Acta Oto-Laryngologica, 2012; 132: 498504

ORIGINAL ARTICLE

Bedside vestibular examination in patients with unilateral denite

Mnires disease
PEDRO SANTOS MARQUES1,2 & NICOLAS PEREZ-FERNANDEZ3
Department of Otorhinolaryngology Hospital de S. Joo, EPE, Porto, Portugal, 2Department of Otorhinolaryngology
University of Oporto Medical School, Porto, Portugal and 3Department of Otorhinolaryngology, Clnica Universidad de
Navarra, University of Navarra, Pamplona, Spain

Abstract
Conclusion: Although vestibular clinical examinations are quite variable in Mnires disease (MD), when used in a grouped
fashion they attach valuable information to the understanding of MD. Objective: Evaluation of unilateral MD vestibular bedside
examination. Methods: This was a retrospective study of patients with denite unilateral MD at a tertiary care facility.
Assessment of spontaneous nystagmus (SN), head-shaking nystagmus (HSN), head impulse test (HIT) and vibrationinduced nystagmus (VIN) was carried out. Clinical manifestations and auditory and vestibular function were studied. Results:
The study included 97 patients: 47 presented SN, 75 a positive HSN (biphasic in 14) and in 73 a VIN was observed. After
excluding patients with biphasic HSN, a homogeneous response was observed in 43.4%: no nystagmus in 15.7%; nystagmus of
similar direction in 27.8% (paretic, 14.5%; irritative, 13.3%). There were no signicant differences in duration of the disease,
functional level and vertigo index, although a trend towards a shorter time since last crisis was observed in patients with an
irritative nystagmus. In 36.1% nystagmus was revealed with a consistent direction in at least one of the tests and in 20.5% it was
non-coherent, something more frequently observed closer to the crisis. Independently only in VIN an irritative response was
associated with a higher functional level and a shorter time from last attack.

Keywords: Nystagmus, vertigo, vestibular function tests

Introduction
Idiopathic endolymphatic hydrops, often referred to
as Mnires disease (MD), is characterized by episodes of vertigo, hearing loss, tinnitus and aural
fullness [1,2]. It is very often a challenge in diagnosis
and description, mostly because of its variability,
which can make it difcult to recognize, thus possibly
delaying treatment [3].
Hearing loss has been widely studied [4-6], a fact
that inclusively supports its staging according to the
guidelines proposed by the AAO-HNS [7]. Vertigo
attacks appear to be the factor that most affects the
health-related quality of life of these patients. But, in
spite of its impact, it seems surprising that it does not

appear in the proposed staging system, even though

the primary goal of treatment is to reduce the frequency, intensity and duration of these episodes. This
is probably related to the limited information available from serial studies of vestibular function, due to
limitations in the methods of assessment in use, the
uctuating nature of the disorder and the high dependency of results on the time since the last vertigo
attack [8,9].
Clinical bedside vestibular examination, such as the
search for spontaneous nystagmus (SN), post headshake nystagmus (HSN) and mastoid vibrationinduced nystagms (VIN), in a collective manner, is
the rst approach to the patient with dizziness and is
very helpful in the diagnosis of patients with any kind

Correspondence: Pedro Miguel Santos Marques, Department of Otorhinolaryngology, Hospital S. Joo, EPE, Alameda Hernani Monteiro, Porto, Portugal.
Tel: +351 225 512 100. Fax: +351 225 025 766. E-mail: pmsmarques@hotmail.com

(Received 19 October 2011; accepted 20 November 2011)

ISSN 0001-6489 print/ISSN 1651-2251 online
2012 Informa Healthcare
DOI: 10.3109/00016489.2011.646357

