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VNG videonystagmography interpretation BPPV posterior canal diagnosis criteria
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VNG Report - Detailed Analysis & Diagnosis
Patient: Rameshwar Singh | Age: 71 years | Gender: Male
Test Date: 06-Aug-2026 | Facility: Priority Hearing Care Pvt. Ltd. | Patient ID: CCDA00419
Summary of All Test Results
1. Smooth Pursuit Testing
| Frequency | Parameter | Right Eye | Left Eye | Normal |
|---|---|---|---|---|
| 0.2 Hz | Rightward Gain | 0.61 | 0.40 | ≥0.80 |
| 0.2 Hz | Leftward Gain | 0.37 | 0.28 | ≥0.80 |
| 0.4 Hz | Rightward Gain | 0.60 | 0.20 | ≥0.70 |
| 0.4 Hz | Leftward Gain | 0.34 | 0.19 | ≥0.70 |
Interpretation: Severely reduced smooth pursuit gain bilaterally, affecting both eyes and both directions. Gain values well below the normal threshold (normal ≥0.80 at 0.2 Hz, ≥0.70 at 0.4 Hz). The left eye shows markedly worse gain than the right at 0.4 Hz (0.20 vs 0.60 rightward; 0.19 vs 0.34 leftward). This pattern is consistent with central nervous system dysfunction - specifically cerebellar or brainstem involvement (flocculus/dorsolateral pontine nucleus pathway). Age-related decline contributes modestly, but values this low (especially in the left eye) exceed normal age-adjusted degradation for a 71-year-old.
2. Optokinetic (OKN) Testing
| Direction | Right Eye Gain | Left Eye Gain |
|---|---|---|
| L→R (10°) | 1.09 | 2.54 |
| R→L (10°) | 1.09 | 2.73 |
| Top→Bottom (10°) | 1.20 | 1.18 |
| Bottom→Top (10°) | 1.04 | 1.09 |
Interpretation: Horizontal OKN shows a significant asymmetry - the left eye gain (2.54-2.73) is approximately 2.5x higher than the right eye gain (1.09) in both L→R and R→L directions. Vertical OKN is symmetrical and within range. The markedly elevated left eye gain in horizontal directions may reflect deficient inhibitory control or inter-ocular coordination abnormality. A symmetrical gain around 1.0 with no fast phase direction noted is generally normal for OKN; the discordance between eyes in horizontal planes is noteworthy and may reflect asymmetric cortical/brainstem processing of visual-vestibular input.
3. Spontaneous Nystagmus
| Condition | Finding |
|---|---|
| In Light | No nystagmus (all parameters negative) |
| In Dark | No nystagmus (all parameters negative) |
| Head Shake | No nystagmus |
Interpretation: No spontaneous or head-shake-induced nystagmus. This rules out an active, compensated, or acute unilateral peripheral vestibular lesion with residual spontaneous nystagmus. The absence of head-shake nystagmus also suggests no significant ongoing vestibular asymmetry at rest.
4. Gaze Testing
With Fixation (all positions - Center, Left, Right, Up, Down): No nystagmus in any direction with fixation.
Without Fixation:
| Gaze Position | Finding |
|---|---|
| Center | Vertical SPV: RE 4.05°/s, LE 6.22°/s (mild upbeat or downbeat vertical nystagmus) |
| Left | Vertical SPV right eye: 5.05°/s; Horizontal SPV: -0.71°/s |
| Up | No nystagmus |
| Right | No nystagmus |
| Down | No nystagmus |
Interpretation: The presence of vertical nystagmus without fixation in center and left gaze positions, which disappears with fixation, is a significant finding. This fixation-suppressed vertical nystagmus is characteristic of central vestibular pathology. The pattern - present only when fixation is removed - indicates the visual fixation system is compensating. This pattern is less typical of peripheral vestibular disease and points to brainstem/cerebellar involvement.
