The Laryngoscope C 2015 The American Laryngological, V
Rhinological and Otological Society, Inc.
Subjective Visual Vertical Testing in Children and Adolescents Jacob R. Brodsky, MD; Brandon A. Cusick, MBA, BBA; Margaret A. Kenna, MD, MPH; Guangwei Zhou, ScD Objectives/Hypothesis: Subjective visual vertical (SVV) is a vestibular test commonly used in adults that has not been well studied in children. In this test, the patient aligns a projected line with the perceived true vertical. Deviation of >28 is usually associated with utricular dysfunction and may also be seen with central vestibular lesions. The goal of this study was to determine the efficacy of SVV in children. Study Design: Prospective, controlled study. Methods: Thirty-three children aged 7 to 18 years with (n 5 21) and without (n 5 12) dizziness underwent static SVV. History, exam, rotary chair, and caloric testing were used to categorize subjects with dizziness into groups with peripheral vestibular loss (PVL), benign paroxysmal positioning vertigo (BPPV), central vertigo (CV), and nonvestibular dizziness (NVD). Results: Mean SVV deviation was significantly higher in the peripheral vestibular loss group (n 5 4; 2.1 6 1.5) compared to BPPV (n 5 5; 0.5 6 0.3), CV (n 5 7; 0.4 6 0.3), NVD (n 5 5; 0.6 6 0.4), and control (n 5 12; 0.7 6 0.5) groups by one-way analysis of variance (P 5.002). SVV deviation >28 demonstrated a sensitivity of 100%, specificity of 75%, positive predictive value of 100%, and negative predictive value of 97% for PVL. Conclusions: SVV is a simple, noninvasive test that provides a valuable contribution to the assessment of peripheral vestibular function in children. Key Words: Subjective visual vertical, utricle, pediatric vestibular testing, vestibular neuritis. Level of Evidence: 3b Laryngoscope, 126:727–731, 2016
INTRODUCTION The vestibular labyrinth is comprised of three semicircular canals, which respond to rotational acceleration, and two otolith organs, the saccule and utricle, which respond primarily to linear acceleration. Objective clinical tests of vestibular end-organ function have been well established for the lateral semicircular canal (rotary chair and caloric tests)1 and the saccule (cervical vestibular evoked myogenic potential test),1–4 but options for testing the function of the other vestibular end organs are limited. The subjective visual vertical (SVV) test has been shown to be a useful test for unilateral peripheral vestibular impairment involving the utricle.5–14 Acute injuries to central vestibular pathways can also affect SVV.15,16 The SVV test requires patients to rotate a projected straight line until it is aligned with their percepFrom the Department of Otolaryngology and Communication Enhancement (J.R.B., B.A.C., M.A.K., G.Z.), Boston Children’s Hospital, Boston, Massachusetts; and the Department of Otology and Laryngology (J.R.B., M.A.K., G.Z.), Harvard Medical School, Boston, Massachusetts, U.S.A. Editor’s Note: This Manuscript was accepted for publication April 23, 2015. Presented at the Eastern Section of the Triological Society Combined Sections Meeting, Coronado, California, U.S.A., January 24, 2015. All financial support for this study was provided by the Department of Otolaryngology and Communication Enhancement at Boston Children’s Hospital. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Jacob R. Brodsky, MD, Department of Otolaryngology and Communication Enhancement, 300 Longwood Avenue, Boston, MA 02115. E-mail: [email protected] DOI: 10.1002/lary.25389
Laryngoscope 126: March 2016
tion of the true vertical. Numerous adult studies have shown SVV deviation >28 in patients with vestibular pathology.6,11,17,18 The SVV test can be performed as a static test or as a dynamic test with off-axis rotation, with the latter showing increased sensitivity for detecting utricular impairment.5,12,14–18 Variations of SVV also include a moving visual field19,20 or tilting of the head or body.5,6,23 The static SVV test does not involve rotation or stimulation of vertigo, which in our experience can sometimes be anxiety-provoking factors that limit the use of other vestibular tests, such as the rotary chair and caloric tests, in children. Objective vestibular testing plays a particularly important role in the evaluation of dizziness in the pediatric population, where the history and examination are often limited, and the differential diagnosis is extensive.24 Vestibular tests that have been validated in adults require separate validation in children due to the varying maturity of the pediatric vestibular system.25 The SVV test has not been studied in children with vestibular dysfunction. The objective of this study was to evaluate the efficacy of the static SVV test in identifying children with peripheral vestibular pathology.
