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VNG videonystagmography interpretation spontaneous nystagmus dark peripheral vestibular disorder
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VNG (Videonystagmography) Report - Detailed Analysis & Diagnosis
Patient: Satish Bansal | Age: 73 years | Gender: Male
Patient ID: CCDA00377 | Test Date: 03-Jun-2026
Facility: Priority Hearing Care Pvt. Ltd.
Handwritten Clinical Note (from Photo)
The accompanying handwritten note records the patient's presenting complaints:
- C/o imbalance, swaying while walking - 1 month duration
- Gait issue while standing
- Rotatory vertigo (twice)
- Vomiting (just once)
COMPLETE VNG TEST FINDINGS
1. Saccades (Eye Movement Speed & Accuracy)
| Parameter | Right Eye | Left Eye | Normal Range |
|---|---|---|---|
| Horizontal Velocity | 500.47 °/s | 1066.99 °/s (HIGH) | ~300-600 °/s |
| Horizontal Precision | 82.22 | 134.83 (HIGH - hypermetria) | 80-120 |
| Horizontal Latency | 247.50 ms | 274.29 ms | 150-250 ms |
| Vertical Velocity | 329.32 °/s | 382.61 °/s | Normal range |
| Vertical Precision | 88.37 | 92.42 | Normal |
| Vertical Latency | 381.82 ms | 374.55 ms | Mildly prolonged |
Interpretation: The left eye shows markedly elevated saccadic velocity and hypermetric saccades (precision >120), indicating the left eye is overshooting its target. This is a subtle oculomotor asymmetry. Prolonged vertical saccade latencies bilaterally may reflect age-related or central slowing.
2. Smooth Pursuit
| Direction | Right Eye Gain | Left Eye Gain | Normal |
|---|---|---|---|
| Horizontal Rightward | 0.16 (LOW) | 0.30 (LOW) | >0.7 |
| Horizontal Leftward | 0.52 | 0.88 | >0.7 |
| Vertical Upward | 0.70 | 0.61 | Acceptable |
| Vertical Downward | 0.69 | 0.76 | Normal |
Interpretation: Significantly reduced horizontal rightward smooth pursuit gain bilaterally (RE: 0.16, LE: 0.30 - both severely reduced). Leftward gain is also reduced in the right eye (0.52). This bilateral smooth pursuit deficit, particularly in the rightward direction, suggests central vestibular or cerebellar pathway involvement, as smooth pursuit is primarily a cortical-cerebellar function. Age-related change is a contributing factor at age 73, but the asymmetric pattern (rightward specifically impaired) is noteworthy.
3. Optokinetic Testing (OKN)
| Stimulus Direction | RE Gain | LE Gain | Normal |
|---|---|---|---|
| Left to Right | 0.84 | 0.67 | >0.7 |
| Right to Left | 1.08 | 1.13 | Normal |
| Top to Bottom | 0.99 | 1.58 (HIGH) | <1.2 |
| Bottom to Top | 1.10 | 0.76 | Normal |
Interpretation: OKN gains are largely preserved. Left eye shows elevated gain during top-to-bottom OKN (1.58), which may indicate asymmetric vertical OKN processing. Overall OKN is relatively intact suggesting cortical visual processing is functional.
4. Spontaneous Nystagmus - KEY FINDING
| Condition | Right Eye SPV | Left Eye SPV | Fast Phase Direction |
|---|---|---|---|
| In Light | None (-) | None (-) | None |
| In Dark | -17.12 °/s | -16.56 °/s | ~169°/157° (leftward/horizontal) |
| Frequency (Dark) | 2.57 Hz | 2.38 Hz | Bilateral |
Interpretation: This is the most diagnostically significant finding.
- No spontaneous nystagmus in light - this means visual fixation fully suppresses the nystagmus (fixation suppression is intact)
- Strong spontaneous nystagmus in darkness at ~17 °/s slow-phase velocity (SPV) - values this high (>6 °/s) are clearly pathological
- The fast phase direction (~169° on right, ~157° on left) corresponds to leftward horizontal nystagmus - meaning the eyes drift to the RIGHT slowly and beat (fast phase) to the LEFT
- Fixation suppresses the nystagmus completely - this is a hallmark of peripheral vestibular dysfunction
This pattern is consistent with a right-sided peripheral vestibular hypofunction (right labyrinthine or right vestibular nerve lesion), where the intact left labyrinth drives leftward nystagmus unopposed.
