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LESSON 153

Bedside vestibular exam

Year 2
Spring semester
Vestibular Assessment I
Vestibular assessment
Duration: 10:12

We explain the core steps of the bedside vestibular exam: observing spontaneous and gaze-evoked nystagmus, the Romberg and tandem Romberg tests, the Fukuda stepping test and the head-shaking test. We cover how each test is done and interpreted, its limits, and the findings that suggest a central cause.

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Hello, and welcome to the AIHEAR Audiology Academy.
In this lesson, we learn the bedside vestibular exam, which needs no special equipment.
We will cover how to perform and interpret nystagmus observation, the Romberg and Fukuda tests, and the head-shaking test.
After the history, the bedside exam is the first physical assessment.
This exam is quick, and most of its steps can be done anywhere without special equipment.
The findings complete the history and guide which laboratory tests are chosen.
In the acute phase, it also gives valuable information when laboratory tests cannot be done.
However, its sensitivity is limited; a normal bedside exam does not exclude a vestibular problem.
Before the exam, ask about neck and back problems, recent surgery and any history of falls.
During standing tests, stay right beside the patient and be ready to prevent a fall.
If possible, have Frenzel goggles or video goggles ready.
The exam usually starts with the eyes while seated and continues with standing balance tests.
Tests that may worsen nausea can be left until the end of the exam.
The first step is to check for spontaneous nystagmus while the patient looks straight ahead.
First, the eyes are watched with fixation, that is, while the patient looks at a target.
Then fixation is removed with Frenzel or video goggles; peripheral nystagmus becomes more obvious this way.
Without goggles, covering one eye and viewing the fundus of the other with an ophthalmoscope also reduces fixation.
This example trace shows right-beating nystagmus; in acute unilateral peripheral loss, nystagmus usually beats toward the healthy ear.
The direction and intensity of the nystagmus, and how it changes with fixation, are recorded.
In gaze testing, the patient looks right, left, up and down without moving the head.
Gaze is held at about thirty degrees; a few beats of nystagmus at extreme gaze can be normal.
Peripheral nystagmus increases when looking in the direction of the fast phase; we called this Alexander's law.
Nystagmus that changes direction with the direction of gaze, however, is important for central causes.
Pure vertical or pure torsional nystagmus is also a central sign and is reported to the physician.
The finding in each direction is noted separately; this record is valuable for comparison with later exams.
We briefly saw the Romberg test in the lesson on the balance systems; now let us look at how it is done.
The patient stands with the feet together and the arms crossed over the chest or held at the sides.
Sway is watched first with the eyes open, then with the eyes closed, usually for thirty seconds.
Marked sway or a tendency to fall when the eyes close is recorded as a positive Romberg.
Classically, it suggests loss of position sense; in acute unilateral vestibular loss, the patient may sway toward the affected side.
In compensated chronic vestibular loss, the test is often normal, so a normal result does not exclude vestibular loss.
To make the test harder, the patient stands in a line with one heel touching the toes of the other foot; this is the tandem Romberg.
Tandem stance gets harder with age, so the result is interpreted carefully in older adults.
Standing on foam with the eyes closed tests the vestibular input more clearly; we saw this in the four-condition sensory balance test.
Standing on one leg is another simple test used to assess fall risk.
In all these tests, the duration, the direction of sway and any tendency to fall are recorded.
The Fukuda stepping test is also known as the Unterberger test.
The patient stretches the arms forward, closes the eyes and takes fifty steps in place, raising the knees.
During the test, sound and light cues that could help the patient orient are kept to a minimum.
At the end of the test, we look at how far the body has rotated and how far it has moved from the starting point.
Rotation of more than forty five degrees in fifty steps is generally considered abnormal.
The rotation is often toward the affected side.
The Fukuda test needs to be interpreted with care.
Studies have shown that the test has limited sensitivity and specificity for detecting unilateral vestibular loss.
In repeated tests on the same person, the rotation angle and direction can change.
So the Fukuda is not used alone to decide the side; it is interpreted together with other findings.
Even so, some clinicians find the test useful for following the process of compensation.
The head-shaking test aims to reveal a hidden imbalance between the two sides.
The patient wears Frenzel or video goggles, and the head is tilted forward about thirty degrees.
The examiner shakes the head side to side for about ten to twenty seconds, at about two times per second.
The shaking is stopped suddenly, and the eyes are watched right away.
In a healthy person, there is no clear nystagmus, or only a few beats.
In patients with neck problems, this test is not done or is done with great care.
In unilateral vestibular loss, a horizontal nystagmus can appear after shaking.
This nystagmus usually beats toward the healthy ear; in the example trace, right-beating nystagmus fits a left-sided loss.
During shaking, the two sides send unequal signals, and the velocity storage mechanism in the brainstem accumulates this difference.
Sometimes a weaker second phase in the opposite direction can be seen shortly afterward.
Vertical nystagmus after horizontal shaking, however, is a central sign and should be reported to the physician.
Let us look at the bedside findings together, in terms of peripheral and central patterns.
Peripheral spontaneous nystagmus is horizontal-torsional; pure vertical or pure torsional nystagmus is a central pattern.
Peripheral nystagmus is reduced by fixation; central nystagmus may not be.
Peripheral nystagmus does not change direction with gaze; direction-changing gaze-evoked nystagmus matters for central causes.
After head-shaking, horizontal nystagmus is a peripheral sign, and vertical nystagmus is a central sign.
In acute peripheral loss, the patient can walk with help; severe stance and gait problems suggest central causes.
The bedside exam has other important parts as well.
The head impulse test assesses the vestibulo-ocular reflex, or VOR, for each side separately; we will see it in the next lesson.
In dynamic visual acuity testing, the line read while the head is shaken is compared with the line read with the head still.
Eye movements such as pursuit and saccades are also observed for central findings.
We will cover positional tests in detail in a later lesson.
A clinical tip: do the bedside exam in the same order for every patient.
A standard order ensures that no step is skipped and that results can be compared over time.
Record the findings on a standard form; also note any test that could not be done, and why.
If possible, record eye findings with video goggles; the recording is very valuable for the physician and later assessments.
Spontaneous and gaze-evoked nystagmus are assessed both with fixation and with fixation removed.
The Romberg test can show loss of position sense and acute vestibular loss, but a normal result does not exclude loss.
In the Fukuda test, rotation of more than forty five degrees in fifty steps is abnormal; the test is not interpreted alone.
Horizontal nystagmus after head-shaking suggests unilateral loss, and vertical nystagmus suggests a central cause.
Test yourself: In a fifty-step Fukuda test, which result is generally considered abnormal?
The correct answer is C: rotation of more than forty five degrees.
Still, the test has limited sensitivity; the result is interpreted together with other findings.
In the next lesson, we will learn the head impulse test and the HINTS exam, which combines it with nystagmus and the test of skew.
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Prerequisites

LESSON 152 Dizziness: history first

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