Acta Oto-Laryngologica.

2014; 134: 1245–1250

ORIGINAL ARTICLE

The video head impulse test

PEDRO LUIZ MANGABEIRA ALBERNAZ1,2 & FRANCISCO CARLOS ZUMA E MAIA3,4

1
Escola Paulista de Medicina, Federal University of São Paulo, 2Hospital Israelita Albert Einstein, São Paulo,
3
Department of Surgery, Federal University of Rio Grande do Sul, Clínica Maia, Canoas, Rio Grande do Sul, Brazil and
4
University Louis Pasteur School of Medicine, Strasbourg, France
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Abstract
Conclusion: Additional research is needed to validate the importance of the video head impulse tests (vHIT), but it provides an
important contribution to the evaluation of anterior and posterior semicircular canal disorders. Objectives: To share
observations of the vHIT test in clinical neurotology and to discuss the significance of the study findings. Methods: This
study comprised 200 patients with a clinical history of vestibular disturbances who were submitted to a vHIT including all
six semicircular canals. Results: Abnormal responses of the anterior and posterior canals were found in several patients, either
alone or combined with altered responses in the lateral canals. A unilateral hypoactive response of a posterior canal was found
For personal use only.

in a patient with a small vestibular schwannoma.

Keywords: Vertigo, vHIT, vestibular evaluation

Introduction The most commonly used techniques for the

The inner ear contains several groups of sensory
cells, divided into two main functions: hearing
(cochlea) and balance (vestibular) receptors. All these
cells have one common characteristic: they have cilia
that when subjected to inclinations alter the cell
polarization and send electric signals to the adjacent
nerve fibers.
The vestibular receptors are located, for each side,
in the ampullae of the three semicircular canals and
the maculae of the utricle and the saccule.
The vestibular system is highly integrated with the
eyes and the proprioceptive system for the mainte-
nance of the body equilibrium. Since the integration
of the three systems occurs at the vestibular nuclei,
it is reasonable to state that the vestibular system is the
main organ related to equilibrium. The clinical
evaluation of the vestibular system is, therefore, of
absolute necessity in patients with symptoms of
disequilibrium, whether they are episodes of vertigo,
instability, abnormal eye movements or falls.
clinical evaluation of the vestibular system are obser-
vations of the spontaneous and gaze nystagmus,
recordings of the optokinetic nystagmus and saccadic
eye movements, rotational tests, and caloric tests.
There is a neurotological consensus that most of
the traditionally used vestibular tests do not explore
all of the frequencies involved in the system’s
responses.
The vestibular hair cells respond to frequencies
from 0 to 16 Hz, being particularly active in the range
of 0.1–10 Hz. Rotational tests are usually limited to a
frequency of approximately 0.1 Hz and caloric tests
are usually in the area of 0.05 Hz.
The caloric tests, devised by Bárány [1] and
modified by Hallpike [2], have been traditionally
considered as the only feasible technique for exam-
ining each labyrinth separately. The caloric stimulus is
not physiological, its responses are mainly caused by
thermally induced convection currents in the peri-
lymph of the semicircular canals. Furthermore, they
are limited to the study of the lateral semicircular

Correspondence: Prof. Dr Pedro Luiz Mangabeira Albernaz, MD PhD, Hospital Israelita Albert Einstein, Av. Albert Einstein, 627 - Pavilion A1, Room 117,
São Paulo, Brazil. E-mail: albernaz@einstein.br

(Received 4 June 2014; accepted 30 June 2014)

