|Year : 2021 | Volume
| Issue : 2 | Page : 368-370
Clinical significance of horizontal high-frequency headshake test
Prateek Porwal1, VR Ananthu1, Srinivas Dorasala2, Ravi Nayar3, Vijayalakshmi Subramaniam4
1 Vertigo and Balance Clinic, Bengaluru, Karnataka, India
2 Department of Otorhinolaryngology, Yenepoya Medical College, Yenepoya Deemed to be University, Mangalore; Department of ENT, JNMC, Belagavi, Karnataka, India
3 Centre of Academics Research, HCG, Bengaluru, Karnataka, India
4 Department of Otorhinolaryngology, Yenepoya Medical College, Yenepoya Deemed to be University, Mangalore, Karnataka, India
|Date of Submission||24-May-2021|
|Date of Decision||07-Oct-2021|
|Date of Acceptance||08-Nov-2021|
|Date of Web Publication||29-Dec-2021|
Dr. Prateek Porwal
Vertigo and Balance Clinic, 6th Block, Jayanagar, Bengaluru - 560 041, Karnataka
Source of Support: None, Conflict of Interest: None
The method of performing the horizontal high-frequency headshake test with its interpretation and clinical significance is described. The videonystagmographic recordings of headshaking nystagmus using BalanceEye videonystagmography system are explained.
Keywords: Headshake test, nystagmus, unilateral vestibular loss
|How to cite this article:|
Porwal P, Ananthu V R, Dorasala S, Nayar R, Subramaniam V. Clinical significance of horizontal high-frequency headshake test. Arch Med Health Sci 2021;9:368-70
|How to cite this URL:|
Porwal P, Ananthu V R, Dorasala S, Nayar R, Subramaniam V. Clinical significance of horizontal high-frequency headshake test. Arch Med Health Sci [serial online] 2021 [cited 2022 Jan 22];9:368-70. Available from: https://www.amhsjournal.org/text.asp?2021/9/2/368/333996
| Introduction|| |
Headshaking nystagmus (HSN) was first described in 1907 by Robert Barany. High-frequency headshake is a type of provocative test used primarily in diagnosing unilateral vestibular loss. It produces a jerk nystagmus that results just after head oscillation.
| Head Shaking Nystagmus Test|| |
A subject should be sitting upright. This test should be done in a dark room or only after removal of fixation. In our center, we use BalanceEye videonystagmography device to record the eye movements and to eliminate fixation.
Instruct the subject to look straight ahead. Explain to the subject that you will shake the subject's head side to side in horizontal direction. Make the subject turn the head right and left to ascertain the range of painless neck mobility. Ask for any history of cervical spine problems.
Pitch the head forward by 20³–30³ to bring the lateral canals into the horizontal plane. Record for 10 s before headshaking to document any baseline nystagmus. Now, hold the head of the subject along with the BalanceEye goggle. Move the head to the right and left, aiming for two cycles per second. The head should move 20³ to the right of midline and 20³ to the left of midline. Stop after 20 cycles. Record during the headshaking and for 1 min after stopping the headshaking. It is important to record for 1 full minute following headshaking so that any late response or biphasic nystagmus response is not missed.
| Discussion|| |
In normal subjects or persons with symmetrical vestibular loss, no nystagmus is expected. In persons with a dynamic tonic imbalance between the two sides, a nystagmus is often seen which usually beats (fast phase) toward the healthy side (though not always). This pattern is usually seen in acoustic neuroma, vestibular neuritis, and vestibular neurectomy.,,
Post vestibular neuritis, sometimes we see that there is no spontaneous nystagmus with and without fixation, which is because of central compensation, but high-frequency headshake produces a nystagmus which manifests when the compensatory mechanisms are disrupted. Leaky neural integrator or impaired central velocity storage mechanism and abnormalities of Vestibulo–ocular reflex (VOR) gain can also produce high-frequency headshake nystagmus. [Figure 1] shows high-frequency headshake test at 25th-day follow-up of right-sided vestibular neuritis [Video 1].
|Figure 1: Left beating nystagmus after high-frequency headshake test in a patient of vestibular neuritis (25th-day follow-up). Note - VNG graph shows right eye horizontal movement in the upper half denoted by red line and left eye horizontal movement is shown by blue line in the bottom half of the graph. Black and purple line represent right eye vertical movement and left eye vertical movement respectively|
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There may also be a headshaking nystagmus in lateral canal BPPV, being more common in the apogeotropic form.
There may be a smaller upbeating component as well, especially in the acute stages. The presence of HSN with unilateral peripheral vestibulopathy may predict greater disability.
Headshaking may also induce nystagmus in patients with central disorders. However, direction of nystagmus is nonlocalizing in these cases.
Ipsilesional-beating HSN also occurs with cerebellar lesions and with Wallenberg's syndrome, in which case the headshaking nystagmus may beat to the affected side even when the spontaneous nystagmus beats to the side opposite the lesion.
Headshaking nystagmus with a prompt strong reversal or biphasic nystagmus is also a feature of central disorders. Short-term VOR adaptation might be the mechanism behind reversal or biphasic nystagmus after headshake test.
Rarely, horizontal headshaking produces a vertical or torsional nystagmus; this is called a “perverted” headshaking nystagmus. This might be due to activation of the vertical velocity-storage mechanism in case of downbeating nystagmus after HFHS. In these cases, a cerebellar or medullary lesion should be suspected.,,
An inappropriate cross-coupling of vestibular drives may cause this type of nystagmus and can be seen in the cerebellar form of multiple system atrophy and cerebellar degeneration.
In lesions of the cerebellar nodulus and ventral uvula, nystagmus with quick reversal,torsional and perverted nystagmus can be observed post- head shaking. [Figure 2] and [Video 2].
|Figure 2: Central Biphasic Nystagmus (left beating nystagmus changing to right beating ) after high frequency head shake test in a patient of infarction of cerebellar nodulus. Note - VNG graph shows right eye horizontal movement in the upper half denoted by red line and left eye horizontal movement is shown by blue line in the bottom half of the graph. Black and purple line represent right eye vertical movement and left eye vertical movement respectively|
Click here to view
Perverted postheadshake nystagmus can also be seen in lamotrigine and pregabalin toxicity.,
In cases of anterior inferior cerebellar artery stroke syndrome, we can see biphasic nystagmus, perverted nystagmus, or nystagmus opposite to spontaneous nystagmus.,
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]