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cd /tmp/workspace/attachments/2d2483c5-c536-4788-b58b-6f10a77e02af/ && python3 -c " import pdfplumber with pdfplumber.open('Report_293.pdf') as pdf: print(f'Total pages: {len(pdf.pages)}') for i, page in enumerate(pdf.pages): print(f'\n=== PAGE {i+1} ===') text = page.extract_text() if text: print(text) tables = page.extract_tables() if tables: print(f'\n--- Tables on page {i+1} ---') for j, table in enumerate(tables): print(f'Table {j+1}:') for row in table: print(row) "
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VNG videonystagmography interpretation nystagmus BPPV diagnosis normal values saccades smooth pursuit
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VNG Report - Detailed Analysis
Patient: Anu Yadav | Female, Age 29 | ID: CCDA00293 | Date: 04-Aug-2026
Clinic: Priority Hearing Care Pvt. Ltd.
1. SACCADE TEST
Horizontal Saccades
| Parameter | 0.3 Hz - Right Eye | 0.3 Hz - Left Eye | 0.45 Hz - Right Eye | 0.45 Hz - Left Eye |
|---|---|---|---|---|
| Velocity | 291.69 °/s | 273.93 °/s | 275.98 °/s | 272.90 °/s |
| Precision | 82.93% | 87.82% | 85.40% | 85.61% |
| Latency | 366.67 ms | 366.67 ms | 392.00 ms | 394.67 ms |
Vertical Saccades
| Parameter | 0.3 Hz - Right Eye | 0.3 Hz - Left Eye | 0.45 Hz - Right Eye | 0.45 Hz - Left Eye |
|---|---|---|---|---|
| Velocity | 264.53 °/s | 238.89 °/s | 199.22 °/s | 192.39 °/s |
| Precision | 93.53% | 87.86% | 75.66% | 67.49% |
| Latency | 418.67 ms | 416.47 ms | 288.00 ms | 289.52 ms |
Saccade Interpretation
Velocity: All values are above the pathological threshold of 275 °/s for horizontal saccades (per StatPearls VNG/ENG guidelines). Vertical saccades at 0.45 Hz dip into borderline range (199-192 °/s), though this is a higher-frequency demand.
Precision (Accuracy): Normal range is 80-134%. Most values fall within range. Vertical precision at 0.45 Hz (75.66% right, 67.49% left) is mildly reduced, suggesting subtle hypometric vertical saccades.
Latency: Normal range is <260 ms. All latency values (288-418 ms) are prolonged, particularly horizontal latencies (366-392 ms) and vertical latencies (416-418 ms at 0.3 Hz). This is a noteworthy finding. Prolonged latency indicates slowed pre-motor initiation pathways.
Saccade Conclusion: Mildly prolonged latencies bilaterally, with borderline reduced precision at higher vertical frequencies. While velocity is largely preserved, the prolonged latency pattern warrants attention. Per K.J. Lee's Essential Otolaryngology, abnormal saccades - especially with normal caloric results - are suggestive of central pathology (brainstem/cerebellar involvement).
2. SMOOTH PURSUIT TEST
| Test | Right Eye Gain | Left Eye Gain |
|---|---|---|
| 0.2 Hz Horizontal - Rightward | 0.87 | 0.83 |
| 0.2 Hz Horizontal - Leftward | 0.94 | 0.89 |
| 0.4 Hz Horizontal - Rightward | 0.60 | 0.57 |
| 0.4 Hz Horizontal - Leftward | 0.71 | 0.77 |
| 0.2 Hz Vertical - Upward | 0.52 | 0.49 |
| 0.2 Hz Vertical - Downward | 0.34 | 0.34 |
| 0.4 Hz Vertical - Upward | 0.45 | 0.51 |
| 0.4 Hz Vertical - Downward | 0.58 | 0.58 |
Smooth Pursuit Interpretation
Normal smooth pursuit gain for low-frequency targets (<20 °/s) is 0.9-1.0. Findings here:
- Horizontal pursuit at 0.2 Hz: Rightward gain (0.83-0.87) is mildly reduced; leftward gain is near-normal (0.89-0.94). Acceptable at this frequency.
- Horizontal pursuit at 0.4 Hz: Gains drop significantly to 0.57-0.77 - this is clearly reduced and represents catch-up saccadic intrusions (saccadic pursuit), bilaterally symmetric.
- Vertical pursuit: All vertical gains are markedly reduced (0.34-0.58), with downward pursuit the most impaired (gain 0.34 at 0.2 Hz). This is significant.
Smooth Pursuit Conclusion: Bilateral, symmetric impairment of smooth pursuit - both horizontal at higher frequency and vertical at all frequencies. This pattern is characteristic of central vestibular dysfunction (cerebellar or brainstem pathways), not peripheral labyrinthine disease. Per the BSA Vestibular Assessment guidelines, decreased gain with catch-up saccades indicates central pathology. However, poor attention and fatigue can also reduce pursuit gain in a 29-year-old - clinical correlation is essential.
