Study reference

Study characteristics

Patient characteristics

Index test

(test of interest)

Reference test

Follow-up

Outcome measures and effect size

Comments

Perez, 2003

Type of study:

Open and prospective study

Setting:

University of Navarra, tertiary centre

Country:

Spain

Source of funding:

Not reported

Inclusion criteria:

Outpatients referred to department with symptoms of vertigo. Caloric   test and head impulse test on same day

Exclusion criteria:

Not reported

N= 265

Mean age ± SD:

50.2 years (95% CI 47.75 – 53.37)

Sex: % M / % F

49.8% M / 50.2% F

Describe index test:

Head impulse test

Cut-off point(s):

Positive (pathological) when refixation saccades were observed in at   least two of three repetitions.

Describe reference test:

Bithermal caloric testing

Cut-off point(s):

Normal when difference in canal paresis was less than 22% and   directional preponderance less than 28%

Endpoint of follow-up:

Both tests were performed on all patients the same day.

For how many   participants were no complete outcome data available?

None

Head impulse test:

Sensitivity: 56%

Specificity: 90%

Positive predictive value: 86%

Negative predictive value: 65%

Authors conclusion: HIT and caloric test are redundant methods.

Beynon, 1998

Type of study:

Prospective, observational study

Setting:

Addenbrooke’s hospital, Cambridge

Country:

United Kingdom

Source of funding:

Not reported

Inclusion criteria:

Series of patients with a history of balance disorder who were   referred for balance assessment by otolaryngologist and series of patients in   neuro –otology clinic referred for balance function testing

Exclusion criteria:

Not reported

N= 150

Mean age ± SD:

50.9 years ± 13.7 (13 – 76)

Sex: % M / % F

Not reported

Other important characteristics:

Diagnostic categories:

-unilateral vestibular schwannoma N=42

-vestibular neuronitis N=6

-Meniere disease N=18

-no clear diagnosis N=84

Describe index test: Head impulse test

Cut-off point(s):

Positive when at least two out of three turns had to show a drift in   direction of gaze followed by a saccadic recovery.

Describe reference test:

Bithermal caloric testing

Cut-off point(s):

Upper limit of normal asymmetries is 25%.

Endpoint of follow-up:

Not reported.

For how many   participants were no complete outcome data available?

None.

Head impulse test:

Sensitivity: 34%

Specificity: 100%

Positive predictive value: NR

Negative predictive value: NR

Authors conclusion: the test does not detect mild or moderate   vestibular weakness but is very sensitive to the presence of severe paresis.

HIT will not replace caloric testing but is a very useful adjunct to   it.

Harvey, 1997

Type of study:

Prospective

Setting:

Outpatient academic tertiary referral center

Country:

USA

Source of funding:

Not reported

Inclusion criteria:

Outpatient presented for evaluation of dizziness between Jan 1 1993   and May 31 1994

Exclusion criteria:

Bilateral vestibular weakness on caloric testing (reason: inability of   HSN to detect bilateral vestibular weakness)

N= 105

Mean age ± SD:

52.1 years (13 – 87)

Sex: % M / % F

33% M / 67% F

Describe index test: Head impulse test (HIT) and head shake   nystagmus (HSN)

Cut-off point(s):

HIT: abnormal when eyes drifted with the head off the stationary   target and compensatory refixation saccades were necessary to reset visual   fixation on examiner’s nose.

HST: abnormal with at least three beats of well –defined nystagmus.

Describe reference test:

Bithermal caloric testing

Cut-off point(s):

Canal paresis (positive caloric result) was considered present if an   asymmetry of > 30% was present (upper limit of normal is 30%).

Endpoint of follow-up:

Not reported.

For how many   participants were no complete outcome data available?

None.

Head impulse test / head shake nystagmus:

Sensitivity: 35% / 35%

Specificity: 95% / 92%

Positive predictive value:

64% / 50%

In combination:80%

Negative predictive value:

86% / 86%

In combination: 88%

Authors conclusion: low sensitivity renders both tests inadequate as   screening tool for peripheral vestibular disease based on caloric results.

Study reference

Study characteristics

Patient characteristics

Index test

(test of interest)

Reference test

Follow-up

Outcome measures and effect size

Comments

Angeli, 2011

Type of study:

Retrospective case -control

Setting:

Academic tertiary referral center

Country:

USA

Source of funding:

Not reported.