5. Head Shake Test
| Parameter | Right Eye | Left Eye |
|---|---|---|
| Horizontal SPV | Not recorded | -2.74 °/s |
| Vertical SPV | Not recorded | -3.39 °/s |
| Fast Phase Direction | - | 129.15° |
| Frequency | - | 1.73 Hz |
Interpretation: Post-head shake nystagmus is present in the left eye only, with the fast phase at ~129° (oblique/mixed horizontal-vertical direction). Head shake nystagmus after horizontal head shaking indicates vestibular asymmetry - nystagmus beating toward the stronger (left) side after shaking, confirming right vestibular hypofunction. The vertical component may suggest a crossed or perverted head shake nystagmus, which can be seen in central lesions.
6. Gaze Testing
| Test | Nystagmus | SPV |
|---|---|---|
| Center with fixation | Left eye only | -5.48 Hz horizontal, -3.59°/s vertical |
| Left without fixation | Bilateral | RE: -12.18°/s H, -4.38°/s V; LE: -8.70°/s H, -9.53°/s V |
| Up without fixation | Bilateral | RE: -19.35°/s H, -9.34°/s V; LE: -20.78°/s H, -12.87°/s V |
| Down without fixation | None | - |
| Right without fixation | None | - |
Key observation: Nystagmus is present during center gaze (with fixation, left eye only) and prominently in multiple gaze-without-fixation positions. The gaze-evoked nystagmus occurring in multiple eccentric positions and persisting even with partial fixation suggests both a peripheral component (which fixation usually fully suppresses) and possible central sensitization or a central component.
The nystagmus present at CENTER gaze with fixation is not typical of purely peripheral disease and warrants attention.
7. Dix-Hallpike Positional Testing - BPPV Assessment
Right Dix-Hallpike (Supine + Head Extension Right):
- SPV: H: -5.63/-6.42 °/s; V: -5.82/-7.01 °/s (bilateral)
- Fast Phase Direction: ~141° (both eyes)
- Frequency: 1.87/1.70 Hz
Left Dix-Hallpike (Supine + Head Extension Left):
- SPV: H: -5.74/-5.62 °/s; V: Left eye: -4.58 °/s
- Fast Phase Direction: Left eye: 134.64°
- Frequency: 1.01/1.82 Hz
Interpretation: Positional nystagmus is present on both Dix-Hallpike maneuvers (right and left). The nystagmus direction (~134-141° fast phase) corresponds to an oblique/upbeat-torsional direction. When present on both sides, this can indicate:
- Bilateral BPPV (uncommon but possible)
- Central positional nystagmus (does not fatigue, present in multiple positions)
- Background spontaneous nystagmus contaminating positional tests
Given the low SPV values (~5-7 °/s) and bilateral presence, this positional nystagmus may partly represent the background spontaneous nystagmus from the peripheral lesion bleeding into positional tests.
8. Static Head Positions
| Position | Nystagmus Present | Notable |
|---|---|---|
| Yaw Right | Yes - bilateral | SPV 6-6.86 °/s |
| Yaw Left | No | - |
| Pitch Forward | Yes - one eye each | Low SPV |
| Pitch Backward | Yes - bilateral | SPV 5-8 °/s |
| Roll Right | Yes - bilateral | SPV 5-9 °/s |
| Roll Left | Partial | Left eye only |
Interpretation: Nystagmus persists in multiple static head positions, particularly Yaw Right, Pitch Backward, and Roll Right. Direction-changing positional nystagmus in multiple positions points to a persistent vestibular imbalance rather than BPPV alone.
9. Subjective Visual Vertical (SVV)
| Trial | Deviation | Normal |
|---|---|---|
| Clockwise | +3° Right | ±2° |
| Anticlockwise | -3° Left | ±2° |
| Blank Background | -1° Left | ±2° |
Interpretation: The SVV deviates slightly beyond the normal ±2° limit in the clockwise trial (+3° to the right). An SVV tilt toward the right may indicate right otolith (utricle) dysfunction, consistent with right-sided peripheral vestibular pathology. The magnitude is mild (3°) but directionally significant.
