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 Table of Contents  
SHORT COMMUNICATION
Year : 2021  |  Volume : 9  |  Issue : 2  |  Page : 368-370

Clinical significance of horizontal high-frequency headshake test


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 Submission24-May-2021
Date of Decision07-Oct-2021
Date of Acceptance08-Nov-2021
Date of Web Publication29-Dec-2021

Correspondence Address:
Dr. Prateek Porwal
Vertigo and Balance Clinic, 6th Block, Jayanagar, Bengaluru - 560 041, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_124_21

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  Abstract 


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 Top


Headshaking nystagmus (HSN) was first described in 1907 by Robert Barany.[1] 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 Top


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 Top


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.[2],[3],[4]

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

Click here to view



There may also be a headshaking nystagmus in lateral canal BPPV, being more common in the apogeotropic form.[5]

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.[2]

Headshaking may also induce nystagmus in patients with central disorders. However, direction of nystagmus is nonlocalizing in these cases.[6]

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.[6]

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.[1]

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.[7],[8],[9]

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.[1]

In lesions of the cerebellar nodulus and ventral uvula, nystagmus with quick reversal,torsional and perverted nystagmus can be observed post- head shaking.[1] [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.[10],[11]

In cases of anterior inferior cerebellar artery stroke syndrome, we can see biphasic nystagmus, perverted nystagmus, or nystagmus opposite to spontaneous nystagmus.[8],[9]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Eggers SD, Zee DS. Vertigo and Imbalance: Clinical Neurophysiology of the Vestibular System. Amsterdam: Elsevier; 2010.  Back to cited text no. 1
    
2.
Angeli SI, Velandia S, Snapp H. Head-shaking nystagmus predicts greater disability in unilateral peripheral vestibulopathy. Am J Otolaryngol 2011;32:522-7.  Back to cited text no. 2
    
3.
Fetter M, Zee DS, Koenig E, Dichgans J. Head-shaking nystagmus during vestibular compensation in humans and rhesus monkeys. Acta Otolaryngol 1990;110:175-81.  Back to cited text no. 3
    
4.
Hain TC, Fetter M, Zee DS. Head-shaking nystagmus in patients with unilateral peripheral vestibular lesions. Am J Otolaryngol 1987;8:36-47.  Back to cited text no. 4
    
5.
Lee SU, Kim HJ, Kim JS. Pseudo-spontaneous and head-shaking nystagmus in horizontal canal benign paroxysmal positional vertigo. Otol Neurotol 2014;35:495-500.  Back to cited text no. 5
    
6.
Choi KD, Oh SY, Park SH, Kim JH, Koo JW, Kim JS. Head-shaking nystagmus in lateral medullary infarction: Patterns and possible mechanisms. Neurology 2007;68:1337-44.  Back to cited text no. 6
    
7.
Minagar A, Sheremata WA, Tusa RJ. Perverted head-shaking nystagmus: A possible mechanism. Neurology 2001;57:887-9.  Back to cited text no. 7
    
8.
Huh YE, Kim JS. Patterns of spontaneous and head-shaking nystagmus in cerebellar infarction: Imaging correlations. Brain 2011;134:3662-71.  Back to cited text no. 8
    
9.
Huh YE, Koo JW, Lee H, Kim JS. Head-shaking aids in the diagnosis of acute audiovestibular loss due to anterior inferior cerebellar artery infarction. Audiol Neurootol 2013;18:114-24.  Back to cited text no. 9
    
10.
Choi JY, Park YM, Woo YS, Kim SU, Jung JM, Kwon DY. Perverted head-shaking and positional downbeat nystagmus in pregabalin intoxication. J Neurol Sci 2014;337:243-4.  Back to cited text no. 10
    
11.
Oh SY, Kim JS, Lee YH, Lee AY, Kim J, Kim JM. Downbeat, positional, and perverted head-shaking nystagmus associated with lamotrigine toxicity. J Clin Neurol 2006;2:283-5.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

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