Caloric Testing


Article Author:
Kelly Murphy


Article Editor:
Arayamparambil Anilkumar


Editors In Chief:
Evelyn Metz
Julie Sewell
Aditya Arya


Managing Editors:
Orawan Chaigasame
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Abdul Waheed
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Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
2/22/2019 4:13:09 PM

Introduction

Caloric testing is a useful clinical tool that can assess and quantify the functional status of the individual vestibular systems. The test utilizes the mechanics of the vestibular-ocular reflex to test for a unilateral peripheral deficit. The vestibular-ocular reflex requires an intact brain stem to function, and its purpose is to maintain eye fixation on a stationary target while the head is in motion, thus keeping the object of attention in the center of the visual field. As described below, caloric testing manipulates the vestibular-ocular reflex to test the lateral semicircular canals and their afferents specifically. [1][2]

Anatomy

The semicircular canals are the three fluid-filled structures in the inner ear that provide the brain with spatial orientation. Each semicircular canal dilates into a fluid-filled sac called the ampulla which contains the sensory component of the vestibular system. When the endolymph is warmed (by air or water), an artificial current is created which moves the hairs in the lateral (horizontal) semicircular canal, thereby causing an imbalance between the right and left vestibular-ocular reflexes. This results in nystagmus with both fast- and slow-beating components, depending on the current in the ampulla. When a cold temperature is applied, it causes a fast-beating nystagmus in the opposite direction of the side being challenged and a slow-beating nystagmus in the contralateral side. The opposite goes for an applied warm temperature. The mnemonic COWS (cold, opposite, warm, same) makes it easy to remember this fast nystagmus component. [1] [3]

Indications

Caloric testing is clinically useful as a bedside test to isolate the peripheral vestibular system and rule out central etiology of vertigo. When there is a high suspicion for a peripheral lesion, bi-thermal caloric testing is typically performed. However, in cases in which there is a low pretest probability, it can be appropriate only to utilize mono thermic caloric testing and stop when the test is negative or in other words, responses are symmetric (therefore likely indicating a central process). The advantage caloric testing has over other studies, such as the vestibular evoked myogenic potential and video head impulse test, is that it does not require head movement to be conducted, rendering better patient compliance in those patients whose symptoms worsen with movement, as well as in patients with limited cervical mobility. [1] [4]

Another indication for the use of this test is for brain stem testing in comatose patients. As described above, the reflex arc requires an intact brain stem, and therefore lack of nystagmus could indicate a brainstem lesion. [5]

Contraindications

Medical use of pharmaceuticals that can affect the vestibular system (anti-emetics, anxiolytics, and antidepressants) within 48 hours of testing is a relative contraindication. [1]

Equipment

Water caloric irrigation system with two baths of 250 cc distilled water, heated to 44 C and 30 C, respectively. [1]

  • Electro-oculography (EOG) or Video-oculography (VOG) (optional)
  • Catch basin that measures up to 250 cc
  • Emesis basin
  • Stopwatch

Personnel

Provider plus one to two additional people to hold the catch basin, stopwatch, and/or dry towel. [1]

Preparation

Use an otoscope to examine the external auditory canal and ensure that there is no obstruction, infection, or cerumen impaction. Elevate the patient’s head to a 30-degree angle. This places the horizontal canal in a vertical plane, optimizing its stimulation. Place the catch basin beneath the patient’s ear. If using EOG or VOG, attach electrodes or place goggles over eyes, respectively. Advise the patient on the procedure and instruct them to perform an “alerting” exercise when the irrigation begins, for example, counting serial sevens out loud, naming animals, or listing words that begin with the same letter. [1]

Technique

Using the irrigation system, deliver 250 cc of either the warm water solution over 25 to 30 seconds to the suspected affected ear. Allow an open system in which the water being delivered can freely dribble out of the external auditory canal and be collected in the basin. The nystagmus beats will occur approximately 30 seconds after the onset of the water delivery and will build in intensity over the ensuing 30 to 45 seconds. The alerting exercise that you have instructed the patient to do will prevent any suppression of nystagmus. Wait five minutes and repeat with the other ear. Repeat with cold water, if indicated. [1]

If there is no response to either warm or cool irrigation, or if the bi-caloric irrigation system is not available, an ice-water irrigation can be considered. The patient is instructed to lie in the semi-recumbent position with the suspected affected ear turned up. Approximately 2 cc of ice water is injected into the ear canal via syringe and kept in that position for 30 seconds. The patient’s head is then turned midline and observed for nystagmus while the patient performs alerting tasks. This has been shown to have both higher sensitivity and higher specificity than warm air or water, though may not be as well tolerated. [6]

Complications

Nausea and vomiting are the most common side effects of caloric testing. Additionally, patients may experience worsening of vertigo. Long-term sequelae are not commonly associated with caloric testing. [1]

Clinical Significance

The caloric test is a useful tool that can help a clinician differentiate a central versus peripheral lesion in the patient who complains of dizziness. Ideally, a warm medium is used to test vesibular function in a patient with a low pretest probability of a peripheral process, as mono-caloric testing (MCT) has a reportedly wide range of sensitivity (0.54-1.00) for a unilateral vestibulopathy, and therefore has limited use when the pre-test probability is intermediate [7]. Therefore, for pateints with a high-pretest probability of a peripheral process, bi-thermic testing should be used.

