Acta Oto-Laryngologica

ISSN: 0001-6489 (Print) 1651-2251 (Online) Journal homepage: http://www.tandfonline.com/loi/ioto20

Video head impulse in comparison to caloric

testing in unilateral vestibular schwannoma

Isaac Tranter-Entwistle, Patrick Dawes, Cynthia L. Darlington, Paul F. Smith &

Nicholas Cutfield

To cite this article: Isaac Tranter-Entwistle, Patrick Dawes, Cynthia L. Darlington, Paul F. Smith
& Nicholas Cutfield (2016): Video head impulse in comparison to caloric testing in unilateral
vestibular schwannoma, Acta Oto-Laryngologica, DOI: 10.1080/00016489.2016.1185540

To link to this article: http://dx.doi.org/10.1080/00016489.2016.1185540

Published online: 25 May 2016.

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 ACTA OTO-LARYNGOLOGICA, 2016
http://dx.doi.org/10.1080/00016489.2016.1185540

RESEARCH ARTICLE

Video head impulse in comparison to caloric testing in unilateral vestibular

schwannoma
Isaac Tranter-Entwistlea, Patrick Dawesa, Cynthia L. Darlingtonb,c, Paul F. Smithb,c,d and Nicholas Cutfielda,c,d
a
Department of Medicine, Dunedin School of Medicine, Dunedin, New Zealand; bDepartment of Pharmacology and Toxicology, School of
Medical Sciences, University of Otago, Dunedin, New Zealand; cThe Brain Health Research Centre, University of Otago, Dunedin, New Zealand;
d
The Brain Research New Zealand Centre of Research Excellence, Dunedin, New Zealand

ABSTRACT ARTICLE HISTORY

Conclusions: Although there was a statistically significant relationship between the results of the vHIT Received 16 March 2016
and the caloric test, the limited strength of this relationship suggests that, for unilateral vestibular Revised 15 April 2016
schwannoma (UVS), caloric testing and vHIT may provide complementary information on vestibular Accepted 20 April 2016
Downloaded by [University of Nebraska, Lincoln] at 07:36 28 May 2016

function. Published online 24 May 2016

Objective: There is limited information that can be used to determine which of the video head impulse KEYWORDS
test (vHIT) and caloric test might be better used in the diagnosis and management of UVS. In this DHI; caloric testing; canal
study, a group of participants with un-operated UVS was studied using both methods. paresis; MRI; vestibular
Methods: The subjects’ vestibular function was assessed using the vHIT and caloric testing. Tumour size schwannoma; video head
was quantified using MRI and their balance disturbance assessed using the Jacobsen Dizziness impulse test
Handicap Inventory (DHI).
Results: Twenty of 30 subjects had an abnormal canal paresis according to the Jongkees’ criterion
(> 0.25); however, only 10/30 had an ipsilesional vHIT gain of <0.79. Canal paresis could be predicted
from the ipsilesional and contralesional vHIT gains. Tumour size could also be predicted from the ipsile-
sional vHIT gain and canal paresis. However, DHI scores could not be predicted from the degree of
canal paresis, vHIT gain, or the MRI measures.

Introduction
Vestibular schwannoma (VS) is a benign, usually slow grow-
ing tumour of Schwann cells of either the superior or inferior
division of the vestibular nerve (also known as an acoustic
neuroma). With growth, it compresses neurons within the
vestibular nerve, may compress the internal auditory artery
and the cochlear nerve, causing unilateral vestibular deficits,
auditory dysfunction, including tinnitus, and when signifi-
cantly enlarged it can be life-threatening. Progressive or dis-
abling vestibular symptoms may also be an indication for
intervention, although measurement of vestibular function is
not routine in many centres. Caloric testing has been the
most common method employed to measure the vestibulo-
ocular reflex (VOR) in those with VS. However, the main
disadvantages of the method are that it is time consuming
and uncomfortable. Additionally, the stimulus is not physio-
logical and there is high variability between those tested
( 25% of normal values). Caloric testing is thought to be
equivalent to low frequency rotational testing, e.g. 2–4 Hz. In
contrast, the video head impulse test (vHIT), which has been
increasingly applied to the diagnosis of vestibular disorders
[1], tests the high frequency range of the VOR, e.g. 5–7 Hz.
However, the practical advantages of testing, and being a
more natural physiological stimulus, do not constitute empir-
ical evidence that the vHIT is suitably sensitive or specific
when used in given clinical conditions.
Only three previous studies have compared caloric and
vHIT testing in participants with VS [2–4]. Two of these
studies appear to be related, and only one of these two is
published in English. Blodow et al. [3] conducted a retro-
spective study of 69 participants (39 females, 30 males, age
27–86 years) with untreated unilateral VS. They defined
abnormal vHIT gain to the lesioned side as <0.79,
abnormal vHIT asymmetry as >8.5%, and an abnormal
caloric ratio as >25%. They found an abnormal ipsilateral
vHIT gain in 36% of participants, an abnormal vHIT gain
asymmetry in 44%, and abnormal caloric results in 72%.
The tumour grade was related to the caloric results, but not
the vHIT results [3]. A regression analysis of the degree of
the caloric weakness predicted by the vHIT gain asymmetry
revealed a very poor relationship and the correlation
coefficient was only 0.54. Batuecas-Caletrio et al. [4] con-
ducted a retrospective study of 50 patients with unilateral
VS and found that the caloric test was abnormal in 31/50
(62%), while the vHIT to the ipsilateral side was abnormal
(i.e. < 0.8) in 27/50 (54%). The caloric and vHIT
gain asymmetry results were both significantly related to
tumour size.
Due to the small number of studies comparing caloric
testing and vHIT in unilateral VS, we compared caloric and
vHIT testing in VS participants using a prospective study
design.

