Determining vestibular hypofunction: start with the video-head impulse test

Caloric testing is considered the ‘reference standard’ in determining vestibular hypofunction. Recently, the video-head impulse test (vHIT) was introduced. In the current study we aimed to assess the diagnostic value of the vHIT as compared to caloric testing in determining vestibular function. In a cross-sectional study between May 2012 and May 2013, we prospectively analysed patients with dizziness who had completed caloric testing and the vHIT. For the left and right vestibular system we calculated the mean vHIT gain. We used a gain cut-off value of 0.8 for the vHIT and presence of correction saccades to define an abnormal vestibular-ocular reflex. An asymmetrical ocular response of 22 % or more (Jongkees formula) or an irrigation response with a velocity below 15°/s was considered abnormal. We calculated sensitivity, specificity, positive and negative predictive values with 95 % confidence intervals for the dichotomous vHIT. Among 324 patients [195 females (60 %), aged 53 ± 17 years], 39 (12 %) had an abnormal vHIT gain and 113 (35 %) had an abnormal caloric test. Sensitivity was 31 % (23–40 %), specificity 98 % (95–99 %), positive predictive value was 88 % (74–95 %), and negative predictive value 73 % (67–77 %). In case of vHIT normality, additional caloric testing remains indicated and the vHIT does not replace the caloric test. However, the high positive predictive value of the vHIT indicates that an abnormal vHIT is strongly related to an abnormal caloric test result; therefore, additional caloric testing is not necessary. We conclude that the vHIT is clinically useful as the first test in determining vestibular hypofunction in dizzy patients.