3. OPTOKINETIC (OKN) TEST
| Direction | Right Eye Gain | Left Eye Gain |
|---|---|---|
| Left-to-Right 10° | 0.99 | 0.91 |
| Right-to-Left 10° | 0.80 | 0.84 |
| Top-to-Bottom 10° | 0.81 | 0.72 |
| Bottom-to-Top 10° | 0.66 | 0.63 |
OKN Interpretation
- Horizontal OKN: Gains are generally adequate (0.80-0.99). Minor asymmetry between L-to-R and R-to-L, which is not strongly lateralizing.
- Vertical OKN: Reduced gain, especially upward (bottom-to-top: 0.63-0.66), consistent with the impaired vertical smooth pursuit findings.
OKN Conclusion: Mildly reduced with a pattern consistent with the smooth pursuit abnormalities. No significant horizontal directional asymmetry to suggest a unilateral central lesion. The vertical reduction parallels the smooth pursuit findings.
4. SPONTANEOUS NYSTAGMUS
| Condition | Horizontal SPV | Vertical SPV | Frequency |
|---|---|---|---|
| In Light | None | None | None |
| In Dark (Horizontal) | None | -3.81 / -3.91 °/s | 0.68 / 0.81 Hz |
Spontaneous Nystagmus Interpretation
- No spontaneous nystagmus in light - This is normal.
- Spontaneous nystagmus in dark: A low-velocity downbeat nystagmus is present bilaterally (vertical SPV ~3.8-3.9 °/s, frequency ~0.68-0.81 Hz). Downbeat nystagmus is a well-recognized central vestibular sign, typically localizing to the craniocervical junction, flocculus/paraflocculus of the cerebellum, or brainstem pathways. It is suppressed by fixation (absent in light), which can occur with both peripheral and central causes.
Key finding: Low-velocity downbeat nystagmus in darkness - clinically significant.
5. HEAD SHAKE NYSTAGMUS
| Component | Right Eye | Left Eye |
|---|---|---|
| Horizontal SPV | -12.79 °/s | -3.51 °/s |
| Horizontal Amplitude | -8.10° | -3.13° |
| Vertical SPV | None | -3.89 °/s |
| Frequency | 0.80 Hz | 1.48 Hz |
| Fast Phase Direction | - | 144.87° |
Head Shake Interpretation
- Strong horizontal nystagmus post head-shake is present, with the right eye showing significantly greater slow phase velocity (-12.79 °/s) compared to the left (-3.51 °/s). This strong asymmetric response indicates a unilateral peripheral vestibular imbalance.
- The right eye dominance of post-head-shake nystagmus suggests the fast phase is beating away from the weaker side. A fast phase direction at 144.87° in the left eye corresponds to an oblique direction (approximately leftward-downward).
- Per Cummings Otolaryngology: "Nystagmus does occur after head shaking in subjects with unilateral vestibular hypofunction" - indicating a right-sided peripheral vestibular hypofunction component.
Head Shake Conclusion: Positive - indicates unilateral peripheral vestibular dysfunction (likely right-sided weakness).
6. GAZE TEST
With Fixation
| Position | Right Eye H-SPV | Left Eye H-SPV | Right Eye V-SPV | Left Eye V-SPV |
|---|---|---|---|---|
| Center | None | None | None | None |
| Left | +1.81 °/s | - | - | +0.74 °/s |
| Right | -0.36 °/s | -3.36 °/s | - | - |
| Up | None | None | None | None |
| Down | None | None | None | +1.15 °/s |
Without Fixation
| Position | Right Eye H-SPV | Left Eye H-SPV | Right Eye V-SPV | Left Eye V-SPV |
|---|---|---|---|---|
| Center | - | -1.57 °/s | -4.18 °/s | -4.90 °/s |
| Left | +4.85 °/s | +1.88 °/s | - | -2.89 °/s |
| Up | - | - | -5.65 °/s | -6.54 °/s |
| Right | -5.02 °/s | -4.74 °/s | - | - |
Gaze Test Interpretation
- Gaze-evoked nystagmus (with fixation): Mild nystagmus is noted in left-gaze position (horizontal SPV 1.81 °/s right eye) and right-gaze (horizontal SPV -3.36 °/s left eye). This bilateral, direction-changing gaze-evoked nystagmus is characteristic of central pathology (cerebellar), in contrast to peripheral unidirectional gaze nystagmus.
- Without fixation: Nystagmus becomes markedly more prominent in all positions, particularly upward gaze (vertical SPV -5.65 to -6.54 °/s) and right-gaze (-4.74 to -5.02 °/s). This enhancement without fixation with a predominantly downward-directed vertical component across positions again reinforces a downbeat nystagmus pattern and points toward central etiology.