CONTACT Nicholas Cutfield nick.cutfield@otago.ac.nz Department of Medicine, Dunedin School of Medicine, Dunedin, New Zealand
ß 2016 Acta Oto-Laryngologica AB (Ltd)
 2 I. TRANTER-ENTWISTLE ET AL.
Materials and methods
Subjects
Data were obtained from 30 participants (17 male, 13 female;
mean age at testing 62.0 years, range ¼34–81 years) diag-
nosed with unilateral VS. They were tested during the course
of March/April and September/October 2013. Twenty-two
were under ‘watch and wait’ surveillance and eight had
received radiotherapy. The study was approved by the
University of Otago Human Ethics Committee (12/303). The
participants were invited to join the project by ORLHNS sur-
geon Mr Patrick Dawes and given the study information
sheet as approved by the University of Otago Human Ethics
Committee. Prospective participants were given an opportun-
ity to ask questions before giving consent.
Adults with unilateral VS, able to give informed consent
and who had not undergone surgery were included.
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Exclusion criteria included: the inability to lie still for
20 min; individuals for whom caloric and/or head impulse
testing was contraindicated; severe structural neck problems;
severe narrowing of the spinal canal; perforated ear drum;
congenital nystagmus; blindness; bilateral VS; central path-
ology; other vestibular pathology; migraine; transient ischae-
mic attack; and multiple sclerosis. No patient included in the
study exhibited spontaneous nystagmus.
Imaging and schwannoma dimensions
All participants whose MRI scans of the cerebellopontine
angle were available were analysed retrospectively for tumour
size. All examinations were performed on 1.5 Tesla scanners
(GE, Milwaukee, WI) and the imaging protocol was sagittal
T1 whole head, axial T2 whole head, and axial FIESTA cere-
bellopontine angle; when a VS was identified, gadolinium-
enhanced axial and coronal T1 CPA images were obtained.
Measurements were taken in the anteroposterior, transverse,
and longitudinal axes as per the methodology of Kanzaki
et al. [5]. Because both extra-cannalicular and intra-cannalic-
ular schwannomas occurred in this small sample of patients,
to divide them according to the site or grade of the tumour
would have resulted in sample sizes that were too small to
analyse.
Video head impulse (vHIT) testing
Participants were instructed to sit upright in a chair, with a
fixed back support, to avoid whole body rotation, and at a
distance of 1.5 m from the fixation target. EyeSeeCam gog-
gles (Interacoustics, Munich, Germany) and EzeEye software
were used to record head movement and eye position signals
at 200 Hz. A minimum of 10 head impulses were delivered
to each side in a pseudo-random order at velocities of 150 /s
or above [1]. These were performed with a variable inter-trial
interval (0.5–4 s) to avoid any anticipatory eye movements.
The eye position signal from the EyeSeeCam was exported
into Matlab where it was differentiated to angular eye vel-
ocity ( /s); head acceleration was integrated to angular head
velocity. VOR gain was calculated (at 60 ms after onset of
the impulse) by dividing eye velocity by head velocity and
was considered abnormal if <0.79. Gain asymmetry was cal-
culated following the Jongkees’ formula for caloric asym-
metry and asymmetry >8.5% was defined as abnormal,
following Blodow et al. [3].
Caloric testing
Caloric testing was performed using the Aquastar 2.0
Irrigator (Aquastar, Difra, Eupen, Belgium) following the
Fitzgerald and Hallpike [6] method. Participants lay supine
on an examination bed with their head raised at 30 .
Irrigations were delivered at 30  C ± 0.4  C, then
44  C ± 0.4  C via a disposable silicon irrigator nozzle, and
lasted for 30 s [7]. The irrigation delivery sequence was cool
contralesional then ipsilesional followed by warm contrale-
sional and then ipsilesional; this sequence does not induce
systematic bias [8]. Opaque lenses were then inserted into
the EyeSeeCam goggles to prevent visual fixation in order to
reduce nystagmus. The subjects were instructed to look
straight ahead, with eyes wide open and not to blink. Eye
movement recording continued for 3 min after cessation of
irrigation, with a 7 min interval between irrigations to avoid
fatigue and cumulative effects. Nystagmus recordings were
exported to Matlab via the EyeSeeCam system. The average
peak slow phase velocity was calculated from the EzeEye
software. The degree of canal paresis was then calculated
according to the Jongkees’ formula, where a value of >0.25
is considered to be pathological [9].
Symptom scoring
The Jacobsen Dizziness Handicap Inventory (DHI) was
administered to quantify the degree of balance disturbance
[10].
Statistical analyses
The data were tested for the assumptions of normality and
homogeneity of variance and, if necessary, transformed to
fulfil these assumptions. The ipsilesional and contralesional
vHIT gains were compared using a two-sample paired t-test.
Linear regression analyses were performed to determine
whether specific variables could be predicted from one
another, using R2 and the ANOVA result as indicators of the
strength of the relationship and statistical significance,
respectively [11]. The validity of the regressions was deter-
mined using the standard error of the regressions, and plots
of the normality of the residuals, the residuals vs fits, and
autocorrelation [11]. P  0.05 was considered significant. All
analyses were performed using SPSS 22. Figures were pre-
pared using Prism 6.0.
Results
The tumour dimensions and individual results for the caloric
tests, the vHIT, and the DHI for the participants are pre-
sented in Table 1; data are missing for two participants
because the images were not available for review. The mean
 ACTA OTO-LARYNGOLOGICA 3