5. Positional Testing (Dix-Hallpike)
Right Dix-Hallpike
| Position | Parameter | Right Eye | Left Eye |
|---|---|---|---|
| Supine Head Ext. & Right | Horizontal SPV | -7.63°/s | - |
| Supine Head Ext. & Right | Frequency | 1.09 Hz | - |
| Sit Head Right (return) | Vertical SPV | 10.56°/s | - |
| Sit Head Right (return) | Frequency | 1.05 Hz | - |
Left Dix-Hallpike
| Position | Parameter | Right Eye | Left Eye |
|---|---|---|---|
| Sit Head Left | Horizontal SPV | 7.03°/s | - |
| Sit Head Left | Frequency | 1.11 Hz | - |
| Supine Head Ext. & Left | Horizontal SPV | 8.03°/s | - |
| Supine Head Ext. & Left | Vertical SPV | -10.61°/s | - |
| Supine Head Ext. & Left | Amplitude | -9.25° | - |
| Supine Head Ext. & Left | Fast Phase Direction | 71.35° | - |
| Supine Head Ext. & Left | Frequency | 1.88 Hz | - |
Interpretation: The left Dix-Hallpike in the supine head extended & left position evokes both horizontal AND vertical components of nystagmus (horizontal SPV 8.03°/s + vertical -10.61°/s), with a fast phase direction of 71.35° (predominantly upward/torsional). This mixed torsional-vertical nystagmus with fast phase directed upward-toward-the-undermost-ear on the left side is the classic pattern of LEFT POSTERIOR CANAL BPPV (canalolithiasis). The nystagmus is also elicited on return to sitting. The right Dix-Hallpike shows only horizontal nystagmus without a strong vertical component, making isolated right posterior canal BPPV less definitive.
6. Yacovino Test (Supine Head Extension/Flexion)
| Position | Parameter | Right Eye | Left Eye |
|---|---|---|---|
| Supine Begin | No nystagmus | - | - |
| Supine Head Ext. 90° | No nystagmus | - | - |
| Supine Head Flex 45° | Horizontal SPV | -15.01°/s | -12.49°/s |
| Supine Head Flex 45° | Amplitude | -3.59° | -4.50° |
| Supine Head Flex 45° | Frequency | 1.42 Hz | 1.20 Hz |
| Supine End | No nystagmus | - | - |
Interpretation: The Yacovino test (also known as the straight head hanging test / supine head extension followed by chin tuck) shows nystagmus specifically in the head-flexed position (45°) bilaterally. The Yacovino maneuver was designed to identify anterior canal BPPV - specifically, a downbeat nystagmus triggered on chin tuck after supine head extension is the hallmark sign. The nystagmus here is horizontal with negative SPV (−15 and −12.49°/s), meaning leftward beating. While not purely downbeat, this horizontal bilateral nystagmus on head flexion warrants attention, as it may also reflect cupulolithiasis of the anterior canal or central positional nystagmus. The Yacovino's positivity adds to a complex multi-canal picture.
7. McClure-Pagnini (Supine Roll) Test
| Position | Parameter | Right Eye | Left Eye |
|---|---|---|---|
| Sit to Supine | No nystagmus | - | - |
| Right Lateral | Horizontal SPV | -6.80°/s | -12.98°/s |
| Right Lateral | Vertical SPV | +14.77°/s | -3.07°/s |
| Right Lateral | Fast Phase Direction | 247.85° | 177.47° |
| Right Lateral | Frequency | 1.90 Hz | 2.13 Hz |
| Supine Head Neutral (after Right) | No nystagmus | - | - |
| Left Lateral | No nystagmus | - | - |
| Supine Head Neutral (after Left) | Horizontal SPV | -4.72°/s | - |
| Supine Head Neutral (after Left) | Frequency | 1.14 Hz | - |
Interpretation: The right lateral roll position evokes geotropic nystagmus (fast phase 247.85° in right eye ~toward ground on the right side = rightward beating). This is the expected pattern for right lateral canal BPPV (canalolithiasis, geotropic type). The left lateral roll shows no nystagmus. In geotropic horizontal canal BPPV, the nystagmus beats toward the ground and is stronger on the affected (right) side. This finding suggests right horizontal/lateral canal BPPV.
