Overview and Assessment of Balance Functions: Electronystagmography/ Videonystagmography

Overview
Electronystagmography/
and Assessment of
Videonystagmography
Balance Functions
Dr. Sujeet Kumar Sinha

Lecturer
AIISH, Mysore
Why You should do ENG?
 Vestibular system lesion ?

 Peripheral or Central
 If Peripheral -- R / L / Bil.
 If Central - Where?
 Static / Progressive / Recovery.
Fundamentals of ENG
CORNEORETINAL POTENTIALS
Nystagmus
se
Fast Phase
Pha
Slo
Fast Phase
w
Ph
Slo
as
e
Duration of the nystagmus

Electrode Placement
Ground
Positive (+ve)
Positive (+ve) Negative (-ve)
Negative (-ve)
Basic Principle of ENG
Precautions before the testing:
• Avoid alcohol and certain other drugs at least 48 hrs

before the testing
• EAM must be examined
• Look for perforation of TM
• Should not take food at least 6-8 hrs before testing
Calibration of Instrument
Light Bar
10 deg
Calibration of Instrument
8 mm
10 mm =160 uv
=200 uv
ENG test Battery
Peripheral tests Central Tests
Saccade Test
Positional Tests
Gaze Test
Proxysmal
nystagmus test Pendulum
Tracking
Spontaneous
Caloric Test Nystagmus
Optokinetic
Positional Tests
Eyes should be closed during the test to avoid visual suppression

Classification of Positional Nystagmus
• Type-1. Direction Changing
• Type-2. direction fixed
• Type-3. Irregular or variable
Proxysmal Nystagmus Test/Dynamic positioning
test/Dix Hallpike test
Interpretation
BPPV Central Nystagmus
Latent period 2-10 sec None
Adaptation Within 30 sec persists
Vertigo Present, severe Usually absent or

Mild
Direction of Towards undermost Variable

Nystagmus ear
Incidence Common Rare

Caloric Test
• Thermal stimulus used

• Temperature selected is 44 & 33 deg C
• Irrigation of water done in following order:
Right-44, Left – 44, Right- 30,Left-30
• Patient is kept alert
Three types of irrigation used
 Open water irrigators

 Closed loop irrigators
 Air caloric irrigators
Range of culmination frequency/30 seconds for all four
caloric stimulation (AIISH, Vertigo Clinics )
Caloric stimulation Range of culmination frequency per 30 seconds
Right warm 22 – 59
Left warm 20 – 70
Right cold 21 – 51
Left cold 22 – 64
Canal (R 44C + R 30C) — ( L 44C + L 30C) x 100
=
Paresis (R 44C + L 44C+ R 30C + L 30C)
(30+50) — (20+20) 40
x 100 x 100 = 33.33%
= =
(30+20+50+20) 120
Right Beating Nystagmus
Right 44 Left 30
Right Ear Left Ear
Right 30 Left 44
Left Beating Nystagmus

Butterfly Chart
Optokinetic Test
+300 to 00
-300 to 00
Gaze Test
• Patient is asked to look 30º to the right, left, up & down

• Duration: 30 mins , Recording in each position
• Nystagmus on gaze deviation suggestive of central lesion
Spontaneous Nystagmus
• Done during caloric test

• Normal patient & patient with peripheral lesion should
be able to supress the nystagmus
• First recorded with eyes closed & then eyes opened with
eyes fixate on a target
• Recorded for one minute.
Interpretation
 Left beating/right beating with eyes closed, frequency

more than 19 betas per 30 sec suggests right/left vestb
lesion
 Left beating/right beating with eyes closed, frequency less
than 19 betas per 30 sec-clinically insignificant
 No Nystagmus with eyes closed but in open condition
Nystagmus present- central lesion
PENDULUM TRACKING TEST
• Evaluate smooth pursuit

• Tracks 10 stimulus cycles, Latter 5 are evaluated
• Sway: 30º visual angle
• Speed: less than 50º/sec
• Records: 4 types
Things to remember
 In ENG you record the corneoretinal potentials.

 Each subject is different.
 Mainly gives information about HSCC.
 Artifacts from muscle potentials.
 Cannot pick up torsional movement.
 Cannot record when no corneoretinal potentials.
Videonystagmography
The term “video-oculography” was introduced
spontaneously by one of the authors during a
presentation at a local meeting in Berlin (Treffpunkt
Medizintechnik) in 1988, when a visiting journalist
insisted that the video-based technique must have
an appropriate, easy-to-remember title.
Basic Instrumentation
Frenzel glasses consist of the
combination of magnifying
glasses (+20 lenses placed in
front of the patient), and a
lighting system. When Frenzel's
goggles are placed on the
patient, and the room lights
darkened, nystagmus can easily
be seen because the patients
eyes are well illuminated and
magnified, and because fixation
is removed as the patient can
hardly focus through magnifying
glasses on a dark room.
Digital Imaging sensors
 Purkinje sensors
 Limbus Sensors
Purkinje sensors
• Purkinje images are reflections of illumination lights

on the different optical surfaces of the eye.
• However, Purkinje trackers require an elaborate
setup, and as a result are rarely employed.
Limbus Sensors
• The reflectivity of the sclera is much larger than the

reflectivity of the darker iris.
• Over short periods such systems can achieve an
accuracy of about 1 deg horizontally and 2 deg
vertically, which is often sufficient for vestibular
screening tests.
How VNG works??
• The camera forms a digital image of the eye, as

well as of reflections on the optical surfaces of the
eye. Then computer algorithms are used to identify
particular structures in this image, in most cases first
the near-circular pupil. Together with appropriate
calibration procedures, the orientation of the eye
with respect to the camera is then calculated.
BRIGHT PUPIL TECHONOLOGY
DARK PUPIL TECHONOLOGY
The Whole Testing is similar to the ENG.
If u are still awake,
please wake up the
person sleeping
next to you.
ACKNOWLEDGMENTS
ORGANISERS
HOD-AUDIOLOGY, AIISH
DIRECTOR, AIISH

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Overview

Dr. Sujeet Kumar Sinha

 Vestibular system lesion ?

Duration of the nystagmus

Positive (+ve) Negative (-ve)

• Avoid alcohol and certain other drugs at least 48 hrs

Peripheral tests Central Tests

Eyes should be closed during the test to avoid visual suppression

Latent period 2-10 sec None

Adaptation Within 30 sec persists

Vertigo Present, severe Usually absent or

Direction of Towards undermost Variable

Incidence Common Rare

• Thermal stimulus used

 Open water irrigators

Caloric stimulation Range of culmination frequency per 30 seconds

Right Ear Left Ear

Left Beating Nystagmus

• Patient is asked to look 30º to the right, left, up & down

• Done during caloric test

 Left beating/right beating with eyes closed, frequency

• Evaluate smooth pursuit

 In ENG you record the corneoretinal potentials.

• Purkinje images are reflections of illumination lights

• The reflectivity of the sclera is much larger than the

• The camera forms a digital image of the eye, as

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