Table 1. Results for study participants.

Tumour dimensions (mm) Caloric Test Video Head Impulse test
Transverse Antero- posterior Longitudinal Paresis Gain tumour side Gain non-tumour side Gain asymmetry (%) DHI score
10.5 5.3 8.8 0.07 1.05 0.97 3.9 18
9.8 8.8 7 0.31 1.02 0.9 6.25 46
22.2 16 16.5 0.75 0.22 0.64 48.0 8
8.2 3.2 3.5 0.29 1.02 0.99 1.4 30
8.4 7.4 3.9 0.25 0.89 0.9 5.3 6
7.3 3.6 3.9 0.06 0.99 1.07 3.8 30
6.2 3.3 4.2 0.54 0.85 0.96 6.0 0
7.5 15.7 9.5 0.14 0.9 0.98 4.2 18
18.1 10.1 8.1 0.63 0.79 0.82 1.8 20
6 3.2 3.5 0.34 0.84 1.04 10.6 22
22.2 28.8 20 0.92 0.45 0.9 33.0 52
2.5 5.3 3.9 0.04 1.03 0.97 3.0 10
11.6 4.2 4.2 0.7 0.3 0.83 46.9 22
12.3 10.8 5.6 0.11 0.66 0.82 10.8 0
11.5 5.1 4.2 0.7 0.51 0.75 19.0 34
12.6 5.9 6.3 0.01 0.95 0.94 0.5 8
7.8 4.9 4.6 0.39 0.87 1 6.9 8
18.2 13.2 9.7 0.16 0.97 1 1.5 4
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15.3 11.9 8.3 0.75 0.19 0.88 65.0 22

10.5 3.4 0.09 0.79 0.9 6.5 2
26.7 16.5 18.3 0.25 0.99 1 0.5 0
15.3 11.9 8.9 0.54 0.95 0.72 13.0 36
17.2 11 11.1 0.94 0.08 0.7 79.0 30
13.1 5 4.2 0.34 0.91 0.98 37.0 32
21.6 12 13.7 0.04 0.92 0.95 1.6 12
14.5 5.3 6.6 0.30 0.55 0.79 17.9 2
13 3.1 3.9 0.99 0.05 0.59 84.0 0
5.3 4.2 4.2 0.72 0.34 0.94 46.87 44
0.37 0.81 0.93 6.89 63
0.10 0.93 1.07 7.0 0