Although warm water tends to be more commonly used, warm-air caloric testing has also been reported to be 87% sensitive with a negative predictive value of 90% when assessing for unilateral vestibular weakness when a cutoff of 25% inter-ear difference is utilized [8]. Despite this, a cold medium produces a more drastic response in the measured slow-phase nystagmus, and is thus easier to identify by the practitioner and therefore it is a more specific test for ruling in a peripheral lesion [9] [4]. For patients in whom air or water stimulation is contraindicated (such as chronic suppurative otitis media or tympanic membrane perforations), near infrared radiation is an equally efficacious, alternative method for caloric testing [10].  

Enhancing Healthcare Team Outcomes

Assessing for vestibular dysfunction by caloric testing can be a bedside test performed primarily by the practitioner, however may require additional assistance by nursing staff to properly and effectively perform. In addition, if Electro-oculography (EOG) or Video-oculography (VOG) will be utilized, special skill and training with this equipment is necessary and may require input and consultation of a trained audiologist.

Caloric testing using warm air can be used in situations where there are chronic suppurative otitis media and or perforations of the tympanic membrane. These enhancements require less cumbursome preparation, personnel requirement and can reduce complications of testing using water. [10] 

NOTE

The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.

I am a military service member. This work was prepared as part of my official duties. Title 17 U.S.C. 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.

Kelly A Murphy, LT, MC, NMCP; Daphne Morrisonponce, LCDR, MC, NMCP


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Caloric Testing - Questions

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Cold caloric testing is performed on an unconscious patient. Which response is paired with the correct interpretation?



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A patient with intact brainstem function is lying supine and her head is elevated 30 degrees. The right auditory meatus is irrigated with warm water. What would be expected?



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The caloric test for vestibular system functions uses both cold and warm water. Which best describes the results?



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A patient presents to complaining of severe vertigo. Which of the following, tests or maneuvers, if abnormal, indicates a central, rather than a peripheral cause, of vertigo?



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A patient presents with vertigo, and caloric testing is performed. What causes the imbalance in the vestibule-ocular reflex, thereby causing the fast beating component of nystagmus?



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Caloric Testing - References

References

The caloric irrigation test., Shepard NT,Jacobson GP,, Handbook of clinical neurology, 2016     [PubMed]
Monothermal Caloric Screening Test Accuracy: A Systematic Review., Adams ME,Telian SA,Kane RL,Butler M,, Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery, 2016 Jun     [PubMed]
Hot or cold? Is monothermal caloric testing useful and cost-effective?, Bush ML,Bingcang CM,Chang ET,Fornwalt B,Rayle C,Gal TJ,Jones RO,Shinn JB,, The Annals of otology, rhinology, and laryngology, 2013 Jun     [PubMed]
From nystagmus to the air and water caloric tests., Barros AC,Caovilla HH,, Brazilian journal of otorhinolaryngology, 2012 Jul-Aug     [PubMed]
Walther LE,Asenov DR,Di Martino E, Caloric stimulation with near infrared radiation does not induce paradoxical nystagmus. Acta otorhinolaryngologica Italica : organo ufficiale della Societa italiana di otorinolaringologia e chirurgia cervico-facciale. 2011 Apr;     [PubMed]
Laurutis VP,Robinson DA, The vestibulo-ocular reflex during human saccadic eye movements. The Journal of physiology. 1986 Apr     [PubMed]
Brown AC, The Sense of Rotation and the Anatomy and Physiology of the Semicircular Canals of the Internal Ear. Journal of anatomy and physiology. 1874 May     [PubMed]
Enticott JC,Dowell RC,O'Leary SJ, A comparison of the monothermal and bithermal caloric tests. Journal of vestibular research : equilibrium & orientation. 2003     [PubMed]
Fisher CM, The neurological examination of the comatose patient. Acta neurologica Scandinavica. 1969     [PubMed]
Schmäl F,Lübben B,Weiberg K,Stoll W, The minimal ice water caloric test compared with established vestibular caloric test procedures. Journal of vestibular research : equilibrium & orientation. 2005     [PubMed]

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