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Claussan’s butterfly chart according to standard ENT textbook

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Claussen's butterfly chart craniocorpography ENT

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https://www.jaypeedigital.com/eReader/chapter/9789352500291/…

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Claussen butterfly chart construction culmination frequency caloric nystagmus normal pattern

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Claussen's Butterfly Chart

What it is

Claussen's butterfly chart (also called the "butterfly diagram" or "butterfly code") is a graphic method devised by Prof. Claussen for interpreting the results of electronystagmography (ENG), specifically the bithermal caloric test, in the vestibular work-up of vertigo. It converts the raw nystagmus data from caloric testing into a simple pictorial pattern that resembles a butterfly, which can be read at a glance by clinicians (and even explained to patients) without needing to interpret raw ENG tracings.

How it is constructed

  • During bithermal caloric testing, each ear is irrigated with warm and cold water/air (giving four stimulations: right warm, right cold, left warm, left cold).
  • The nystagmus response to each stimulation is expressed as the culmination frequency (the peak beats of nystagmus per 30 seconds).
  • Normal culmination frequency ranges (commonly cited):
    • Right warm: 22-59 beats/30 sec
    • Right cold: 24-67 beats/30 sec
    • (with corresponding ranges for the left ear)
  • These four values are plotted on a template with four "wings" radiating from a central axis, one wing for each stimulus (RW, RC, LW, LC). When normal, the four wings are roughly symmetric and resemble the two wings of a butterfly - hence the name.
  • Each wing/response is then assigned a numeric grade (0, 1, or 2) depending on how far it deviates from the normal range, giving a four-digit "butterfly code" (e.g., 0000 = normal; 1111, 2222, 2200, 0002, etc., for various abnormal patterns).

Clinical interpretation

  • 0 = normal response
  • 1 = mild/moderate deviation (often associated with peripheral vestibular lesions)
  • 2 = marked deviation (often associated with central lesions, though some code combinations also occur peripherally)
Patterns such as 2222, 1111, 0222, 2200, 2000, 0002, 0020 have been more frequently linked to central pathology, whereas 1111, 1100, 0011, 2000, 0002, 0020, 0001, 0100 have been reported in peripheral lesions - showing that some overlap exists and the code must be interpreted alongside clinical findings rather than in isolation.

Purpose and utility (as taught in ENT texts)

Standard ENT teaching (e.g., in the vertigo/vestibular investigations chapters of Indian ENT textbooks such as Dhingra's Diseases of Ear, Nose and Throat) presents the butterfly chart as part of craniocorpography and caloric/ENG testing for vertigo work-up, with these key teaching points:
  1. It tests the vestibulo-spinal and vestibulo-ocular systems via the caloric response.
  2. It gives a simple, pictorial summary of an otherwise complex ENG tracing.
  3. It helps localize the lesion (peripheral vs central) and lateralize it (right vs left).
  4. It is easy to communicate to referring physicians and patients, unlike raw ENG waveforms.
  5. It should always be correlated with the clinical picture, since code overlap between central and peripheral disease exists (of the 27 common butterfly codes originally described by Claussen, only a subset reliably discriminates central from peripheral disease).

Supporting literature

Clinical correlation studies have validated its diagnostic usefulness:
  • A study of 50 vertigo patients found the butterfly chart patterns correlated well with final clinical diagnosis, supporting its use as a simple diagnostic aid (Correlation between clinical diagnosis and Claussen's butterfly chart patterns in patients with vertigo, IJORL, 2019).
  • Electronystagmography plotted on Claussen's butterfly chart has been described as reflecting "definitive and comprehensive patterns" useful in diagnosing peripheral vertigo (Gupta SK et al., PMC4678276, 2015).
Note: this specific eponymous chart is a niche, Claussen-originated concept most thoroughly covered in Indian ENT postgraduate texts and clinical practice articles rather than in the major Western reference texts (Cummings, Scott-Brown, Shambaugh) available in this library's ENT collection - those instead cover ENG/caloric testing in more general engineering/technical terms without naming the butterfly chart specifically. If you have access to Dhingra's ENT textbook or a neurotology-focused reference, that is where you'll find the fullest classic description with the illustrated chart itself.
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