*** subjects with no canal paresis, one had an ipsilesional vHIT

gain <0.79.
Significant regressions were found for predicting canal
paresis from the ipsilesional vHIT gain (R2 ¼ 0.69,
p  0.0001; Figure 2(A)) and contralesional vHIT gain
1.0 (R2 ¼ 0.45, p  0.0001; Figure 2(B)), although the relationship
was stronger for the ipsilesional vHIT gain. For this reason,
0.8 gain asymmetry also showed a relationship with canal paresis
(R2 ¼ 0.35, p  0.001; Figure 2(C)), although the regression
vHIT Gain

0.6
coefficient was relatively low.
There was no significant relationship between the gain for
0.4
the ipsilesional or contralesional vHIT and the age of the
0.2
subjects (data not shown).
There were statistically significant regressions for predicting
0.0 transverse tumour dimensions from the ipsilesional vHIT gain
(R2 ¼ 0.38, p  0.0001; Figure 3) and canal paresis (R2 ¼ 0.33,
r
r

ou

p  0.001); Figure 3(A and B) shows examples using the trans-

ou

m
m

Tu
Tu

verse plane measurements. Similarly, the antero-posterior and

on

longitudinal tumour dimensions could also be significantly

N

vHIT Side
Figure 1. The mean ipsilesional (tumour) and contralesional (non-tumour) VOR
gains measured at 60 ms using the vHIT. Bars represent means ± SEM.
*** p  0.0005.
canal paresis according to the Jongkees’ formula was 0.39
(SD ¼0.30); 21 out of 30 participants had an abnormal canal
paresis (> 0.25). The ipsilesional vHIT gain was <0.79 in
10/30. The mean ipsilesional and contralesional vHIT gains
at 60 ms were 0.73 (SD ¼0.31) and 0.90 (SD ¼0.12), respect-
ively (t(29) ¼ 3.9, p  0.0005; see Figure 1). Of the 10
predicted from the ipsilesional vHIT gain (p  0.01 and
p  0.002, respectively; data not shown) and canal paresis
(p  0.007 and p  0.001, respectively; data not shown).
The mean DHI score was 19.30 (SD ¼17.34); no significant
regression was found for predicting the DHI score from canal
paresis, vHIT gain, or the tumour dimensions (data not shown).
Discussion
To the best of our knowledge, there have been only three
previous studies comparing the results of caloric testing and
 4 I. TRANTER-ENTWISTLE ET AL.

0.0 30

Tumour Diameter Axial Plane

−0.2
Canal Paresis

20
−0.4

−0.6 10

−0.8

0
−1.0
0.0 0.5 1.0
0.0 0.5 1.0
vHIT Gain Tumour Side
vHIT Gain Tumour Side
30

Tumour Diameter Axial Plane

0.0

−0.2
20
Canal Paresis
Downloaded by [University of Nebraska, Lincoln] at 07:36 28 May 2016

−0.4

−0.6 10

−0.8
0
−1.0 −1.0 −0.8 −0.6 −0.4 −0.2 0.0
0.6 0.8 1.0
Canal Paresis
vHIT Gain NonTumour Side Figure 3. Linear regressions predicting the tumour size in the axial (transverse)
plane (in mm) from vHIT gain tumour side (R2 ¼ 0.38, p  0.0001) and canal par-
0.0 esis (R2 ¼ 0.33, p  0.001).

−0.2
the reliability of any inter-relationship dubious. Blodow et al.
[3] reported abnormal vHIT gain asymmetry in 44% of their
Canal Paresis

