Kindly. Write the diagnosos could. It ne Pppd Or prebyvestibulopathy she is having more. Subjevtive dizziness.
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Now I have enough information to write a thorough diagnosis code for this patient. Let me analyze the VNG findings systematically.
VNG Report Analysis — Mrs. Darshana Jain, 74F (21-Apr-2026)
Summary of VNG Findings
| Test | Result | Interpretation |
|---|---|---|
| Spontaneous Nystagmus (Light) | Absent | Normal |
| Spontaneous Nystagmus (Dark) | Absent | Normal |
| Gaze-Evoked Nystagmus | Absent in all directions (with fixation) | Normal |
| Center Gaze – Without Fixation | Low-amplitude horizontal nystagmus, SPV 4.26°/s, amplitude 3.03°, freq 0.90 Hz (right eye only) | Mild spontaneous nystagmus unmasked without fixation — subclinical peripheral vestibular asymmetry |
| Saccades (Horizontal) | Right eye velocity 190°/s, latency 470 ms (prolonged); Left eye velocity 2142°/s (likely artifact/calibration), latency 322 ms | Right eye saccadic latency prolonged; asymmetry noted |
| Saccades (Vertical) | Right 150°/s / Left 614°/s; latencies 433 / 328 ms | Right eye vertical saccades slower |
| Smooth Pursuit (Horizontal) | Right eye gain 0.82–1.00 (normal); Left eye gain 0.07 bilaterally | Markedly reduced left eye smooth pursuit — suggestive of monocular tracking deficit or oculomotor abnormality in the left eye |
| Smooth Pursuit (Vertical) | Right 0.76–0.82; Left 0.12–0.21 | Same pattern — left eye pursuit severely reduced |
| OKN (Left→Right & Right→Left) | Gains 0.41–0.59; No fast phase on right eye in both directions | Reduced bilateral OKN gains; absent fast phase in right eye |
| OKN (Top→Bottom / Bottom→Top) | Gains 0.33–0.83 | Moderately reduced on right eye |
| SVV (Subjective Visual Vertical) | Clockwise: +8° right (abnormal); Anticlockwise: −2° (normal); Blank: 90° trial-1 (invalid, 0s), −3° trial-2 (normal) | +8° rightward SVV tilt in clockwise condition is borderline/abnormal (normal ≤2–2.5°); suggests possible utricle/otolith asymmetry |
Key Diagnostic Points
1. Absent spontaneous nystagmus with fixation + low-grade nystagmus without fixation (SPV 4.26°/s)
This is the classic pattern of a compensated peripheral vestibular asymmetry — fixation suppresses the nystagmus, but it is unmasked in darkness. The slow-phase velocity of 4.26°/s is low (borderline threshold ~5°/s for significance) but consistent with subclinical residual vestibular imbalance.
2. Left eye smooth pursuit markedly reduced (gain ~0.07)
This is a striking finding. Smooth pursuit gain of 0.07 in the left eye across both horizontal and vertical planes is extremely low. This could indicate:
- Monocular ocular pathology (reduced acuity, cataract, or poor left eye cooperation during testing)
- Central oculomotor pathway dysfunction affecting the left eye
- Testing artifact (note: all tests done with default calibration, meaning no true individual calibration was performed — this is a significant limitation)
3. SVV deviation +8° rightward (clockwise rotation trial)
Normal SVV is ≤2°–2.5°. A rightward tilt of 8° suggests right-side utricular/otolith dysfunction or ipsilateral superior vestibular nerve involvement. However, this is a single trial; the anticlockwise trial was nearly normal (−2°). This inconsistency lowers confidence.
4. Saccadic latency prolonged on right eye (470 ms horizontal, 433 ms vertical)
Normal latency is ~150–250 ms. Values >250 ms suggest central oculomotor slowing consistent with aging-related changes.
