Electronystagmography: Dr. Supreet Singh Nayyar, AFMC For More ENT Topics & PPTS, Visit

Electronystagmography
Dr. Supreet Singh Nayyar, AFMC
For more ENT topics & ppts, visit www.nayyarENT.com
1 www.nayyarENT.com 28-07-2012
HISTORY
 Rhythmical movement of eyes was known even in Ancient Greek
medicine
 Hippocrates, the father of medicine (460 B.C) & Galen (180 A.D) called
it ‘Hippus’ which means small horse
 Term ‘nystagmus’ was reserved for slow movement of the head
 Berlin (1891) first attached a watch glass on the eye bulb to record
nystagmus
 Dodge & Clinc (1901) photographed light reflex from the eye &
recorded nystagmus
VESTIBULAR REFLEX ARC
 Sensory receptors: 3 cristae & 2
maculae
 Afferent neuron: From the sensory
cells to the vestibular nuclei
 2nd order neurons: Vestibular nuclei
to:
 A) Oculomotor nuclei
 B) Anterior horn cells of spinal cord
 C) Cerebellar cortex
 Temporal lobe cortex
 Autonomic nervous system
28-07-2012 www.nayyarENT.com 3
VESTIBULO-OCULAR REFLEX
 Stimulation of left ear with warm water (44ºC)
 Stimulation of left labyrinth
 Impulse to the VIth nerve of opposite side & IIIrd nerve of same side
 Contraction of Rt LR & Lt MR leading to conjugate deviation of eyes
to the right (slow phase)
 Stimulation of reticular formation in brainstem
 Counter the slow deviation of the eyes that jerk back to original
position (fast phase)
 Inhibition/facilitation: Cerebral cortex, cerebellum, reticular
formation
FUNDAMENTALS OF ENG
 Nystagmus
 Continuous electrical processes in the retina
 Electrical field created by positive corneoretinal potential
 Coincides with the optical axis of the eye
 Change with movement of the eye
 Detected with the help of electrodes
 Amplified & recorded on a running strip of paper/computer
 Positive & negative deflection
ELECTRODE LOCATIONS
ELECTRONYSTAGMOGRAPH TRACING
 Depends upon the machine
 Monochannel/Multichannel
 Sawtoothed curve
 Criteria to identify nystagmus beats
 Direction of nystagmus
Pendular Nystagmus Oblique Nystagmus
Latent Period of Caloric Response Nystagmus Perversion9

28-07-2012 www.nayyarENT.com
Visual Fixation Suppression Failure of Visual Fixation Suppression
Divergent Dissociation Monocular Nystagmus
ENG PROCEDURE
 ENG Room: quiet, lightproof
 Away from heavy electrical
equipments
 ENG Machine: single/multi-
channeled
 Properly grounded
 Bed/table/positioning chair
 Head-end raised to 30º
 Calibration cross/pendulum
 2 thermostatically controlled
caloric water baths
 Irrigation apparatus
 Air caloric irrigator
 Optokinetic stimulator
PREPARATION OF THE PATIENT
 Avoid alcohol & certain drugs 48 hrs before

 Examination of the ears
 Cleaning the area
 Patient asked to lie down
 Application of the electrodes

 Silver, coated with non-polarizing silver chloride
 Electrolyte paste should be applied
 Should be firmly applied over the skin
CALIBRATION
Electrical Calibration
 200 microvolt signal produces a 10mm deflection

 Amplitude of nystagmus: in microvolts
 Depends on: corneoretinal potential
 Frequency & Slow phase: independent
CALIBRATION
Biocalibration
 By using a pendulum
 Mounted in a inverted fashion
 Patient follows the movement for 10 cycles
OPTOKINETIC NYSTAGMUS TEST
 Evaluates the optokinetic system

 Passing before the patient's eyes a series of repetitive visual stimuli
 Rotating drum/moving lights on a calibration bar
 Vertical black stripes on a white background
 Diameter of the drum: 8 inches
 Height: 12 inches
 Movement elicites nystagmus
 Symmetry of responses is evaluated
THE POSITIONING NYSTAGMUS TEST
 Elicit BPPV nystagmus

 Recording 1st in erect position for 30 secs
 Position changed rapidly to head hanging position with head turned to
the right for 30 secs
 Turned to the erect position & recorded for 30 secs
 Repeated on the left side
 Nystagmus: rotatory with predominant vertical component
 Done with both eyes open/closed
THE CALORIC TEST
 Position: Supine
 Head end of table: Raised by 30º
 Ears irrigated with warm & cold water for 40 secs each
 Nystagmus noted
 Interval of 8 mins between 2 successive irrigations
PENDULUM TRACKING TEST
 Evaluate optokinetic function of smooth pursuit

 Tracks 10 stimulus cycles
 Latter 5 are evaluated
 Sway: 30º visual angle
 Speed: less than 50º/sec
 Records: 4 types
PENDULUM TRACKING TEST
 Normal: 10 jerky beats
superimposed on 5 pendulum
cycles
 Abnormal: >10 jerky beats
(Lt/Rt) on 5 cycles
 A) Normal tracing
 B) Central lesion
 C) Grossly disorganized/ataxic
tracing…Advanced central lesion
SPONTANEOUS NYSTAGMUS TEST
 Supine/ caloric position

 1min recording of eyes closed nystagmus
 Eyes open & asked to look straight…1 min recording
 Latter 30 secs is considered
 Number of beats to Rt & Lt are counted
 Co-ordination of 2 eyes is noted
 Over 70% normal individuals may show nystagmus
 Normal: upto 19 beats/30 secs in any direction
 Abnormal: >19 beats/30 secs in any direction
 Limited localization value
SPONTANEOUS NYSTAGMUS TEST
Failure of Visual Fixation Suppression Direction changing Spontaneous Nystagmus
Vertical Spontaneous Nystagmus

