by the sound evoked stimulation of the saccule. So the
presence of a normal VEMP implies that the saccule and the inferior vestibular nerve and of course
the other constituents of the neural pathway described above are functioning normally. The
important parameter in VEMP recordings is the amplitude of contraction of the sternomastoid
muscle evoked by the saccular stimulation. The amplitude of contraction of the sternomastoid on
the 2 sides is compared by recording the EMG. The difference between the 2 sides should be less
than 35%. If the difference of amplitude between the two sides is more than 35% then the side
having the lesser EMG amplitude is considered abnormal. Now there are many types of VEMP setups available. VEMP usually comes as a part bundled in many low-end evoked potential machines
and is not uncommonly offered as a freebee to buyers of auditory evoked potential machines by the
vendors peddling these machines. Though these machines dish out a VEMP test, yet this is not
clinically reliable and the VEMP test data obtained from these machines serve no clinical purpose
whatsoever and are extremely misleading. They can lead to a wrong diagnosis about saccular
function and what is obtained in many if not most cases, is an un-rectified VEMP. For the VEMP test

data to be clinically reliable, the test has to be a rectified VEMP. So before purchasing an evoked
potential machine in which the VEMP facilities are there, it is always judicious to ensure that the
VEMP supplied is a rectified VEMP and not an un-rectified one. The neurotologist has to read the
technical specifications of the auditory evoked potential machine and satisfy himself that what he is
purchasing in the guise of VEMP is actually a rectified VEMP. In the VEMP test the change in
contraction of the sternomastoid muscle brought about by the saccular stimulation is measured and
the amplitude of contraction of the sternomastoid between the two is sides is compared by
recording the electromyography activity of the sternomastoid. Measureable VEPMs is generated
only on tonically contracted sternomastoid muscle and the VEMP response amplitude is dependent
upon the level of pre-stimulus EMG activity of the sternomastoid muscle. If the sternomastoid
muscle is tonically strongly contracted, then the VEMP response will be very robust and high in
amplitude but if the prestimulus contraction of the sternomastoid is not adequately strong, then the
amplitude of the VEMP response will be low irrespective of saccular function. It is hence a vital
necessity that the prestimulus as well as intra-stimulus contraction of the sternomastoid muscle is
equal on both sides as otherwise, comparing the amplitude of the VEMP response between the left
and right sides will have no meaning. Pre-stimulus EMG activity in sternomastoid may not be equal
on Left & Right sides causing grossly erroneous and completely misleading results. It is hence
essential that the clinician knows the electromyographic (EMG) activity during VEMP recording.
Only the high-end and very sophisticated auditory evoked potential machines come equipped with
the facility where the prestimulus electromyographic activity of the sternomastoid can be monitored
and documented. Even if the prestimulus electromyographic activity of the sternomastoid is not
shown online during the VEMP recording (which is available in some high-end evoked potential
machines like Eclipse of Interacoustics ) yet then, there has to be some electronic mechanism in the
VEMP hardware/software by which the VEMP amplitude shown in the final recording has been
computed by taking into consideration the prestimulus and intra-stimulus tonic contraction of the
sternomastoid muscle by a process called scaling. This method of VEMP where the VEMP amplitude
is calculated and recorded by taking into consideration the pre and intrastimulus tonic contraction of
the sternomastoid is what is known as a rectified VEMP. In unrectified VEMP, the pre stimulus and
intra-stimulus tonic contraction of the sternomastoid muscle is not taken into account and the VEMP
recording obtained is irrespective of the prestimulus and intra-stimulus tonic contraction of the
sternomastoid and hence invalidates the comparision of the responses of the left and right sides.