Evaluation of unilateral MD vestibular bedside examination

of vestibular disorder [10]. In particular, it is of great
help for differential diagnosis and prognosis in patients with vestibular neuritis [11]. The purpose of this
examination was to determine whether any static or
dynamic vestibular imbalance occurs in a given
patient and, because of its reliability (as shown individually for the different tests), it should be of great help
in the follow-up assessment of patients [12].
The aim of this study was to characterize and evaluate the usefulness of vestibular bedside examination
in MD and its correlation with other measures of
auditory and vestibular decit and patient-perceived
disability.
Material and methods
Patients
The study group comprised outpatients referred to
a tertiary care facility with the diagnosis of unilateral
denite MD according to the 1995 AAO-HNS
criteria [7], for a 1-year period. After taking a detailed clinical history, a complete neuro-otological
bedside examination was performed. Hearing and
other vestibular function tests were carried out on
the same day. Data were stored in the Mnire
2.0 database.
The nal group analyzed included 97 patients
(55.4% males and 44.6% females). Mean age was
54 years (minimum 22 years, maximum 83 years).
Patients in stage 3 of the AAO-HNS were the most
prevalent group (54.2%). None of them had been
surgically treated before, either with intraympanic
treatment (steroid or gentamicin) or with other types
of surgery. None suffered from any middle or inner
ear or central nervous system comorbidity.
Bedside vestibular examination
In particular, the following signs were taken into
consideration for this study.

499

Post head-shake nystagmus (HSN). The HSN test was

performed with the patient sitting with the head
leaning 30 and wearing a mask in which the camera
(Ulmer, SYNAPSIS) registered one eye while the
other was obscured. The patients head was vigorously rotated 20 times, with maximum amplitude of
40o in the horizontal plane and, after this, the eye
movements were recorded for 2 min. A test was
considered positive when nystagmus was present for
at least 5 s after head-shaking terminated, and if it was
reproduced in a second test performed afterwards.
HSN was classied as monophasic if only one beating
direction was seen, and as biphasic if nystagmus
beating direction changed spontaneously after a variable period of time. In the former case, nystagmus
was dened as paretic or irritative as previously
stated for the SN and in the latter similarly but taking
into account the rst phase.
Vibration-induced nystagmus (VIN). Vibration was
performed with a commercially available system
(Brookstone, Mini Muscle Massager, USA) oscillating at 100 Hz. In order to provide vibration, a pad
was applied and rmly pressed over the region to be
stimulated, covering a circular area 1.3 cm in radius.
Each stimulation was preceded by a 30 s lag period to
test for SN. The vibrator was applied immediately
after and maintained in place for 30 s. Eye movements
were recorded with videofrenzel goggles (Ulmer,
SYNAPSIS) for the acquisition and analysis of the
eye response. The points of stimulation in this study
were the right and left mastoid. VIN when no SN was
observed was considered to be present if it appeared
after both stimulations and lasted for more than 15 s,
and when SN was detected, if the nystagmus changed direction or there was an increase in perceived
frequency without adaptation. The nystagmus was
dened as paretic or irritative, as described earlier
for SN.
Caloric test

Spontaneous nystagmus (SN). Eye movement was analyzed and taped with videofrenzel goggles (Ulmer
VNC, SYNAPSIS; Marseille, France). The patient
was seated on a standard clinical chair. After recording SN in the primary eye position for more than 10 s,
eye movements were observed in eccentric positions.
Examination was performed with and without visual
xation; in the non-visual xation exam, nystagmus
was considered to be present when it was at least of
a second degree. SN was dened according to its
fast phase direction as paretic when directed towards
the healthy ear and irritative when towards the
pathologic ear.

The bithermal caloric test was used according to

Fitzgerald and Hallpike, in which eye movements
were recorded by means of a video-based system
(Ulmer VNG, v.1.4, SYNAPSIS). Each ear was
irrigated alternatively with a constant ow of water
(200 cc) cold/warm at temperatures of 30 C and
44 C, and for a constant period of time (40 s); the
order of irrigation was changed between patients. The
maximum slow phase velocity (SPV) of nystagmus
was calculated following each irrigation, and Jongkees
formula was used to determine canal paresis (CP) and
directional preponderance (DP). If the asymmetry