5. No caloric test was performed — this is the most important limitation. Caloric irrigation is the gold standard for quantifying unilateral canal paresis. Without it, a definitive peripheral vs. bilateral vestibular hypofunction diagnosis cannot be made.
Diagnosis (Most Likely) — Given Predominant Subjective Dizziness
Given:
- Age 74 years (elderly female)
- Predominantly subjective dizziness (as stated)
- Subclinical nystagmus without fixation (SPV 4.26°/s)
- No significant spontaneous or gaze nystagmus
- Asymmetric smooth pursuit (likely monocular/technical issue but central aging component possible)
- Borderline SVV tilt
- No caloric data available
- Absent objective nystagmus with fixation
Primary Diagnosis:
Presbyvestibulopathy (Age-Related Vestibular Dysfunction) with Functional/Subjective Dizziness component consistent with PPPD features
Differential Diagnosis Table
| Diagnosis | Supporting Features | Against |
|---|---|---|
| Presbyvestibulopathy (ICD-10: H81.8) | Age 74, female, chronic subjective dizziness, subclinical nystagmus without fixation, no acute episodes, multisystem oculomotor aging signs | No caloric data; no bilateral reduced VOR confirmed |
| PPPD (ICD-10: F45.8 or H81.8X) | Predominantly subjective dizziness, chronic (presumably), functional pattern, triggered by motion/visual environment | PPPD requires 3+ months history + specific precipitant; clinical history not provided in this VNG |
| Compensated Unilateral Peripheral Vestibular Hypofunction | Low SPV nystagmus unmasked without fixation; borderline SVV right tilt | Fixation suppression normal; no caloric to confirm side |
| Central vestibular disorder | Abnormal saccadic latencies, reduced OKN gains, age-related | No gaze-evoked nystagmus, no direction-changing nystagmus; low probability |
| Bilateral Vestibular Hypofunction | Age-related, subjective imbalance | Cannot confirm without caloric/vHIT testing |
Impression for Report
Impression:
VNG testing reveals:
- Subclinical spontaneous nystagmus unmasked without fixation (horizontal, right eye, SPV 4.26°/s) — consistent with a compensated peripheral vestibular asymmetry, most likely right-sided.
- Borderline SVV rightward tilt (+8°) on clockwise trial — suggests possible right otolith asymmetry (interpret with caution — single trial only).
- Markedly reduced left eye smooth pursuit and OKN gain — likely related to monocular ocular limitation or testing calibration (performed with default calibration); central oculomotor contribution in the context of aging cannot be fully excluded.
- Prolonged saccadic latencies — consistent with age-related central oculomotor slowing.
- No spontaneous or gaze-evoked nystagmus with visual fixation — no active peripheral decompensation or clear central pathology.
- No caloric testing was performed — bilateral vestibular function and unilateral canal paresis cannot be quantified.
Conclusion:
In a 74-year-old female presenting with predominantly subjective dizziness, the overall VNG profile is most consistent with:
Presbyvestibulopathy (age-related vestibular dysfunction) — characterized by subclinical vestibular asymmetry, aging-related oculomotor changes, and absent objective nystagmus on fixation. The predominance of subjective dizziness over objective vestibular signs raises the possibility of a co-existing functional overlay consistent with PPPD (Persistent Postural-Perceptual Dizziness).
Recommended further evaluation:
- vHIT (Video Head Impulse Test) — to assess VOR gain per semicircular canal
- Caloric irrigation — to quantify unilateral canal paresis
- Cervical and Ocular VEMP — to complete otolith assessment
- Clinical assessment using Bárány Society PPPD criteria (3-month symptom duration, exacerbation by upright posture and visual environments) to confirm or exclude PPPD diagnosis
- Consider fall risk assessment and vestibular rehabilitation referral
— Cummings Otolaryngology Head and Neck Surgery (Presbyvestibulopathy section); Harrison's Principles of Internal Medicine 22E (PPPD); Bárány Society ICVD classification
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