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TitleDescriptionSubject
1 Assessing for hyperventilation-induced nystagmusHyperventilation induced nystagmus is tested by asking the patient to take quick deep breaths (~1/s) for 40-60 seconds. This increases ICP and CSF pH. This can be helpful in diagnosing irritative conditions of the vestibular nerve, including an acoustic neuroma (see video, https://collections.lib....Hyperventilation
2 Dynamic visual acuityAfter assessing static binocular visual acuity, dynamic visual acuity (DVA) is determined by repeating the test during horizontal and vertical head shaking at 2-3 Hz. Dynamic visual acuity is most important to test when bilateral vestibular loss is suspected. A loss of at least 4 lines is typical ...Dynamic Visual Acuity
3 Evaluation of ConvergenceThe assessment of convergence includes measuring alignment at near versus distance (see video, https://collections.lib.utah.edu/details?id=187677), near point of convergence and convergence amplitude. Near point of convergence is assessed by bringing a fixation target toward the bridge of the patie...Normal Convergence
4 Evaluation of auditory function using Rinne and Weber testsThe Rinne test is an assessment of auditory thresholds to air and bone conduction of sound. The Weber test is a comparison of bone conducted sound of either ear. Conductive hearing loss results in a loss of air conducted greater than bone conducted sound, whereas sensorineural hearing loss results...Auditory Testing
5 Measuring Divergence AmplitudeDivergence insufficiency should be suspected in patients with binocular horizontal diplopia at distance (but not near) who lack abduction deficits. There should be an esodeviation greater at distance, and in older patients with levator dehiscence (or previous ptosis surgery) and prominent superior s...Insufficient Divergence
6 Ocular motor & vestibular features of the MLF syndromeThis 61-year-old woman with HTN and DM presented for evaluation of acute onset diagonal diplopia. Adduction OS was about 60% of normal while medialization OS improved with convergence. In right gaze, dissociated abducting nystagmus was present OD, and there was a clear adduction lag when asking he...INO, Jerk Nystagmus, Torsional Nystagmus, Gaze-evoked Nystagmus
7 Ocular motor & vestibular features of the MLF syndrome - Figures 1, 2, and 3This 61-year-old woman with HTN and DM presented for evaluation of acute onset diagonal diplopia. Adduction OS was about 60% of normal while medialization OS improved with convergence. In right gaze, dissociated abducting nystagmus was present OD, and there was a clear adduction lag when asking he...INO, Jerk Nystagmus, Torsional Nystagmus, Gaze-evoked Nystagmus
8 Oculopalatal tremor and internuclear ophthalmoplegia due to hemorrhagic pontine cavernomaThis is a 60-year-old woman who experienced 2 episodes of vertigo, nausea and vomiting, which was felt to be related to recurrent hemorrhage of a pontine cavernoma that was adjacent to the fourth ventricle. The cavernoma was resected, and diplopia and left facial palsy were noted after the surgery. ...Pendular Nystagmus, Oculopalatal Tremor; INO; Pons OMS; Seventh Facial Nerve
9 Oculopalatal tremor and one-and-a-half syndrome due to pontine hemorrhageThis is a 65-year-old man who was put on a blood thinner, and shortly thereafter experienced a midline pontine hemorrhage, which was more dense on the left side. Immediately afterwards, right hemiparesis and hemi-anesthesia, left lower motor neuron (LMN) facial palsy and ophthalmoparesis were noted....Pendular Nystagmus; Oculopalatal Tremor; INO; One and a Half; Pons OMS; Seventh Facial Nerve; Sixth Abducens Nerve
10 Oculopalatal tremor with prominent nystagmus, bilateral horizontal gaze palsy, and bilateral facial palsiesThis is a 50-year-old woman who experienced the acute onset of right sixth and seventh nerve palsies and left hemiparesis. Two cavernomas within the right pons (one in the region of the facial colliculus) were demonstrated by MRI. Five years after her initial presentation she developed recurrent r...Abnormal Range, Sixth Nerve Palsy, Facial Nerve, Horizontal Gaze Palsy, OMS Pons, Pendular Nystagmus, Oculopalatal
11 Oculopalatal tremor with prominent nystagmus, bilateral horizontal gaze palsy, and bilateral facial palsies Figure 1Figure 1, MRI T2 sequence demonstrating hyperintensities involving bilateral inferior olives of the medulla. This is a 50-year-old woman who experienced the acute onset of right sixth and seventh nerve palsies and left hemiparesis. Two cavernomas within the right pons (one in the region of the facia...Abnormal Range, Sixth Nerve Palsy, Facial Nerve, Horizontal Gaze Palsy, OMS Pons, Pendular Nystagmus, Oculopalatal
12 Optokinetic nystagmusDuring the bedside evaluation of optokinetic nystagmus (OKN), the patient is instructed to look at each red (or white) square as it moves past. Because this is not a full-field visual stimuli, using an optokinetic flag mainly allows the examiner to quickly evaluate for right/left and up/down symmet...Optokinetic Nystagmus
13 Paraneoplastic downbeat nystagmus and cerebellar ataxia due to small cell lung carcinomaThis is a 61-year-old woman (non-smoker) who developed a gait disorder, dizziness and oscillopsia that was progressive over 2 months. Exam demonstrated spontaneous downbeat nystagmus with side pocket nystagmus in lateral gaze (a combination of horizontal gaze-evoked and downbeat nystagmus, giving an...Jerk Nystagmus, Downbeat Nystagmus, Cerebellar Ataxia, Carcinoma