500

P. S. Marques & N. Perez-Fernandez

analysis of variance was evaluated when continuous
variables without a normal distribution were involved
with test results. Additionally, a chi-squared test was
used to analyze categorical variables. A p value < 0.05
was considered statistically signicant.
According to the ndings in the bedside vestibular
examination, results were classied as homogeneous
(if all of them were congruent in the direction of
nystagmus) or non-homogeneous (when at least
one direction of nystagmus was contrary to the
others). In the former there were three additional
subgroups: one in which no nystagmus was found
in any of the examinations and two others in which
HSN and VIN were in accordance with the direction
of SN (as such, those were in fact an increase in the
intensity of SN after vigorous head stimulation),
classied as paretic or irritative type of nystagmus.
In patients with a non-homogeneous response, two
additional subtypes were created: a revealed type, in
which no SN was registered but still detected in any of
the other examinations, and a non-coherent type, in
which the different examinations showed a nystagmus
beating in distinct directions.

Table I. Bedside vestibular examination results (number of

patients).
Nystagmus

SN (%)

HSN (%)

VIN (%)

Absent

50 (53)

22 (23)

24 (25)

Paretic*

19 (20)

46 (49)

40 (42)

Irritative*

28 (30)

29 (31)

33 (35)

HSN, head-shaking nystagmus; SN, spontaneous nystagmus; VIN,

vibration-induced nystagmus.
*In biphasic HSN according to its rst phase.

between the responses for the left and right ear

was >20%, the result was considered indicative of
unilateral vestibular weakness (UW). For directional
preponderance a difference between the right and
left beating nystagmus of >28% was considered
pathologic.
Statistical analysis
Statistical analysis was performed using SPSS
19.0 (SPSS Inc., Chicago, IL, USA). KruskalWallis

SN
HSN
VIN

13

SN
HSN
VIN

12

SN
HSN
VIN

11

Figure 1. Findings in the whole group of studied patients. Patients distribution according to bedside vestibular examination results. HSN,
head-shaking nystagmus; I, irritative nystagmus, beating towards the side of the disease; O, no nystagmus; P, paretic nystagmus, beating
towards the healthy ear; SN, spontaneous nystagmus; VIN, vibration-induced nystagmus.

HSN, head-shaking nystagmus; UCP, unilateral canal paresis as percentage of patients showing a canal paresis >20%.
*Classes: percentage of patients in each group according to Soto et al. [9].

55%

1: 41%
2: 48%
3: 11%
1: 47%
2: 47%
3: 6%

64%

501

Results

1: 33%
2: 50%
3: 17%

53%
36%

1: 64%
2: 36%
1: 33%
2: 59%
3: 8%

75%
46%

1: 39%
2: 46%
3: 15%
Classes*

UCP

1:10 (12%)
2:18 (21.7%)
3:45 (54.2%)
4:10 (12%)
2:5 (29.4%)
3:12 (70.6%)
1:5 (16.7%)
2:4 (13.3%)
3:17 (56.7%)
4:4 (13.3%)
1:2 (18.2%)
2:2 (18.2%)
3:5 (45.5%)
4:2 (18.2%)
1:1 (8.3%)
2:4 (33.3%)
3:6 (50.0%)
4:1 (8.3%)
1:2 (15.4%)
2:3 (23.1%)
3:5 (38.5%)
4:3 (23.1%)
AAO-HNS [7]

10
9

3
3

10

10
12
Vertigo index [1]

3
3.5
Functional level scale [7]

8.5

15
12
15
7
23
Time since last attack
(days) (median)

15

54

2
5
2.5
2
2
Duration (years) (median)

83
17

54
53

30
11

53
59
53
Age (years) (median)

12
13
Patients (n)

Paretic nystagmus
Nystagmus absent
Groups

Table II. Bedside vestibular examination analysis (excluding biphasic post HSN).

