Audiology

‘Dizzy’ Patient: So Many Test
Choices! How Do I Get It Right?
STACY MORROW
CLINICAL SCIENTIST – NEURO-SENSORY SCIENCES (&AUDIOLOGY)
1
STACY MORROW MSC CS AAA 2020 'DIZZY' PATIENT: SO MANY CHOICES! HOW DO I GET IT RIGHT?
Describe what areas of the balance system the following tests

Learning evaluate:
Objectives
 HIMP
 SHIMP
 VVOR
 VORS
Describes the benefits of an efficient/improved testing

workflow to both the clinician and the patient.
STACY MORROW MSC CS AAA 2020 'DIZZY' PATIENT: SO MANY CHOICES! HOW DO I GET IT
RIGHT?
2
1
Balance - Bread and Butter
Typical VNG Localising
Check Eye Smooth Pursuit/
Optokinetic
Movement Tracking
Oculomotor testing Central

Positional Vision
Oculomotor Random Saccades
Denied
Static Positional Non localising
testing
30 deg Gaze test
(R/L/U/D) Caloric Vision
Spontaneous
Vision Denied
Denied Dynamic Positional Peripheral
testing
Spontaneous 30 deg Gaze test Caloric Testing Peripheral

Vision Denied (R/L/U/D)
STACY MORROW MSC CS AAA 2020 'DIZZY' PATIENT: SO MANY CHOICES! HOW DO I GET IT RIGHT? 3
So many tests which one to choose?

HIMP- Head IMpulse test: head is moved quickly to the side to initiate a
VOR response and the eyes are assessed for the presence of saccades
•HIMP/ SHIMP
SHIMP- Suppression Head IMpulse Paradigm test: measures the patients
•VVOR/ VORS ability to generate a saccade to keep with the focus a target that moves
•Rotational Chair with the patients head.
•C and O VEMP VVOR- visually enhanced vestibular-ocular reflex. It is a test of visual

vestibular interaction.
•Skew deviation/
Cover Test VORS- vestibular ocular reflex suppression, assess the same neurological
•Posturography pathways as tracking.
•SVV
2
How do we choose the correct test?
Image taken from VEDA:

Patient tool kit for diagnosis
Patient History
Vestibular
Disease
Trigger
Profile Fingerprint
Symptom
Profile
Time
Profile
3
‘SO STONED’
History taking
+
VNG
= Unsure diagnosis ?
More Tests needed:
Consider the vestibular fingerprint?

+
What parts of the anatomy
have not been evaluated to drive diagnosis
/management? (Wuyts et al. 2016)
HIMP- VOR pathway
(Image taken from Halmagyi et al. 2017)
4
HIMP- Bedside
How does it measure?
Patient asked to look at fixed target straight What does it measure?
ahead
Angular acceleration
Head rotated to right or left in unpredictable
fashion using low amplitude, high velocity, Asymmetry between inhibitory and
high acceleration motions excitatory neural firing pattern
Examiner determines if steady gaze is VOR has two components; one of which, the
maintained angular reflex, controlled by semicircular
◦ Patients with canal deficiencies cannot keep up canals will compensate for head rotation
with high-velocity head turns (Hain and Helminski 2007)
◦ Generate catch-up saccades after impulses
towards affected side
HIMP- Bedside versus vHIT

Bedside vHIT
Subjective Objective
Mean sensitivity of 46% and specificity of 94% High sensitivity/ specificity (mean ~95%)
Relies on examiners ability to interpret and detect Able to detect overt

overt saccades Able to detect covert saccades
Difficult to detect covert saccades occurring during
head movement (Weber et al 2008)
Results variable due to technique and experience High speed camera to ensure the correct speed of
head thrust, and accelerometers.
No feedback as to how well impulses are delivered Feedback system.
or at which frequency
5
HIMP Results
Normal- Gain of close to 1 AND no consistent
saccades.
Abnormal- Decreased gain AND complimentary

saccades indicate pathology.
HIMP versus SHIMP
(Hylmagyi et al. 2017)
6
SHIMP
What does it measure?
 The basic physiology underlying both HIMPs and