Inclusion criteria:

1)18 years or older

2) symptoms of vertigo or disequilibrium for at least 2 months before   presentation

3) unilateral or asymmetric peripheral vestibular hypofunction defined   by caloric test of the VNG between January 2006 and December 2008.

4) complete HSN and VNG tests

Exclusion criteria:

Conditions that   may impair or contribute to their disability

beyond unilateral   peripheral vestibular hypofunction such as

BPPV, bilateral   peripheral

hypofunction,   central nervous system disease, and musculoskeletal

or visual impairment.

N= 53

Median age (range):

57 (24-85) years

Sex:

21 men and 32 women

Describe index test:

Head shaking nystagmus.

All subjects were   examined

with Frenzel's lenses in partial darkness.

Cut-off point(s):

A positive HSN

test was defined   as the presence of at least 3 beats of

nystagmus after 30   cycles of passive head rotation at a rate of

1 to 2 Hz with   head tilted 30° forward in the plane of the

horizontal semicircular canal.

The maximum

slow phase velocity of nystagmus was calculated for each

set of tests and   then analyzed using the manufacturer's

normative data.

Describe reference test:

Bithermal caloric test

Cut-off point(s):

Abnormal caloric   testing was considered

diagnostic of   unilateral canal paresis when the interaural difference in nystagmus response   (degrees per second of the slow phase velocity) for the 2 temperatures was   30% or greater.

Endpoint of follow-up:

Not reported.

For how many   participants were no complete outcome data available?

None.

Head shake test:

Sensitivity: 31%

Specificity: 96%

Positive predictive value: 97%

Negative predictive value: not reported.

Authors   conclusion: The HSN has sufficient sensitivity to be used as screening test of   uncompensated vestibulopathy in this series. However, a negative HSN alone   does not rule out the diagnosis of peripheral vestibular dysfunction.

Iwasaki, 2004

Type of study:

Retrospective cohort

Setting:

General hospital

Country:

Japan

Source of funding:

Not reported.

Inclusion criteria:

Patients with complaints of balance problems.

Exclusion criteria:

Not reported.

N= 132

Median age ± SD:

56 ± 16 years

Sex:

49 men and 83 women

Describe index test:

Head shaking nystagmus using electrony-stagmography with Frenzel's glasses.

Cut-off point(s):

HSN was present   when

(i) at least three   beats of nystagmus within 5s;

(ii) a latency   from the end of head-shaking of no more than 5 s; and (iii) a slow-phase eye   velocity of at least 2.5 degrees/s  or   more than 5 degrees per second in patients with a spontaneus nystagmus

Describe reference test:

Bithermal caloric test

Cut-off point(s):

Normal limit of CP is 20%.

Endpoint of follow-up:

Not reported.

For how many   participants were no complete outcome data available?

None.

Head shake test:

Sensitivity: 66%

Specificity: 77%

Positive predictive value:

Not reported.

Negative predictive value:

Not reported.

Authors   conclusion: the HSN test is not very sensitive but it is still acceptable as one   of the screening tests available for detecting asymmetrical vestibular   dysfunction.

Asawavichiangianda, 1999

Type of study:

Prospective cohort study

Setting:

General hospital

Country:

Canada

Source of funding:

Supported by an   educational

grant from the   Thailand Ministry of Health and by an educational grant from the Japan   Ministry of Education.

Inclusion criteria:

Consecutive patients assessed for dizziness

Exclusion criteria:

Not reported

N= 1364

Median age ± SD:

Not reported

Sex:

Not reported.

Describe index test:

Head shaking nystagmus during ENG testing (both active and passive)

Cut-off point(s):

Present if an   evoked horizontal nystagmus

was identified   that increased in frequency and/or attained a slow-phase velocity >5°/s   above any preexistent

spontaneous nystagmus in the upright position.

Describe reference test:

Bithermal caloric test

Cut-off point(s):

R/L excitability difference > 20%

Endpoint of follow-up:

Not reported.

For how many   participants were no complete outcome data available?

Not reported.

Head shake test:

Sensitivity: 50.2%

Specificity: 73.2%

Positive predictive value:

Not reported.

Negative predictive value:

Not reported.

Authors   conclusion: HSN is a simple bedside test that complements other aspects of the formal   otoneurological examination. A positive test is highly suggestive for   underlying vestibular pathology, although not diagnostic in itself. A   negative

head-shake test,   however, does not necessarily exclude

pathology.