Consolidated Diagnostic Assessment
Primary Diagnoses
1. LEFT POSTERIOR CANAL BPPV (High Confidence)
- Classic mixed torsional-vertical nystagmus on left Dix-Hallpike (SPV horizontal 8.03°/s + vertical -10.61°/s, fast phase 71.35° = upward/geotropic torsion)
- Nystagmus also present on returning to sitting after left Dix-Hallpike
- Consistent with canalolithiasis (free-floating otoliths in left posterior semicircular canal)
2. RIGHT HORIZONTAL/LATERAL CANAL BPPV (Moderate Confidence)
- Geotropic horizontal nystagmus on right lateral roll (McClure-Pagnini)
- Right eye SPV -6.80°/s + significant vertical component 14.77°/s with fast phase 247.85°
- Pattern consistent with right lateral canal canalolithiasis
- Multi-canal BPPV (involving both posterior and horizontal canals) is well-documented, especially after head trauma or in elderly patients
3. CENTRAL VESTIBULAR INVOLVEMENT / POSSIBLE CEREBELLAR-BRAINSTEM DYSFUNCTION (Important Finding)
- Severely reduced smooth pursuit gain bilaterally (0.19-0.61 vs normal ≥0.80), with markedly asymmetric left eye deficit - this is the most clinically concerning central finding
- Fixation-suppressed vertical gaze nystagmus in center and left gaze positions without fixation
- Positive Yacovino with horizontal (rather than purely downbeat) nystagmus
- These central signs do NOT fit peripheral BPPV alone and suggest a concurrent central process
Clinical Significance & Recommendations
| Finding | Clinical Implication |
|---|---|
| Bilateral reduced smooth pursuit | Central cerebellar/brainstem pathology; age alone does not account for values this low |
| Left posterior canal BPPV | Treat with Epley maneuver (left side) |
| Right horizontal canal BPPV | Treat with Barbecue roll (360° roll) or Gufoni maneuver |
| Fixation-suppressed vertical nystagmus | Central sign - further neuroimaging warranted |
| Yacovino test response | May indicate anterior canal involvement or central positional nystagmus |
Recommended Next Steps
-
MRI Brain (with FLAIR, DWI, and posterior fossa sequences): Given the combination of markedly impaired smooth pursuit, fixation-suppressed nystagmus in a 71-year-old male, CNS pathology (cerebellar atrophy, small vessel disease, posterior fossa lesion, or demyelination) must be excluded. This is a priority referral.
-
Canalith Repositioning Maneuvers:
- Left Epley maneuver for left posterior canal BPPV
- Barbecue rotation / Gufoni maneuver for right horizontal canal BPPV
- Consider sequential treatment: treat posterior canal first, then horizontal canal
-
Neurology/Neuro-otology Referral: The central signs (smooth pursuit deficit + fixation-suppressed nystagmus) in a 71-year-old warrant neurological evaluation to rule out cerebellar, brainstem, or demyelinating pathology.
-
Follow-up VNG after canalith repositioning to confirm resolution of positional nystagmus and reassess central parameters.
-
Fall Risk Assessment: At age 71 with multi-canal BPPV + central vestibular signs, this patient has an elevated fall risk. Vestibular rehabilitation and home safety evaluation are advised.
Key Takeaway
This VNG reveals a complex dual pathology: predominantly peripheral BPPV affecting at minimum the left posterior canal and right horizontal canal, superimposed on central vestibular system dysfunction evidenced by severely impaired smooth pursuit and fixation-suppressed nystagmus. The central findings are the most clinically urgent and must not be attributed to BPPV or aging alone. Prompt neuroimaging and neurology referral are recommended alongside canalith repositioning therapy.
Disclaimer: This analysis is based solely on the objective VNG data provided. Clinical correlation with the patient's symptoms, history, and physical examination findings is essential. Final diagnosis and management must be determined by the treating clinician.
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