This is a VEMP test done in the Eclipse EP25 model of Interacoustics. The portion at the top shows
the intra-stimulus EMG recording of the tonic contraction of the sternomastiod. It clearly shows that
that the tonic contraction of the sternomastoid is much lesser on the left as compared to that on
the right (red colour). The VEMP amplitude is accordingly lesser on the left side (lower part of the
picture). The low amplitude of VEMP on the left is hence not due to saccular disorder on the left but
due to an improper test condition where there was a difference in the tonic contraction of the
muscle between the left and right sides. Had the intra-stimulus electromyography of the tonic
contraction of the left and right sides not been shown, any clinician would have misdiagnosed this as
a saccular hypoactivity on the left side. In such a condition, the VEMP test needs to be repeated with
equal contraction of the sternomastoid muscle ensured on both sides. The Eclipse model of
Interacoustics that we have in our clinic ( as well as some other sophisticated VEMP systems
available) has an inbuilt facility as a part of the software package whereby a visual representation of
the intensity of contraction of the sternomastoid muscle during the test can be shown on a
computer screen to the patient undergoing the test. From this visual feedback, the patient can
himself/herself make the sternomastoid adequately and equally taut on both sides such that VEMP
is recorded with equal tonic contraction of the sternomastoid on the left and right sides. This makes
the VEMP clinically relevant and without it, the VEMP test becomes clinically irrelevant. Sometimes
however for example due to stiffness in the neck, the patient has problems in ensuring equal
contraction of the sternomastoid during the VEMP test of the left and right sides. Under such
conditions, there is a system called VEMP scaling in which the machine automatically records and
compares the tonic contraction of the sternomastoid of the two sides and accordingly up or down
scales the VEMP amplitude so that the VEMP amplitude recorded is done as a function of the equal
tonic contraction on both sides. But such facilities are available only in the very high end models like
the Eclipse evoked potential system of Interacoustics and some similar costly models only. The figure
below is a scaled up version of the same VEMP as the previous figure where the amplitude of the left
side has been scaled up by comparing with the difference in the prestimulus EMG activity of the

right side.

In our clinic we have VEMP systems from Labat of Italy (www.labat.it and www.labatasia.com ) and
Interacoustics of Denmark (www.interacoustics.com) . The Interacoustics Eclipse is a humongously
costly model of evoked potential system, but it offers the facility of rectified VEMP. The test is a
noninvasive test and in a not-too-difficult patient takes about 15- minutes time. The patient has no
unpleasant sensation or any vertigo and no special preparation is necessary. The test can be very
easily done on children also. The only limitation of VEMP is that it cannot be done in ears with a
conductive pathology and so patients of CSOM, otosclerosis and secretory otitis media cannot be
undertaken for VEMP and grossly erroneous results are obtained in such cases even though VEMPS
are carried out in patients with conductive deafness in many clinics and doctors due to their
ignorance accept it. VEMP test can however be done very reliably in completely dead ears provided
there is no superadded conductive pathology. This is so as the middle ear has to be able to conduct
the vibration caused by the loud sound stimulus to the oval window and induce movement there so
that the saccule gets stimulated; this is not possible in conductive pathology but easily possible if
there is a normal middle ear but a cochlear /retrocochlear damage.

Video Head Impulse Test (VH IT)

The video head impulse test (VH IT) is one of the newer tests to evaluate the structural and
functional integrity of the vestibular system. It offers a much deeper insight into the functioning of
the semicircular canals. The test measures the gain of the vestibular ocular reflex (VOR) separately in
all the six semicircular canals. The anterior, posterior and lateral semicircular canals of the left side
as well as these three canals of the right side are separately evaluated. The clinician now can know
whether the left anterior semicircular canal is at fault or the right posterior canal is defective. So
long with all the other vestibular function tests, the sensitivity of only the lateral semicircular canals
could be ascertained but with the video head impulse test all the six semicircular canals can be
tested separately. This is the uniqueness of this test. The test is based on the clinical Halmagys head
impulse test - a test by which the neurotological community now swears. The renowned
neurologists Prof Thomas Brandt and Michael Strupp in Clinical Neurophysiology Vol-116 (2005) has
opined According to our experience, the head impulse test is very helpful; if it gives pathological
The Ulmer canalogram showing the VOR in the 6
semicircular canals i.e., the anterior, lateral and posterior
canals on both sides. VOR within 40% deficit is considered
as normal and is depicted as green dots and VOR values
above 40% deficit is considered as abnormal and is
depicted as red dot. This is a Ulmers canalogram
showing normal VOR in all 6 semicircular canals. Each
concentric circle depicts an abnormality of 20%. In this
patient all dots are green in colour and within the first
concentric circle of 20% indicating a normal VOR for all
the 6 canals.

finding, it is not necessary to do an additional caloric test. So high is the reliability of this test. The
VH IT basically uses very sophisticated computer and image processing technology to sharpen,
quantify and very accurately document this very reliable clinical test. It records the gain of the
vestibulo-ocular reflex on head movement in the plane of the six semicircular canals. The result is
synoptically plotted in a chart called the Ulmers canalogram and is very easy to interpret. It is a noninvasive and easy to perform quick test that does not generate any unpleasant vertiginous or
nauseating sensation for the patient unlike the VNG/ENG tests. The caloric tests done by ENG or
VNG is not only a very time consuming and unpleasant test but have poor patient compliance(many
patients discontinue the test after one or two caloric stimulations) and is dependent on the alertness
of the patient. Moreover the stimulus used in a caloric stimulation of the vestibular system is an
unphysiological stimulus and stimulates the vestibular system at an acceleration which is much
below the acceleration at which the head moves during day to day activities. In VHIT the vestibular
system is stimulated at a speed of thousands of degrees per second which is the speed at which the
head moves in our day to day activities. This is not to discount the value of the caloric ENG / VNG.
The sensitivity of the caloric ENG /VNG test is more than that of the VHIT test but as discussed the

calorics evaluate only the lateral canals and not the other canals that VHIT does. The VHIT can be
performed very easily even in children and in ears with a perforation in the ear drum.