- Fast phase direction in center-without-fixation: 105.48° (oblique, predominantly horizontal with downbeat component).
7. POSITIONAL TESTS (Dix-Hallpike & McClure-Pagnini)
Dix-Hallpike Right
- Sit Head Right (initial): No nystagmus
- Supine Head Ext. & Right: Vertical SPV -3.11 °/s (right eye), Frequency 0.63 Hz - mild nystagmus
- Sit Head Right (return): Vertical SPV -4.78 °/s (right eye), Frequency 1.84 Hz
Dix-Hallpike Left
- Sit Head Left (initial): Strong oblique nystagmus - Horizontal SPV +9.65 °/s (right eye), Vertical SPV +6.65 °/s (right eye), Fast Phase Direction 333.84° (upper pole torsional, approximately toward upper-right), Frequency 2.38 Hz
- Supine Head Ext. & Left: No nystagmus
- Sit Head Left (return): No nystagmus
Dix-Hallpike Interpretation
The left Dix-Hallpike is positive with nystagmus beating at 333.84° (upward-torsional direction with fast phase toward the upper pole of the left eye = geotropic torsional-vertical nystagmus). This is the classic pattern of left posterior semicircular canal (P-SCC) BPPV. Per Shambaugh Surgery of the Ear: "BPPV is often referred to as a positioning nystagmus... paroxysmal positional nystagmus can be observed."
The right Dix-Hallpike shows only mild low-frequency nystagmus (SPV 3-4 °/s) without the classic high-amplitude burst, suggesting the right side is not the primary BPPV-affected canal.
Supine Straight Head Extension
- Supine Head Ext. 90°: Vertical SPV -4.57 °/s (right eye), 0.93 Hz
- Supine End (coming back): Vertical SPV +30.59 °/s (right eye, 1.36 Hz) - very high amplitude
This large-amplitude vertical nystagmus on straight head extension return is notable and may indicate anterior canal involvement or a canalith repositioning transition effect.
McClure-Pagnini (Supine Roll Test)
| Position | Right Eye SPV | Left Eye SPV | Fast Phase Direction |
|---|---|---|---|
| Sit to Supine | - | -2.86 H / -2.43 V °/s | 138.42° |
| Right Lateral | None | None | - |
| Supine Head Neutral (1st) | - | -3.79 V °/s | - |
| Left Lateral | -0.59 H / -5.25 V °/s | -5.92 V °/s | 106.89° |
| Supine Head Neutral (2nd) | -3.53 H / -4.50 V °/s | -3.53 H / -4.32 V °/s | 123.55° |
McClure-Pagnini positional nystagmus is predominantly vertical (downbeat-direction) across multiple head positions, without the clear geotropic/ageotropic horizontal pattern expected for horizontal canal BPPV. This supports the ongoing downbeat nystagmus theme.
8. HEAD POSITION TESTS (Static)
| Position | H-SPV (Right/Left) | V-SPV (Right/Left) | Fast Phase Direction |
|---|---|---|---|
| Yaw Right | -5.74 / -5.44 °/s | None | - |
| Yaw Left | +21.77 / +4.77 °/s | None | - |
| Pitch Forward | None | - / -3.84 °/s | - |
| Pitch Backward | -2.16 / -4.45 °/s | -5.38 / -6.55 °/s | 128.74° / 127.29° |
| Roll Right | None | None | - |
| Roll Left | - / -5.25 °/s | None | - |
Head Position Interpretation
- Yaw Left: Right eye SPV of +21.77 °/s is very high amplitude, indicating strong horizontal positional nystagmus beating leftward (rightward fast phase) in the left-yaw position. Significant.
- Pitch Backward: Strong oblique nystagmus (SPV -5.38 to -6.55 °/s vertically + horizontal component), fast phase at ~128°. This is consistent with the downbeat pattern worsened by neck extension.
- Direction-changing nystagmus across different head positions further supports central vestibular pathology (not consistent with simple peripheral positional vertigo alone).
9. SUBJECTIVE VISUAL VERTICAL (SVV)
| Trial | Deviation | Direction |
|---|---|---|
| Clockwise | 1° Right | Clockwise |
| AntiClockwise | 1° Right | Clockwise |
| Blank Background | 2° Right | Clockwise |
SVV Interpretation
Normal SVV deviation is ≤2°. All deviations are 1-2° rightward. The blank background trial at 2° right is at the upper limit of normal (≤2° is generally accepted, with >2.5° clearly abnormal). Per Cummings Otolaryngology: "Subjects with recent unilateral loss of otolith function will consistently displace a lighted line" - a consistent rightward tilt, even if marginal, may indicate subtle right utricular/otolith dysfunction.