SYNTHESIS AND DIAGNOSIS
Primary Diagnosis:
Acute/Subacute Right-Sided Peripheral Vestibular Hypofunction
- Most likely etiology: Vestibular Neuritis (right side) or Labyrinthitis (right side)
Supporting Evidence:
| Finding | Significance |
|---|---|
| Strong spontaneous nystagmus in darkness (~17 °/s), suppressed by fixation | Classic peripheral vestibular sign |
| Fast phase directed leftward (~157-169°) | Indicates right labyrinthine/nerve hypofunction |
| Head shake nystagmus - left-beating | Confirms right vestibular asymmetry |
| SVV tilted rightward (+3°) | Right utricular dysfunction |
| Positional nystagmus (multiple positions) | Secondary to background tonic imbalance |
| Symptoms: 1 month imbalance, rotatory vertigo x2, vomiting x1 | Consistent with peripheral vestibular event |
Secondary/Additional Findings Warranting Attention:
-
Impaired rightward smooth pursuit (gain 0.16 bilaterally) - This degree of smooth pursuit impairment in a specific direction, along with hypermetric saccades in the left eye, may represent an additional central component, possibly a mild cerebellar or central vestibular lesion. In a 73-year-old, vertebrobasilar insufficiency or small vessel disease should be considered.
-
Gaze nystagmus persisting with fixation at center - This "fixation-failure to suppress" finding at center gaze is atypical for pure peripheral disease.
-
Bilateral positional nystagmus - While partly attributable to background nystagmus, this warrants a central cause to be ruled out.
CLINICAL CORRELATION TABLE
| Parameter | Finding | Implication |
|---|---|---|
| Spontaneous nystagmus in dark | Abnormal - 17°/s | Active peripheral vestibular lesion (right side) |
| Fixation suppression | Intact | Favors peripheral origin |
| Head shake nystagmus | Present (left-beating) | Right vestibular asymmetry confirmed |
| Smooth pursuit (rightward) | Severely reduced (0.16/0.30) | Central pathway concern |
| Saccades | Left eye hypermetric | Possible cerebellar component |
| Dix-Hallpike | Bilateral low-grade positional nystagmus | Background imbalance or BPPV |
| SVV | +3° rightward tilt | Right otolith dysfunction |
| Gaze with fixation (center) | Nystagmus in left eye | Partial fixation failure - atypical for pure peripheral |
RECOMMENDATIONS
-
MRI Brain with MRI IAM (Internal Auditory Meatus) with gadolinium - to rule out vestibular schwannoma, MS, or posterior fossa lesion, given the central features (smooth pursuit deficit, asymmetric saccades).
-
Audiometry / Pure Tone Audiogram - to assess for sensorineural hearing loss (distinguish labyrinthitis from vestibular neuritis; Meniere's disease).
-
Caloric testing (not performed in this VNG) - would quantify the degree of right canal paresis and confirm unilateral vestibular hypofunction definitively.
-
Neurology/ENT referral - Given the patient's age (73) and combination of peripheral AND possible central features, consultation is advised.
-
Vestibular rehabilitation exercises (Cawthorne-Cooksey or VRT) - to promote central compensation for the vestibular imbalance and improve gait/balance.
-
Fall risk assessment - The combination of imbalance, gait disturbance and age 73 poses significant fall risk.
Note: This interpretation is based on the VNG data recorded on 03-Jun-2026. The report page (Page 1) has blank fields for Clinical History, Physical Examination, Impression, and Signature - these should be completed by the treating clinician. A formal diagnosis requires clinical correlation with examination findings, audiological data, and imaging. This analysis is for informational/educational purposes.
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VNG spontaneous nystagmus 17 degrees per second fixation suppression vestibular neuritis diagnosis criteria peripheral vs central
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spontaneous nystagmus fixation suppression gaze evoked nystagmus central peripheral VNG criteria
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