ISSN 0001-6489 print/ISSN 1651-2251 online ! 2014 Informa Healthcare
DOI: 10.3109/00016489.2014.942439
 1246 P. L. Mangabeira Albernaz & F. C. Z. Maia
canals and are related to frequencies below 0.1 Hz;
they do not, therefore, investigate the most important
frequencies of vestibular function.
The present study focused on the head impulse
test, a procedure that employs physiological stimuli
and can identify responses from all six semicircular
canals.
The head impulse test was described by Halmagyi
and Curthoys in 1988 [3]. They stated that in a high
percentage of cases short and quick head movements
would induce saccadic eye movements and demon-
strated that these saccades resulted from the stimu-
lation of phasic receptor cells in the crista of one of
the lateral semicircular canals, the contralateral one
being inhibited by the quick movement, of the order
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of 200o /s. These physiological principles have been
confirmed by other investigators [4].
Aw et al. [5] and Halmagyi et al. [6] verified that
with the patient’s head in different positions it was
possible to investigate each of the six semicircular
canals. Magnusson et al. [7], in 2002, demonstrated
that it was possible to improve the reliability
and sensitivity of the test using videonystagmoscopy.
The video head impulse test (vHIT) is easier to inter-
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pret, particularly in relation to the vertical canals.
Several studies [8–17] have confirmed and vali-
dated the use of the vHIT in neurotological diagnosis.
The present study investigated normal controls
and patients with different types of neurotological
disorders who were submitted to the vHIT.
Material and methods
The present study was conducted in 200 patients
with different kinds of cochlear and/or vestibular
disorders. There were 129 females (64.5%) and
71 males (35.5%). Their ages varied from 16 to
n = 200
50
40
Number of patients
30
20
10
0
11–20 21–30 31–40 41–50 51–60 61–70 71–80 81–90 91–100
Age (years)
Figure 1. Age distribution of the 200 patients in the study.
95 years, with a mean of 47.00 and a standard devi-
ation of 15.56. The age distribution is shown in
Figure 1.
All the patients were submitted to an evaluation
that included a detailed clinical history and otolaryn-
gological examination. Audiological tests were also
performed, including pure-tone audiometry, speech
discrimination tests, and immitance tests. For some
patients auditory brainstem responses were recorded
and some underwent electrocochleography.
Vestibular tests were performed, including evalua-
tions of spontaneous and semi-spontaneous nystag-
mus, positional nystagmus, pendular eye tracking,
optokinetic nystagmus, pendular rotatory tests and,
in some cases, caloric tests. For some patients cervical
vestibular evoked myogenic potential (cVEMP) and
ocular VEMP (oVEMP) were recorded.
The vHIT was performed using an Otometrics ICS
Impulse system. Recordings were obtained for each of
the six semicircular canals in all patients.
This research was approved by the Ethics Commit-
tee of the Albert Einstein Hospital (CAAE: 06137
012.3.0000.0071).
Results
Table I summarizes the findings for the 200 patients.
Many patients (n = 103) had normal results in the
vHIT test. Of the patients with reduced vestibulo-
ocular reflex (VOR) gain observed in the anterior
semicircular canals, 21 presented it on the right
side, 4 on the left, and 3 bilaterally, making a total
of 28 patients.
Reduced VOR gain of the lateral semicircular
canals was observed in 23 patients; 3 on the right
side, 18 on the left side, and 2 bilaterally. Of the
14 patients who presented low VOR gain in all
 Video head impulse test 1247

Table I. Findings in 200 patients. Table II. Vestibular disorders.

Finding n % Disorder n %

Normal 103 51.5 Vestibular neuronitis 47 235

Anterior canal low VOR gain 28 14.0 Ménière’s disease 15 75
Lateral canal low VOR gain 23 11.5 Vestibular migraine 15 75
Low VOR gain in all canals 14 7.0 Benign paroxysmal postural vertigo 13 65
Lateral and posterior canals low VOR gain 9 4.5 Central vestibular disorders 12 60
High VOR gain in all canals 8 4.0 Metabolic inner ear disorders 6 30
Lateral and anterior canals low VOR gain 6 3.0 Kinetosis 4 20
Posterior canal low VOR gain 4 2.0 Vascular compression 2 10
Covert saccades 2 1.0 Dehiscence of superior semicircular canal 1 5
Overt saccades 1 0.5 Vestibular schwannoma 1 5
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Multiple saccades 1 0.5

VOR, vestibulo-ocular reflex.
be established between the clinical diagnoses and the
findings in the vHIT tests.
3 semicircular canals, 1 presented it on the right side, Table II shows the clinical diagnoses for this group
5 on the left, and 8 presented it bilaterally. of patients. They will each be considered in turn.
In nine patients there was a combination of
malfunctioning lateral and posterior canals. In one Vestibular neuronitis
patient the changes were found on different sides, the
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left lateral and the right posterior canals presented low
VOR gain. Two patients had changes only on the
right side, two on the left, and four presented bilateral
changes.
In eight patients all six semicircular canals showed
high VOR gain.
In seven patients malfunction of the lateral and
anterior canals was observed. In three patients these
changes were found only on the left side; in three
patients the left lateral and the right anterior canals
had low VOR gain. One patient showed low VOR gain
of the left lateral and right and left anterior canals.
Four patients presented low VOR gain in the
posterior semicircular canals, two on the right side
and two on the left.
In 1952, Dix and Hallpike [18] described vestibular
neuronitis as a vestibular disorder characterized by
recurring episodes of vertigo associated with either
unilateral or bilateral hypoactive responses to the
caloric stimulation and normal hearing. This disor-
der, therefore, is totally different from the vestibular
neuritis described by Nylen [19] in 1924, which
consists of one single, non-recurring, violent episode
of vertigo.
In 55 of the patients in this group, all presenting
recurring episodes of vertigo, isolated responses of
different canals were recorded. Table III illustrates
these findings. It is hypothesized that these are cases
of vestibular neuronitis involving different semicircu-
lar canals, the diagnosis of which would be impossible
with caloric tests.