−0.4
-0.6
−0.8
−1.0
−1.0 −0.5 0.0 0.5
Gain Asymmetry
Figure 2. Linear regressions predicting canal paresis from the ipsilesional
(tumour) vHIT gain (R2 ¼ 0.69, p  0.0001), contralesional (non-tumour) vHIT gain
(R2 ¼ 0.45, p  0.0001), and gain asymmetry (R2 ¼ 0.35, p  0.001).
the vHIT in participants with unilateral VS, and two of these
studies appear to be related [2,3] and all three were retro-
spective [2–4]. In the current prospective study we also
investigated caloric testing and the vHIT in VS participants
and included a symptom measure (DHI). To the best of our
knowledge, this is the first prospective study of unilateral VS
in which caloric testing and vHIT have been compared. We
found that 20 out of 30 participants (67%) exhibited an
abnormal canal paresis according to the Jongkees’ formula,
but that the ipsilateral vHIT gain was less than 0.79 in only
10/30 (33%). These results are very similar to those reported
by Blodow et al. [3], who reported an abnormal caloric result
in 72%, and an abnormal ipsilateral vHIT gain in 36% of
participants. Although the degree of caloric test canal paresis
could be predicted from the ipsilesional and contralesional
vHIT gain, the R2 values were less than 0.7, and this renders
study group, compared to 40% in our study. The R2 for the
prediction of canal paresis from the vHIT gain asymmetry
was low, which indicates a weak relationship between canal
paresis and ipsilesional vHIT gain asymmetry.
Batuecas-Caletrio et al. [4] conducted another retrospect-
ive study of 50 patients with unilateral VS, and found that
the caloric test was abnormal in 31/50 (62%) while the vHIT
to the ipsilateral side was abnormal (i.e. < 0.8) in 27/50
(54%). The caloric and vHIT gain asymmetry results were
both significantly related to tumour size. Current opinion is
leading away from reporting gain asymmetry as it is not con-
sidered a reliable indicator of abnormality of the high fre-
quency VOR [12]; however, we have included this measure
to allow greater comparison with Blodow et al. [3] and
Batuecas-Caletrio et al. [4].
We found that tumour dimensions could be significantly
predicted from both ipsilesional vHIT gain as well as canal
paresis; however, once again, in both cases the R2 values
were less than 0.40. This is consistent with Batuecas-Caletrio
et al. [4], but in contrast to Blodow et al. [3], who reported
that tumour grade was related to the caloric results but not
the vHIT results. Similar to previous studies [14,15], we
could find no relationship between either canal paresis or the
ipsilesional or contralesional vHIT and age. The DHI score
could not be predicted from either canal paresis or vHIT
gain; this is not surprising because VS is a slow growing
tumour and central compensation can ameliorate the effect
of the tumour on vestibular nerve function.
 ACTA OTO-LARYNGOLOGICA 5

The correspondence between the results of caloric testing
and the vHIT has often been inconsistent [3,4,15–17]. It is
[3]
not surprising that the two forms of horizontal VOR tests
would lead to different results in some cases. Caloric testing
is generally regarded as being equivalent to low frequency [4]
rotational testing (e.g. 2–4 Hz), whereas the vHIT tests the
high frequency range of the VOR (e.g. 5–7 Hz). Nonetheless,
the relatively modest correlation between the results of the [5]
two tests, and their poor prediction of both the tumour size
and DHI score [13], indicate limited diagnostic utility of
each as a stand-alone test. Blodow et al. [3] suggest using a [6]
combination of VOR tests in the assessment of unilateral VS.
The caloric test and vHIT measure different aspects of the
horizontal VOR and there may be merit in exploring how
[7]
these and other measures inter-relate when either investigat-
ing a potential diagnosis of VS or in clinical decision-making
regarding intervention [4]. [8]
Downloaded by [University of Nebraska, Lincoln] at 07:36 28 May 2016
Contemporary diagnostic tests for vestibular schwannoma. HNO
2013;61:781–5.
Blodow A, Blodow J, Bloching MB, Hebig R, Walther LE.
Horizontal VOR function shows frequency dynamics in vestibu-
lar schwannoma. Eur Arch Otorhinolaryngol 2015;272:2143–8.
Batuecas-Caletrio A, Santa Cruz-Ruiz S, Mu~ noz-Herrera A,
Perez-Fernandez N. The map of dizziness in vestibular schwan-
noma. Laryngoscope 2015;125:2784–9.
Kanzaki J, Tos M, Sanna M, Moffat DA. New and modified
reporting systems from the consensus meeting on systems for
reporting results in vestibular schwannoma. Otol Neurotol
2003;24:642–9.
Fitzgerald G, Hallpike CS. Studies in human vestibular function
I. Observations on the directional preponderance
(‘‘Nystagmusbereitschaft’’) of caloric nystagmus resulting from
cerebral lesions. Brain 1942;65:115–37.
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tibular autorotation and caloric testing. Otolaryngol Head Neck
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Lightfoot GR. The origin of order effects in the results of the

We employed a similar investigation protocol to Blodow
et al. [3], and report results using the same cut-offs for nor-
mal/abnormal. The tests were undertaken by one investiga-
tor, and this adds to the internal consistency of our results.
This ensures that our comparisons with others are valid and
increases the amount of comparable data available for any
future meta-analysis in this area of investigation. The main
limitations of our study are the smaller sample size (n ¼ 30
compared to n ¼ 69 and n ¼ 50 in the Blodow et al. [3] and
Batuecas-Caletrio et al. [4] studies, respectively), the fact that
we did not have age-matched healthy controls, and that we
did not analyse corrective saccades. On the other hand, we
employed a prospective design rather than a retrospective
one. However, the interpretation of the results of this study
must be qualified by recognizing that a limited range of
tumour sizes were included.
Disclosure statement
The authors report no conflict of interest. The authors alone are respon-
sible for the content and writing of the paper.
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