Tseng, 1997

Type of study:

Cohort

Setting:

University hospital

Country:

Taiwan

Source of funding:

Not reported.

Inclusion criteria:

Consecutive patients with the complaint of vertigo undergoing   vestibular function tests between August 1992 and July 1994

Exclusion criteria:

Not reported.

N= 258

Median age ± SD:

14-79 years (peak in 6^th and 7^th decade)

Sex:

97 men and 161 women

Describe index test:

Head shaking nystagmus (passive)

Cut-off point(s):

Any nystagmus more than 6 degrees /s.

1. Deficiency: when post-shaking nystagmus immediately appears,   lasting for 5-15s, then diminishes gradually.

2. Recovery: as post- shaking nystagmus does not appear until about   10s later and lasts for 20s or more.

Describe reference test:

Bithermal caloric test

Cut-off point(s):

Normal limit of CP at 20%

Endpoint of follow-up:

Not reported.

For how many   participants were no complete outcome data available?

None.

Head shake test:

Sensitivity: 90%

Specificity: 53%

Positive predictive value:

Not reported.

Negative predictive value:

Not reported.

Authors conclusion: HSN could be used as a screening test for dizzy   patients.

Study reference

(first author, year of publication)

 Was the spectrum of patients representative   of the patients who will receive the test in practice?

yes/ no/ unclear

Is the reference   standard likely to correctly classify the

target condition?

yes/ no/ unclear

Is the time period   between reference standard and index test short enough to be reasonably sure   that the target

condition did not   change between the two tests?

yes/ no/ unclear

Did the whole   sample or a random  selection of the

sample, receive verification using a reference standard?

yes/ no/ unclear

Did patients receive   the same reference standard irrespective of the index test result?

yes/ no/ unclear

Was the reference   standard independent of the index

test (i.e. the   index test did not form part of the reference

standard)?

yes/ no/ unclear

Were the index test results interpreted without

knowledge of the results of the reference standard and vice versa?

yes/ no/ unclear

Were the same clinical   data available when test results were interpreted as would be available when the test is used in practice?

yes/ no/ unclear

Were uninterpretable/ intermediate (unclear) test results reported?

yes/ no/ unclear

Were withdrawals from the study explained?

yes/ no/ unclear

Kessler, 2008

Yes

Yes

Yes

Whole sample

Yes

Yes

Unclear

Yes

Not applicable

Not applicable

Perez, 2003

Yes

Yes

Yes

Whole sample

Yes

Yes

No

Yes

Not applicable

Not applicable

Beynon, 1998

Yes

Yes

Yes

Whole sample

Yes

Yes

No

Yes

Not applicable

Not applicable

Harvey, 1997

Yes

Yes

Yes

Whole sample

Yes

Yes

Yes

Yes

Not applicable

Not applicable

Study reference

(first author, year of publication)

 Was the spectrum of patients representative   of the patients who will receive the test in practice?

yes/ no/ unclear

Is the reference   standard likely to correctly classify the

target condition?

yes/ no/ unclear

Is the time period   between reference standard and index test short enough to be reasonably sure   that the target

condition did not   change between the two tests?

yes/ no/ unclear

Did the whole   sample or a random  selection of the

sample, receive verification using a reference standard?

yes/ no/ unclear

Did patients receive   the same reference standard irrespective of the index test result?

yes/ no/ unclear

Was the reference   standard independent of the index

test (i.e. the   index test did not form part of the reference

standard)?

yes/ no/ unclear

Were the index   test results interpreted without

knowledge of the results of the reference standard and vice versa?

yes/ no/ unclear

Were the same clinical   data available when test results were interpreted as would be available when   the test is used in practice?

yes/ no/ unclear

Were uninterpretable/   intermediate (unclear) test results reported?

yes/ no/ unclear

Were withdrawals   from the study explained?

yes/ no/ unclear

Angeli, 2011

Yes

Yes

Yes

Whole sample

Yes

Yes

Yes

Yes

Not applicable

Not applicable

Iwasaki, 2004

Yes

Yes

Yes

Whole sample

Yes

Yes

Unclear

Yes

Not applicable

Not applicable

Asawavichiangianda, 1999

Yes

Yes

Yes

Whole sample

Yes

Yes

Unclear

Yes

Not applicable

Not applicable

Tseng, 1997

Yes

Yes

Yes

Whole sample

Yes

Yes

No

Yes

Not applicable

Not applicable