Irritative nystagmus

Revealed nystagmus

Non-coherent nystagmus

Total

Evaluation of unilateral MD vestibular bedside examination

The results for the whole group are presented

in Table I.
We shall initially exclude from the assessment those
patients with biphasic HSN (n = 14) and, as such,
83 patients (Figure 1) represent the rst group of the
assessment. Of those, 48.2% presented with SN,
73.5% showed an HSN and in 71.1% VIN was
observed. In 36 patients (43.4%) a homogeneous
vestibular response was observed: of them, in
13 patients (15.7%) no nystagmus was detected in
either of the examinations performed and of the
23 (27.8%) with nystagmus of similar direction in
all the examinations, 12 (14.5%) patients displayed a
paretic pattern of nystagmus and 11 (13.3%) an
irritative type. In all these patients there were no
signicant differences with respect to age, duration
of the disease, functional level and vertigo index,
although a trend towards a shorter time since last
crisis could be observed in those patients with an
irritative nystagmus (Table II) and UW was more
frequently observed in those patients with a paretic
nystagmus, even though this relation was not statistically signicant. In 47 patients (56.6%) the results in
the examination were considered non-homogeneous:
30 (36.1%) were of the revealed type of response and
17 (20.5%) of the non-coherent type. There were no
clear differences with respect to the variables related
to the intensity of vertigo or duration of the disease. As
shown in Figure 2, relating the pattern of response to
the time distance from the last Mnire attack, a nonhomogeneous response is more frequently observed
closer to the crisis. However, differences were not
found to be statistically signicant for each of the
patterns of response, whether they were grouped as
homogeneous or as non-homogeneous.
When individually evaluating the examinations performed, there were no statistically signicant differences or relationships when analyzing the type of SN,
HSN and the studied variables. However, regarding
VIN ndings, in this whole group of patients, when
VIN was irritative there was a signicant trend
towards a higher functional level score (Kruskal
Wallis, p = 0.017) and a shorter distance from the
last vertigo attack (KruskalWallis, p = 0.018). In
patients in the non-homogeneous group without
SN, a longer duration of disease was detected for
those with an irritative VIN with respect to those
without VIN (KruskalWallis, p = 0.041) and, in
the same group but one in which ndings were
non-coherent, a higher CP was found when VIN
was paretic with respect to those without VIN.
Patients with biphasic HSN were analyzed separately, and individual results are shown in Table III.

502

P. S. Marques & N. Perez-Fernandez

Normal

Paretic

Irritative

Other

8
7
6
5
4
3
2
1

0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
48
49
52
58
60

Figure 2. Bedside vestibular examination pattern of response according to time (days) since last Mnires attack.

No conclusive ndings were obtained, other than the

presence of paretic HSN (according to rst phase)
being the most frequent nding.
Discussion
In this work we have found that bedside vestibular
examination of patients with unilateral denite MD
provides important signs of dynamic vestibular imbalance, and signs that are very diverse and heterogeneous. This is similar to previous ndings in which all
of the signs were evaluated individually, in the SN
[13], HSN [14] and VIN [15].
To bring some order to the ndings and to try and
obtain more relevant information we decided to build

up some groups based on the presence or not of

nystagmus and its beating direction with relation to
the side of the disease. This was done because of its
feasibility, as the information relative to the side of the
disease is clear from the very rst step of the clinical
history and initial assessment of the vestibulo-ocular
reex (VOR). We think that the results of this work
support the recommendation to use that grouping
system for the initial assessment and for follow-up
of bedside vestibular examination of the patients.
In our work, performed at the bedside, we found
normal results in all the tests in 13.4% (13/97) of the
patients; however, individually normal ndings are
more frequent in SN assessment than in HSN and
VIN. In this sense, this study clearly points to the need

Table III. Individual ndings for patients with biphasic post HSN classied according to rst phase beating direction.
Patient no.

Spontaneous nystagmus

Post head-shake nystagmus

Vibration-induced nystagmus

No

Paretic

Irritative

Irritative

Paretic

Irritative

Paretic

Paretic

Irritative

Irritative

Paretic

Irritative

Paretic

Irritative

Irritative

Irritative

Paretic

Paretic

No

Paretic

Irritative

No

Paretic

Paretic

No

Paretic

Irritative

10

Irritative

Paretic

Irritative

11

No

Paretic

Irritative

12

No

Paretic

Paretic

13

Irritative

Paretic

Paretic

14

No

Paretic

Paretic

Irritative: nystagmus fast phase beating towards the pathologic ear; paretic: nystagmus fast phase was directed towards the healthy ear.