Discussion Table III. Patients with recurring episodes of vertigo showing low
VOR gain in semicircular canals (n = 55).
Vestibular disorders are common in the population Semicircular canals n
and have been classified into several different types.
Right lateral 6
Despite the fact that each of the vestibular end organs
can now be adequately subjected to evaluation, no Left lateral 19
precise correlations can be established between the Right anterior 16
clinical findings and the types of disorders presented Left anterior 5
by each patient. Right posterior 2
The clinical diagnoses of the patients in this study
Left posterior 1
were essentially established through their clinical his-
All canals – unilateral 2
tories and then confirmed by neurotological findings,
sometimes corroborated by laboratory tests and/or All canals – bilateral 4
medical imaging. However, some correlations could VOR, vestibulo-ocular reflex.
 1248 P. L. Mangabeira Albernaz & F. C. Z. Maia

Table IV. Findings in Ménière’s disease (n = 16). gain. The inconsistency is probably related to the
Finding n clinical variability of Ménière’s disease in terms of
duration, severity, and associated pathologies, such as
Normal 7 migraine (one patient) and benign paroxysmal pos-
High VOR gain, all canals 5 tural vertigo (two patients).
Low VOR gain, anterior canal 2
Low VOR gain, lateral canal 1 Vestibular migraine
Low VOR gain, lateral and posterior canals 1
Twelve of the 15 patients with vestibular migraine
VOR, vestibulo-ocular reflex. had normal vHIT; one had a hypoactive left lateral
canal, one had bilateral low VOR gain of the anterior
canals, and one had low VOR gain in all of the
It must be taken into account that vHIT and caloric semicircular canals on the left side.
tests stimulate different frequency ranges. Further
studies will be necessary to fully understand the
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Benign paroxysmal postural vertigo (BPPV)

significance of low gain VOR responses of different
semicircular canals. Twelve of the 14 patients with BPPV presented
normal results with the vHIT. This is understandable,
Ménière’s disease since this disorder is essentially mechanical. In one
patient with a left anterior canal BPPV this canal
The results for the patients with Ménière’s disease, presented low VOR gain. However, one patient
shown in Table IV, were not consistent. In seven with a right posterior canal BPPV presented low
patients the vHIT was normal. Five patients pre- VOR gain in all canals on the left side.
sented high VOR gain in all semicircular canals, One patient diagnosed as having BPPV is worth
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probably related to associated metabolic problems. mentioning in detail. In 1992 she had epidemic
Vestibular hyperactivity is a common finding in parotiditis accompanied by profound hearing loss in
patients with hyperinsulinemia, due to changes in the left ear. In 1997 she began to present episodes
the composition and density of endolymph [20]. of severe vertigo and was diagnosed as having
The others had one or two canals with low VOR delayed endolymphatic hydrops. In view of the

Lateral 2D analysis
Gain Info Remarks Test Display 300 Eye 300 Eye
Head & eye velocity

Head & eye velocity

Left Right × Left mean:0.97.σ.0.03 × Right mean:0.97.σ.0.04

200 Left 200 Right
1.2
1.0
0.8
Gain

0.6 0 0
0.4
0.2 –100 –100
0.0 –140 0 200 400 560 –140 0 200 400 560
40 60 80 100 120 140 160 180 200 220 240 260 280 300
Peak velocity (deg/sec) Left lateral ms Right lateral ms

Lateral 2D analysis
Gain Info Remarks Test Display 300 Eye 300 Eye
Head & eye velocity

Head & eye velocity

LA RP × LA mean:0.58.σ.0.14 × RP mean:0.75.σ.0.16
200 Left 200 RP
1.2
1.0
0.8
Gain

0.6 0 0
0.4
0.2 –100 –100
0.0 –140 0 200 400 560 –140 0 200 400 560
40 60 80 100 120 140 160 180 200 220 240 260 280 300
Peak velocity (deg/sec) Left anterior ms Right posterior ms

RALP 2D analysis
Gain Info Remarks Test Display 300 Eye 300 Eye
Head & eye velocity