Congenital Fixation Nystagmus
GAZE TEST
 Patient is asked to look 30º to

the right, left, up & down
 Recording in each position
 Duration: 30 mins
 Nystagmus on gaze deviation
 Always pathological
 Differenciate from fatigue
nystagmus
INTERPRETATION OF GAZE TEST
 No nystagmus in any position: Normal
 Right beating nystagmus in right lateral position: CNS pathology

(cerebellar)
 Left beating nystagmus in left lateral position: CNS pathology

(cerebellar)
 Gradually diminishing intensity of right/left beating nystagmus:

Physiological end-point nystagmus
 Rebound nystagmus: Chronic cerebellar pathology

POSITIONAL TEST
 Static test to stimulate the otolith organs
 Recording: for 1min with eyes closed
 Positions: sitting erect, supine, supine with head turned left & right
lateral, supine with head hyperextended
 Non-specific evidence of vestibular disorder
 Little localizing value
 Significant: with eyes open/ 3 or more positions out of 7
 Positional nystagmus changing direction: CNS lesion
 Factors affecting the nystagmus
Benign Central
Positional Positional
Nystagmus Nystagmus
Latency 2-10 sec None
Adaptation Within 30 sec Persists
Fatiguabilit Disappears on Persists

y repetition
Vertigo Persistent Absent/Mild
Direction Undermost Variable

side
QUANTITATIVE EVALUATION OF ENG
DURATION
 Popular when nystagmus was directly

observed
 ENG: not a satisfactory parameter
 Induced nystagmus declines over a
period of time
 Difficult to identify the end point
accurately
 Nystagmus reactions of different
intensity may have same duration
Maximum Slow Phase

Velocity
 Widely used parameter
 True representative of
vestibular activity
 Manual calculation: Bias
Culmination Frequency
 Fq of nystagmus in culmination phase

of caloric response
 Simple & accurate measurement
 Minimal personal error
 Indicated as: No.of beats/30 sec
 Midpoint: Culmination point (b/w
50-110sec)
 Delay: Central pathology
CLAUSSEN’S BUTTERFLY CHART
 Pictorial representation of caloric testing

 Represented in 4 quadrants showing caloric response in each ear
 Horizontal axis: represents time
 Vertical axis: no. of nystagmus beats
 Readings shown as normal (0), hypoactive (1) and hyperactive (2)

 Normal 19 beats/ 30 sec = 0
 Hypoactive < 19 = 1
 Hyperactive >19 = 2
 Made for easier and faster interpretation
Normal Range
 Rt 44˚ : 22 – 59 beats /
30 sec
 Lt 44˚ : 23 – 63
beats / 30 sec
 Rt 30˚ : 24 – 67
beats / 30 sec
 Lt 30 ˚: 27 – 68 beats /
30 sec
 Minor & major

butterfly
DIGITAL ENG TELEMETRIC ENG
 Accurate calculation  Time 7 place independent

recording by patient himself
 Minimal unwanted artifacts
 Specially developed goggles
 Good quality ENG record

 Connected to recording device
 Convenient
THE ROTATORY TESTS
 Concept of ‘retinal slip’
 Prevented in normal person by VOR
 Rotatory test thus tests this VOR
 Conducted in special chairs
 !st carried out by Barany
 Present method: Torsion swing chair
 Asymmetry suggests vestibular
pathology
 Slow harmonic acceleration test
VIDEONYSTAGMOGRAPHY
 Recording of eye movements by

camera
 Artifacts are non existent
 Can record rotational nystagmus
 Advantages & disadvantages over

ENG
THANK YOU
for more ENT ppts & topics, visit
www.nayyarENT.com

Electronystagmography: Dr. Supreet Singh Nayyar, AFMC For More ENT Topics & PPTS, Visit

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Electronystagmography: Dr. Supreet Singh Nayyar, AFMC For More ENT Topics & PPTS, Visit

Uploaded by

Copyright:

Available Formats

Electronystagmography

Dr. Supreet Singh Nayyar, AFMC

For more ENT topics & ppts, visit www.nayyarENT.com

 Depends upon the machine

 Criteria to identify nystagmus beats

Latent Period of Caloric Response Nystagmus Perversion9

Divergent Dissociation Monocular Nystagmus

 Avoid alcohol & certain drugs 48 hrs before

 Application of the electrodes

 200 microvolt signal produces a 10mm deflection

 Evaluates the optokinetic system

 Elicit BPPV nystagmus

 Evaluate optokinetic function of smooth pursuit

 Supine/ caloric position

Failure of Visual Fixation Suppression Direction changing Spontaneous Nystagmus

Vertical Spontaneous Nystagmus

 Patient is asked to look 30º to

 Right beating nystagmus in right lateral position: CNS pathology

 Left beating nystagmus in left lateral position: CNS pathology

 Gradually diminishing intensity of right/left beating nystagmus:

 Rebound nystagmus: Chronic cerebellar pathology

Latency 2-10 sec None

Adaptation Within 30 sec Persists

Fatiguabilit Disappears on Persists

Vertigo Persistent Absent/Mild

Direction Undermost Variable

 Popular when nystagmus was directly

Maximum Slow Phase

 Widely used parameter

 Manual calculation: Bias

 Fq of nystagmus in culmination phase

 Pictorial representation of caloric testing

 Readings shown as normal (0), hypoactive (1) and hyperactive (2)

 Made for easier and faster interpretation

 Minor & major

 Accurate calculation  Time 7 place independent

 Good quality ENG record

 Recording of eye movements by

 Artifacts are non existent

 Can record rotational nystagmus

 Advantages & disadvantages over

You might also like