Evaluation of unilateral MD vestibular bedside examination

for including at least these two signs of VOR examination in the regular diagnostic work-up of patients
with MD, not only because they seem to be more
sensitive, but also because they expand the knowledge
of the pathological process, as we discuss below.
When nystagmus direction is taken into consideration, we have seen that it beats well to the ipsilesional
side or to the contralesional. This could be due to
technical differences in the performance of the tests,
although these were minimal as only one of the
authors was responsible for all the examinations.
A similar nystagmus for all the tests was seen in
23 patients, probably reecting the importance of
the SN, which was enhanced by the complementary
examinations. However, the different groups created
were not associated with any specic clinical characteristic of the disease or nding in the caloric test,
although some trend was found for irritative responses
and recent attacks and, paretic responses and higher
vestibular deciency.
When paying particular attention to the noncoherent group, most of these patients showed
irritative responses despite the time distance to the
last crisis: 12/17 (SN) and 9/17 (HSN). VIN was
more variable, showing three types of responses
almost equally: i.e. absent (5/17), irritative (5/17)
and paretic (7/17). Discordance between VIN and
HSN directions in patients with MD has been found
by previous authors [16]. It is probably due to the
different effect that vestibular compensation has on
SN (and HSN) with respect to VIN. Other justication could also be the disparity in the frequency of
the stimulation to which the inner ear might be
physiologically able to respond at certain periods
of the disease with relation to different degrees of
hydrops. A relation of this pattern of response to the
studied variables was not observed in this group.
When each of the tests was evaluated it was found
that VIN appeared to provide some better characterization of patients with MD, which merits its use for the
assessment and follow-up. In the whole group the
irritative response was associated with a recent attack,
and also with a higher level of disability as measured
with the functional level scale (FLS). We agree with
others that an irritative or ipsilesional VIN suggests the
restoration of temporarily paralyzed vestibular function
in patients with MD [17], something that has recently
been shown to be of relevance, such as for the differential diagnosis of a rst attack of vertigo in patients
with MD with respect to a suspected vestibular neuritis
[18] in which a paretic nystagmus is usually found [11].
We have additionally found in our patients that it
points to a more severe disease, something not related
to the frequency of attacks, as their frequency was
similar between groups of patients. We are not able

503

to say that this nding has a similar meaning as the

irritative HSN precluding an imminent recurrence
[19]; only the detailed follow-up of these patients
will provide us with that information. The relation
between irritative VIN and functional recovery after
an attack of vertigo explains why this type of nystagmus
occurs mainly in patients with a lower amount of CP
[17]; in our study, we have found that the paretic type
of VIN is more frequently seen in patients with a higher
amount of canal paresis and this usually occurs in
patients in the non-homogeneous group. It could
probably be due to the process of vestibular compensation that, in those patients, is mainly based on a
short-term habituation, rather than on recovery of
peripheral vestibular function.
In patients with biphasic HSN we found only one
case showing an irritative rst phase, the majority
being paretic, which is usual in patients with MD
[20]. This could eventually be linked to a higher value
of CP, as 11/14 patients presented an average value of
53.7% in the pathologic ear. This seems to be well
compensated, as SN is not frequently found. However
the patients needed an extra vestibular stimulation
(head-shake or skull bone vibration) to elicit the
nystagmus. According to our methodology of classication, 8/14 could be classied as non-coherent and
interestingly VIN was more frequently irritative. In
spite of this no clear associations could be observed
within the studied variables.
In spite of these encouraging results, further work
on these bedside evaluation examinations is necessary
to emphasize their importance, namely the VIN, for
the diagnosis and follow-up of MD and other vestibular disorders.
Conclusions
The vestibular clinical examination results are quite
variable in MD. In addition, no straight or clear
relationship with the duration of the disease, functional level, vertigo index or time since last attack
could be observed. However, the description of the
examinations involved appears to have produced
valuable information that may be useful in the clarication of the phase of the disease and might be
helpful in the explanation of its physiopathology.
Declaration of interest: The authors report no
conicts of interest. The authors alone are responsible
for the content and writing of the paper.
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