14 Pendular, gaze-evoked and abducting nystagmus in MSThis is a 40-year-old woman with a history of multiple sclerosis who presented for oscillopsia. On examination, she had bilateral internuclear ophthalmoplegia (INO-adduction lag OU and abducting nystagmus OU), with a corresponding exotropia that increased in right and left gaze. She also had horiz...Jerk Nystagmus, INO, Pendular Nystagmus; Abducting Nystagmus, Gaze-Evoked Nystagmus, Cerebellar OMS
15 Pressure testing for superior canal dehiscence syndromeSuperior semicircular canal dehiscence syndrome (SCDS) is caused by a third mobile window in the inner ear. This allows for transmission of sound or pressure to the superior canal. Tragal compression and/or glottic and pinched nose Valsalva may provoke vertigo and vertical-torsional nystagmus in t...Valsalva; Superior canal dehiscence syndrome
16 Provocative maneuvers (removal of fixation, vibration, head-shaking) to accentuate peripheral vestibular nystagmus)With an acute destructive process like vestibular neuritis that causes significant unilateral vestibular loss, spontaneous nystagmus is always present. However, over days to months, spontaneous nystagmus should resolve completely. In a patient with vestibular neuritis involving the right side, left-...Headshaking Nystagmus
17 Rotary Chair TestingRotary chair testing includes rotation around a vertical axis, and evaluates the horizontal semicircular canal vestibulo-ocular reflex (VOR). The patient sits in a mechanized chair with the head secured in a neutral position or in 30 degree forward flexion (to better isolate the horizontal canals)....Normal VOR, Abnormal VOR, Vestibular Lab Testing, Rotary Chair
18 Skew deviation and spontaneous nystagmus due to posterior fossa lesionsThis is a 50-year-old woman who reported the abrupt onset of imbalance, right upper extremity incoordination and binocular vertical diplopia several months prior to her presentation to our clinic. On examination, she had a left hypertropia that was fairly comitant (measuring 5 prism diopters) assoc...Abnormal Alignment, Jerk Nystagmus, Upbeat Nystagmus, Vestibular Nystagmus, Rotary Nystagmus, Skew Deviation
19 Slow saccades due to unilateral paramedian pontine reticular formation (PPRF) injury with preserved movements using the vestibulo-ocular reflexThis is a 60-year-old man who presented for imbalance and oscillopsia 10 months after surgery and 8 months after radiation for Merkel cell carcinoma of the neck. He developed imbalance after surgery and diplopia and oscillopsia 6 months prior to our evaluation. MRI showed enhancement of both 6th n...Abnormal Saccades, Pons OMS, Sixth Abducens Nerve, Abnormal VOR, Vestibulocochlear Nerve, Horizontal Gaze Palsy
20 Slow volitional saccades and poor fast phases to an optokinetic stimulus, with preserved head impulse testingThis is a 67-year-old woman presenting with imbalance and binocular horizontal diplopia at near. On examination there were frequent square wave jerks, limited supraduction OU and convergence insufficiency, which explained her diplopia. Pursuit and suppression of the vestibulo-ocular reflex were sa...Abnormal Saccades, VOR HIT Normal
21 Summary of the most common audio-vestibular testingChart describing common audio-vestibular testing.Vestibular lab testing
22 Test Your Knowledge - Optokinetic nystagmus with a parietal lesionGiven the finding seen in the first part of the video, which of the following associated features are most likely? (more than one answer may be correct); A.; Left homonymous visual field defect; B.; Right homonymous visual field defect; C.; Visual neglect and/or extinction; D.; Alexia without agraph...Abnormal OKN, Jerk Nystagmus
23 Test your knowledge - Bilateral 4th nerve palsiesWatch the video until instructed to stop. Which of the following features is likely to be present given her exam findings? ; a.; Gaze-evoked nystagmus and impaired smooth pursuit; b.; History of traumatic brain injury; c.; History of blepharoplasty or brow lift surgery and prominence of superior su...Abnormal Alignment, Fourth Nerve, Trochlear Nerve
24 Test your knowledge: The acute vestibular syndrome with gaze-evoked nystagmus and bilaterally abnormal head impulse testing due to middle cerebellar peduncle and flocculus hemorrhageThis is a 70-year-old woman with a history of atrial fibrillation on warfarin presenting with acute prolonged vertigo and imbalance. In addition to the findings demonstrated in the first part of the video, what else should be seen to reassure the examiner that the etiology of her vertigo is benign? ...Abnormal VOR, Jerk Nystagmus, Acute Vestibular Syndrome, Cerebellar OMS, Gaze Evoked Nystagmus,
25 Testing for adduction lag in partial INO using an optokinetic stimulusIn this patient we demonstrate the use of an optokinetic stimulus to elicit an internuclear ophthalmoplegia (INO). Occasionally adduction appears to be normal with an INO, and an adduction lag with horizontal saccades should be sought as a confirmatory sign. Optokinetic tape is an easy way to assess...INO, Jerk Nystagmus
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