The VHIT set up. Patient seated in front of the camera and the infra red light source. The images are
seen in the computer monitor. The infrared light is projected as a small speck / dot in the patients
eye and the head is suddenly moved. The movement of the head and that of the small speck of light
in the patients eye is videographed by the infrared camera. Sophisticated image processing
technology records and analyses the captured images and then computer softwares plot the eye
and head movements, calculates the gain of the VOR and finally presents it as a synoptic chart called
the Ulmers canalogram.

Clinician stands behind the patient and moves the head in sudden jerks in the plane of the
semicircular canals. The head movement is for about 20 degrees only but at a very high speed. If the
VOR of the semicircular canals are normal then the eyes do not follow the movement of the head and
maintains its fixed position by compensatory adjustment movements in the other direction thereby
causing the position of the speck of light to remain fixed, but if the gain of the VOR is subnormal,
the eyes follow the head movement and then the speck of light moves in the direction of the head
movement. The VHIT by analysing the head and eye movement can calculate the gain of the VOR. If
the deficit of VOR gain is below 40% it is considered as within normal limits but if the deficit of VOR
gain is above 40% it is considered as abnormal and is indicative of a dysfunction of the corresponding
semicircular canals.
In our clinic we use the VHIT system of SYNAPSYS of France (www.synapsys.fr)

---------------------------------------------------------------------------------------------------------------------------------

Subjective Visual Vertical (SVV) test

The subjective visual vertical (SVV) test evaluates otolithic function. Orientation of the vertical and
horizontal is a function of the utricle and saccule (otolithic systems) in the vestibular labyrinth and is
one of the primary functions of the vestibular system. The subjective visual vertical test evaluates
this faculty of the vestibular system. The patient is asked to place a light bar projected on a wall in a
dark room without any visual references using a joystick. If the patient has a peripheral vestibular
lesion that has not yet been compensated the patient cannot place the bar perfectly vertically or
horizontally and tilts the bar towards the side of the weaker labyrinth. This is hence a good quick and
very easy as well as entertaining test for uncompensated unilateral peripheral vestibular lesions. A
further improvement of the test called dynamic visual vertical test evaluates the patient's ability of
placing the bar vertically or horizontally on the background of a moving visual field. The patient is
asked to place the bar vertically on the background of an optokinetic stimulus. The optokinetic
stimulus is provided by rotating the background clockwise and counterclockwise and the patient is
asked to place the light bar vertically on this moving background. Patients having a unilateral
vestibular failure are unable to place the bar perfectly vertically even if the peripheral vestibular
lesion has compensated. Subjects with normal vestibular function can place the bar within 0 to 2.5,
whereas those with defects in the vestibular system cannot do so. This applies both for the static as
well as the dynamic visual vertical tests. Tilting the bar more than 10 is considered to be evidence of
very gross abnormality in the vestibular system. By performing the static and dynamic tests the
clinician can ascertain whether the patient has compensated or not.

The patient undergoing the subjective visual vertical test is using a joy stick placed in his hands to
place vertically the light bar projected on the wall through a LCD projector. The goggles that the
patient is made to wear ensure that the patient has a narrow tunnelled vision and cannot see
anything outside the projected image from which he may get a visual reference. It is essential that
the patient does get any visual references while placing the light bar vertically

The image of the light bar projected on the wall. The patient has to place this light bar vertically by
manipulating the joystick placed in his hands.

The subjective visual vertical test in progress. The software is programmed to automatically tilt the
bar randomly to any side and the patient is asked to place it vertically using the joysticlk. The test is
repeated 10-15 times and the average is calculated. Normal range is 0 to 2.5 degrees. If the
deviation is above 10 degrees it indicates a very gross vestibular abnormality.

The dynamic subjective visual vertical test in progress. In the dynamic test, the background is
optokinetically rotated both in the clockwise as well as in the counterclockwise directions and the
patient is asked to place the bar vertically during the clockwise rotation of the background as well as
during counter clockwise rotation of the background. In compensated vestibular lesions the patient
tilts the bar abnormally to the side of the weaker labyrinth even if the static visual vertical test has
shown normal findings.
In our clinic we use the SVV system of SYNAPSYS of France (www.synapsys.fr)