Head & eye velocity

LP RA × LA mean:0.73.σ.0.06 × RA mean:1.21.σ.0.25
200 Left 200 RA
1.6
1.4
1.2
Gain

1.0
0.8 0 0
0.6
0.4
0.2 –100 –100
0.0 –140 0 200 400 560 –140 0 200 400 560
40 60 80 100 120 140 160 180 200 220 240 260 280 300
Left posterior ms Right anterior ms
Peak velocity (deg/sec)

Figure 2. Results of video head impulse test (vHIT) in a patient with benign paroxysmal postural vertigo (BPPV) who had undergone a left ear
labyrinthectomy 15 years earlier.

profound hearing loss she was submitted to a labyr-
inthectomy in the left ear, performed through a post-
auricular approach. The three semicircular canals
were destroyed, the stapes was removed, and genta-
micin was injected into the vestibule.
After the compensation period she remained
asymptomatic for 15 years and then returned with a
complaint of postural vertigo. It was felt that a con-
tralateral delayed endolymphatic hydrops had to be
discarded, and she was submitted to vHIT (Figure 2)
that showed less VOR gain for the left anterior and
posterior semicircular canals, but this gain was larger
than expected in an ear submitted to labyrinthectomy.
A CT scan of the temporal bones showed clearly the
destruction of the left semicircular canals. It is
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conceivable that some reorganization of the VOR
may occur at the level of the vestibular nuclei. The
Hallpike maneuvers demonstrated that she had
BPPV.
Central inner ear disorders
Twelve patients were diagnosed as presenting central
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vestibular disorders. Two had a clinical history of
cerebrovascular accidents, one had marked brain
ischemia, one had a brainstem glioma, and one had
Ehlers-Danlos syndrome with dysautonomia. Two
presented age-related normal pressure hydrocepha-
lus. The other five had less severe vascular problems.
None of these patients had normal vHIT results.
The patient with the brainstem glioma and the patient
with severe brain ischemia presented bilaterally
altered lateral and posterior canals. The patients
with normal pressure hydrocephalus had poor
responses in all six semicircular canals. The patient
with Ehlers-Danlos syndrome presented bilateral
hypoactive anterior canals. One patient had hypoac-
tive left anterior and right posterior semicircular
canals.
Metabolic inner ear disorders
Six patients presented mild low and high tone hearing
losses with normal thresholds for the middle frequen-
cies. One of them was found to have intolerance to
lactose, the others had hyperinsulinemia [20]. Two of
them had normal vHIT results, the others had
hypoactive responses of one of the lateral canals.
Kinetosis
The four patients with intense kinetosis had normal
vHIT responses.
Video head impulse test 1249
Figure 3. Magnetic resonance image showing a vestibular schwan-
noma in the internal acoustic meatus on the left side.
Vascular compression
The two patients with vascular compression of the
eighth nerve seen in magnetic resonance imaging
(MRI) presented normal vHIT responses.
Dehiscence of the superior semicircular canal
Normal vHIT responses were recorded in the one
case diagnosed with a dehiscence of a superior semi-
circular canal.
Vestibular schwannoma
A 68-year-old female patient complained of progres-
sive hearing loss in both ears, starting approximately
10 years earlier. During this period of time she had
several episodes of vertigo. A recent audiogram
showed a sudden loss of discrimination in the left
ear, from 72% to 16%. MRI showed a 1.5 mm
schwannoma in the left internal acoustic meatus
(Figure 3). The vHIT showed a hypoactive response
of the posterior canal on the left side, suggesting that
this tumor arose from the inferior vestibular nerve.
Conclusions
The possibility of examining each of the six semicir-
cular canals separately introduces a revolutionary
change in clinical neurotology and may in time con-
tribute to newer diagnostic possibilities, particularly
when associated with the electrical responses of the
saccule and utricle.
However, further research is needed, including
comparison with other tests, to validate the contribu-
tion of the vHIT. The cases discussed in this study
suggest that the vHIT can be significant in neuroto-
logical diagnosis, particularly in relation to vestibular
disorders related to the anterior and posterior semi-
circular canals.
 1250 P. L. Mangabeira Albernaz & F. C. Z. Maia
Acknowledgments
This research was financed by the Instituto Israelita de
Ensino e Pesquisa Albert Einstein, in São Paulo, Brazil.
The authors are indebted to Renato Valerio Cal MD,
for valuable suggestions, and to audiologist Thaisa
Brusco, who performed many of the vHIT tests.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper.
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Acta Otolaryngol Downloaded from informahealthcare.com by 191.180.250.53 on 11/16/14
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