SVV: Borderline - marginal rightward tilt across all conditions, most prominent with blank background. Suggestive of mild right otolith asymmetry.
INTEGRATED DIAGNOSTIC SUMMARY
Key Abnormal Findings Tabulated
| Test | Finding | Significance |
|---|---|---|
| Saccade Latency | Prolonged bilaterally (288-418 ms) | Central (brainstem pre-motor pathways) |
| Vertical Precision | Reduced at 0.45 Hz | Mild cerebellar/central |
| Smooth Pursuit | Reduced gain - bilateral, vertical >> horizontal | Central (cerebellum/brainstem) |
| OKN Vertical | Reduced gain | Central |
| Spontaneous Nystagmus in Dark | Downbeat nystagmus (~3.9 °/s) | Central (flocculus/craniocervical) |
| Head Shake | Asymmetric (right > left) | Peripheral - right vestibular hypofunction |
| Gaze Nystagmus | Direction-changing, without-fixation predominant | Central |
| Dix-Hallpike Left | Positive (fast phase 333.84°, upward-torsional) | Left posterior canal BPPV |
| Head Extension (Return) | High-amplitude vertical nystagmus (30.59 °/s) | Anterior canal or transition |
| Head Position Yaw Left | High SPV (21.77 °/s) | Positional - left-beating |
| Pitch Backward | Oblique nystagmus increasing | Downbeat exacerbation |
| SVV | 1-2° rightward tilt | Mild right otolith asymmetry |
DIAGNOSIS
Based on this VNG analysis, the findings are most consistent with a mixed peripheral and central vestibular disorder:
Primary Diagnoses:
1. Left Posterior Canal BPPV (Primary Finding)
The positive left Dix-Hallpike with upward-torsional nystagmus at 333.84° is the most classic and specific finding in this report. This is the dominant symptomatic diagnosis. Treatment: Epley repositioning maneuver (left side).
2. Right Peripheral Vestibular Hypofunction (Likely Concurrent)
The asymmetric head-shake nystagmus (right eye SPV 12.79 °/s vs. left 3.51 °/s) and marginal rightward SVV tilt suggest reduced right-labyrinthine output. Caloric testing would be necessary to quantify the degree of canal paresis, but the pattern is consistent with a right unilateral peripheral vestibular lesion (e.g., right vestibular neuritis or labyrinthitis in resolution phase).
3. Central Vestibular Signs Requiring Further Evaluation
Multiple findings cannot be explained by BPPV or simple peripheral hypofunction alone:
- Bilateral prolonged saccade latency
- Downbeat nystagmus in darkness
- Direction-changing gaze nystagmus
- Impaired vertical smooth pursuit (symmetric)
- Widespread positional nystagmus not following typical canal patterns
These findings collectively suggest possible central vestibular pathway involvement - likely at the level of the cerebellum (flocculus/nodulus) or craniocervical junction. The differential includes:
- Vestibulo-cerebellar dysfunction (e.g., cerebellar ataxia, multiple sclerosis, vestibular migraine)
- Chiari malformation (downbeat nystagmus + positional exacerbation is a classic presentation)
- Vertebrobasilar insufficiency (less likely in 29-year-old female without risk factors)
- Vestibular migraine (common in young females, can produce multiple VNG abnormalities)
RECOMMENDED NEXT STEPS
| Investigation | Rationale |
|---|---|
| Caloric test (bithermal) | Quantify right canal paresis, confirm peripheral component |
| vHIT (Video Head Impulse Test) | Assess high-frequency VOR gain per semicircular canal |
| cVEMP / oVEMP | Evaluate saccular and utricular function bilaterally |
| MRI Brain + posterior fossa (with contrast) | Rule out Chiari malformation, MS plaques, cerebellar lesion, vestibular schwannoma |
| Neurology / Neuro-otology referral | Central findings require specialist evaluation |
| Epley maneuver (left posterior canal) | Treat BPPV - should produce immediate symptomatic relief |
| Audiometry | Rule out associated sensorineural hearing loss |
Clinical Bottom Line: This 29-year-old female has a positive left Dix-Hallpike consistent with left posterior canal BPPV as the primary treatable diagnosis. However, the concurrent findings of downbeat nystagmus in darkness, impaired bilateral smooth pursuit (especially vertical), prolonged saccade latency, and direction-changing positional/gaze nystagmus constitute a red flag pattern requiring exclusion of central pathology - most importantly a posterior fossa/cerebellar lesion or Chiari malformation. MRI brain (posterior fossa protocol) and neurology referral are strongly recommended alongside Epley maneuver treatment for the BPPV.
Note: This analysis is based solely on the VNG recordings. Clinical correlation with symptom history, physical examination, and additional vestibular and audiological testing is required for a definitive diagnosis. No caloric test results were included in this report, which limits assessment of horizontal semicircular canal function.
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