SHIMPs is the same.
 SHIMP requires tracking the projected target, it is

expected in a normal subject that suppression of the
VOR will dominate.
 The high-acceleration vHIT protocol takes around 80

ms from the onset of the head turn, so VOR
suppression is just starting around the end of the head
impulse stimulus. (Image taken from Halmagyi et al. 2017)
SHIMP - Results
Normal VHIT/ SHIMP Abnormal VHIT/ SHIMP
7
VVOR- Visually enhanced Vestibular-
Ocular Reflex
A test of visual- vestibular interaction.
Vision predominates over the

vestibular system.
It evaluates Low frequency head

movements.
VVOR- Test procedure
8
VVOR - Results
Image taken from

Ramos et al. 2019
VORS- vestibular ocular reflex

suppression
The VORS test assesses the patient’s VOR during visual
suppression. .
Vision predominates over the vestibular system.
It evaluates Low frequency head movements.
9
VORS – Test Procedure
VORS - Results
Image taken from

Ramos et al. 2019
10
SO STONED Reported Symptoms
Symptoms? Vertigo, followed by unsteadiness
Often? One prolonged episode, many smaller repeat daily
episodes
Since? Since the first episode, I was fine before that.
Trigger? It just started out of nowhere and now when I go to
busy places I sometimes feel dizzy and unsteadiness
Otology? I have no symptoms Name: Kate M

Neurology? I have headaches, no other neurological symptoms DOB: 9th Jan 1982
Job: Charity worker
Evolution? Better than the initial episode, and different. Seems
to be improving.
Duration? The first episode lasted 4 or more hours and the
unsteadiness lasts whilst I am in the busy situations.
I am nervous about shopping and working.
Extract from the patient Report:
Performed tests:
- Spontaneous
- Gaze (left right up down), vison and vision
denied
- Tracking
- Saccades
- OPK
‘ Oculomotor results were unremarkable and

within the normal limits’
11
Positional tests:
- Dix hallpike – Negative Left and Right
Caloric testing:
Patient did not tolerate the test well.

Results indicate no canal pareisis or asymmetry
in the responses.
No abnormalities detected in Fixation Index
What Next?
HIMP
History led decision to add HIMP
• Require information regarding vertical SSC

• Require Information on Inferior Nerve
12

Symptoms? General unsteadiness and off balance.
Often? Constant problem happening for years
Since? 4- 5 years, could have been there before?
Trigger? None that I know of. Randomly. Some days are

better than others?
Otology? I have a hearing problem, I wear hearing aids
Neurology? No known problem, stiff neck- no diagnosed neck Name: Clint E
issue. High BP. General aches and pains.
Evolution? Consistent problem, doesn’t appear to worsen or
DOB: May 31, 1930
better. Job: Retired
Duration? Always present.
13
Test Results
Performed tests:
- Spontaneous- NAD
- Gaze (left right up down), vison and vision
denied- NAD
- Tracking- poor; unable to complete
- Saccades- Not within normal limits, not
consistent.
VVOR
VORS
Jacobson, GP, and Shepard, NT. Balance Functional Assessment and Management, 2nd Ed. San Diego; Plural
Publishing, 2015
14
Symptoms? General unsteadiness and off balance. Bobbing
sensation
Often? Constant problem for over a year, since I was
hospitalised for sepsis.
Since? Symptomatic from last year was fine before that.
Trigger? Worse when I get up at night in the dark, I struggle
with my balance on the beach, it worsens when I am
sick. I had a cold a few weeks back and I felt off
balance.
Otology? I have a hearing problem, I wear hearing aids Name: Richard G
Neurology? Phonophobia with no head aches DOB: 31.4.1949
Job: Actor
Evolution? Consistent problem, doesn’t appear to worsen
Duration? Always feeling like I am on a boat.
Oculomotor testing:
All tests unremarkable with the exception of the

tracking. Patient unable to track.
Positional:
Negative Dix Hallpike Results Left and Right
Caloric:
Patients results indicate a bilateral vestibular

hypofunction.
Bilateral Vestibular Hypo-function

15
SHIMP
Paralysis versus Paresis
Battery approach versus Targeted test

Benefits to patient clinical outcome:
 Only the tests required are performed (those that give the most diagnostic information and drive appropriate
management) .
 Thus less stress to patient undergoing unnecessary tests.
 More information is established in the necessary area.
Benefits to service efficiency:

 Less time spent on a series of unnecessary tests.
 More time to focus on appropriate referrals to other areas and time with patients who require your expertise.
Benefits to finance
 Less cost incurred to the patient for tests that are not needed.
16
Learning Summary
 Battery versus targeted testing: Battery approach does not always fulfil the clinical needs
History should direct target testing
Novel testing approaches are emerging and should be considered
 HIMP evaluates the VOR at ~4Hz, assessing 6 SSC’s and both nerve innervations
 SHIMP evaluates paralysis versus paresis of a vestibular deficit
 VVOR and VORS give additional VOR information under ~1Hz
Remember that balance testing requires tests that differentiates central versus peripheral and
use the central elements tests to acquire further neurological information
 A central and peripheral problem can also occur together
More target testing improves patient comfort, increases efficiency and has beneficial financial
implications for the patient
References:
Patient tool kit VEDA. https://vestibular.org/toolkit
Wuyts FL, Van Rompaey V, Maes LK. "SO STONED": Common
Sense Approach of the Dizzy Patient. Front Surg. 2016;3:32.
Thank you for Published 2016 Jun 1. doi:10.3389/fsurg.2016.00032
Hain TC, Helminski JO. Mal de Debarquement. in "Vestibular
listening Rehabilitation", 2nd edn (Ed. S. Herdman), 2007
Halmagyi G. M., Chen Luke, MacDougall Hamish G., Weber
Konrad P., McGarvie Leigh A., Curthoys Ian S, The Video Head
Impulse Test. Frontiers in Neurology .2017
Ramos, Bernardo & Cal, Renato & Carmona, Sergio & Weber,
Konrad & Zuma e Maia, Francisco. (2019). Corrective Saccades in
Unilateral and Bilateral Vestibular Hypofunction During Slow
Rotation Expressed by Visually Enhanced VOR and VOR
Suppression: Role of the Cerebellum. The Cerebellum.
10.1007/s12311-019-01066-w.
Jacobson, GP, and Shepard, NT. Balance Functional Assessment
and Management, 2nd Ed. San Diego; Plural Publishing, 2015
STACY MORROW MSC CS AAA 2020 'DIZZY' PATIENT: SO MANY CHOICES! HOW DO I GET IT
RIGHT?
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‘Dizzy’ Patient: So Many Test

Choices! How Do I Get It Right?

Describe what areas of the balance system the following tests

Describes the benefits of an efficient/improved testing

Oculomotor testing Central

Spontaneous 30 deg Gaze test Caloric Testing Peripheral

So many tests which one to choose?

•C and O VEMP VVOR- visually enhanced vestibular-ocular reflex. It is a test of visual

Image taken from VEDA:

Consider the vestibular fingerprint?

HIMP- VOR pathway

(Image taken from Halmagyi et al. 2017)

HIMP- Bedside versus vHIT

Relies on examiners ability to interpret and detect Able to detect overt

Abnormal- Decreased gain AND complimentary

HIMP versus SHIMP

(Hylmagyi et al. 2017)

 The basic physiology underlying both HIMPs and

 SHIMP requires tracking the projected target, it is

 The high-acceleration vHIT protocol takes around 80

A test of visual- vestibular interaction.

Vision predominates over the

It evaluates Low frequency head

VVOR- Test procedure

Image taken from

VORS- vestibular ocular reflex

Vision predominates over the vestibular system.

It evaluates Low frequency head movements.

Image taken from

Otology? I have no symptoms Name: Kate M

Extract from the patient Report:

‘ Oculomotor results were unremarkable and

- Dix hallpike – Negative Left and Right

Patient did not tolerate the test well.

• Require information regarding vertical SSC

SO STONED Reported Symptoms

Often? Constant problem happening for years

Since? 4- 5 years, could have been there before?

Trigger? None that I know of. Randomly. Some days are

Duration? Always feeling like I am on a boat.

All tests unremarkable with the exception of the

Negative Dix Hallpike Results Left and Right

Patients results indicate a bilateral vestibular

Bilateral Vestibular Hypo-function

Paralysis versus Paresis

Battery approach versus Targeted test

Benefits to service efficiency:

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