MATERIALS AND METHODS Patients Enrolled subjects consisted of 21 patients presenting to a pediatric vestibular clinic for evaluation of dizziness and 12 control patients presenting to a general pediatric otolaryngology clinic for evaluation of nonotologic problems (e.g., sinusitis,
Brodsky et al.: SVV in Children
727
TABLE I. Patient Diagnoses by Category. Category
Diagnosis
No.
PVL, n 5 4 (12%)
Vestibular neuritis
3
BPPV, n 5 5 (15%)
Labyrinthine concussion Unilateral posterior canal BPPV
1 5
CV, n 5 7 (21%)
Postconcussion syndrome
4
Vestibular migraine Chiari malformation
2 1
CSD
2
Chronic sinusitis Hypothyroidism
1 1
Postural orthostatic tachycardia
1
NVD, n 5 5 (15%)
Control, n 5 12 (36%) BPPV 5 benign paroxysmal positioning vertigo; CSD 5 chronic subjective dizziness; CV 5 central vertigo; NVD 5 non-vestibular dizziness; PVL 5 peripheral vestibular loss.
tonsillitis) without any history of dizziness or balance impairment. Patients with a history of chronic middle ear disease, ear surgery, or brain surgery were excluded. All subjects were 18 years of age or younger at the time of testing. All subjects underwent a comprehensive otologic and neurologic examination by a pediatric otolaryngologist (J.R.B.) as part of their routine evaluation for their presenting complaint. Written consent was obtained from the subjects’ parents, and verbal assent was obtained from subjects who were
Rhinological and Otological Society, Inc.
Subjective Visual Vertical Testing in Children and Adolescents Jacob R. Brodsky, MD; Brandon A. Cusick, MBA, BBA; Margaret A. Kenna, MD, MPH; Guangwei Zhou, ScD Objectives/Hypothesis: Subjective visual vertical (SVV) is a vestibular test commonly used in adults that has not been well studied in children. In this test, the patient aligns a projected line with the perceived true vertical. Deviation of >28 is usually associated with utricular dysfunction and may also be seen with central vestibular lesions. The goal of this study was to determine the efficacy of SVV in children. Study Design: Prospective, controlled study. Methods: Thirty-three children aged 7 to 18 years with (n 5 21) and without (n 5 12) dizziness underwent static SVV. History, exam, rotary chair, and caloric testing were used to categorize subjects with dizziness into groups with peripheral vestibular loss (PVL), benign paroxysmal positioning vertigo (BPPV), central vertigo (CV), and nonvestibular dizziness (NVD). Results: Mean SVV deviation was significantly higher in the peripheral vestibular loss group (n 5 4; 2.1 6 1.5) compared to BPPV (n 5 5; 0.5 6 0.3), CV (n 5 7; 0.4 6 0.3), NVD (n 5 5; 0.6 6 0.4), and control (n 5 12; 0.7 6 0.5) groups by one-way analysis of variance (P 5.002). SVV deviation >28 demonstrated a sensitivity of 100%, specificity of 75%, positive predictive value of 100%, and negative predictive value of 97% for PVL. Conclusions: SVV is a simple, noninvasive test that provides a valuable contribution to the assessment of peripheral vestibular function in children. Key Words: Subjective visual vertical, utricle, pediatric vestibular testing, vestibular neuritis. Level of Evidence: 3b Laryngoscope, 126:727–731, 2016
INTRODUCTION The vestibular labyrinth is comprised of three semicircular canals, which respond to rotational acceleration, and two otolith organs, the saccule and utricle, which respond primarily to linear acceleration. Objective clinical tests of vestibular end-organ function have been well established for the lateral semicircular canal (rotary chair and caloric tests)1 and the saccule (cervical vestibular evoked myogenic potential test),1–4 but options for testing the function of the other vestibular end organs are limited. The subjective visual vertical (SVV) test has been shown to be a useful test for unilateral peripheral vestibular impairment involving the utricle.5–14 Acute injuries to central vestibular pathways can also affect SVV.15,16 The SVV test requires patients to rotate a projected straight line until it is aligned with their percepFrom the Department of Otolaryngology and Communication Enhancement (J.R.B., B.A.C., M.A.K., G.Z.), Boston Children’s Hospital, Boston, Massachusetts; and the Department of Otology and Laryngology (J.R.B., M.A.K., G.Z.), Harvard Medical School, Boston, Massachusetts, U.S.A. Editor’s Note: This Manuscript was accepted for publication April 23, 2015. Presented at the Eastern Section of the Triological Society Combined Sections Meeting, Coronado, California, U.S.A., January 24, 2015. All financial support for this study was provided by the Department of Otolaryngology and Communication Enhancement at Boston Children’s Hospital. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Jacob R. Brodsky, MD, Department of Otolaryngology and Communication Enhancement, 300 Longwood Avenue, Boston, MA 02115. E-mail: [email protected] DOI: 10.1002/lary.25389
Laryngoscope 126: March 2016
tion of the true vertical. Numerous adult studies have shown SVV deviation >28 in patients with vestibular pathology.6,11,17,18 The SVV test can be performed as a static test or as a dynamic test with off-axis rotation, with the latter showing increased sensitivity for detecting utricular impairment.5,12,14–18 Variations of SVV also include a moving visual field19,20 or tilting of the head or body.5,6,23 The static SVV test does not involve rotation or stimulation of vertigo, which in our experience can sometimes be anxiety-provoking factors that limit the use of other vestibular tests, such as the rotary chair and caloric tests, in children. Objective vestibular testing plays a particularly important role in the evaluation of dizziness in the pediatric population, where the history and examination are often limited, and the differential diagnosis is extensive.24 Vestibular tests that have been validated in adults require separate validation in children due to the varying maturity of the pediatric vestibular system.25 The SVV test has not been studied in children with vestibular dysfunction. The objective of this study was to evaluate the efficacy of the static SVV test in identifying children with peripheral vestibular pathology.
MATERIALS AND METHODS Patients Enrolled subjects consisted of 21 patients presenting to a pediatric vestibular clinic for evaluation of dizziness and 12 control patients presenting to a general pediatric otolaryngology clinic for evaluation of nonotologic problems (e.g., sinusitis,
Brodsky et al.: SVV in Children
727
TABLE I. Patient Diagnoses by Category. Category
Diagnosis
No.
PVL, n 5 4 (12%)
Vestibular neuritis
3
BPPV, n 5 5 (15%)
Labyrinthine concussion Unilateral posterior canal BPPV
1 5
CV, n 5 7 (21%)
Postconcussion syndrome
4
Vestibular migraine Chiari malformation
2 1
CSD
2
Chronic sinusitis Hypothyroidism
1 1
Postural orthostatic tachycardia
1
NVD, n 5 5 (15%)
Control, n 5 12 (36%) BPPV 5 benign paroxysmal positioning vertigo; CSD 5 chronic subjective dizziness; CV 5 central vertigo; NVD 5 non-vestibular dizziness; PVL 5 peripheral vestibular loss.
tonsillitis) without any history of dizziness or balance impairment. Patients with a history of chronic middle ear disease, ear surgery, or brain surgery were excluded. All subjects were 18 years of age or younger at the time of testing. All subjects underwent a comprehensive otologic and neurologic examination by a pediatric otolaryngologist (J.R.B.) as part of their routine evaluation for their presenting complaint. Written consent was obtained from the subjects’ parents, and verbal assent was obtained from subjects who were
