Expansion
Whisper test, tuning forks, then the vestibular tests
Expansion
Cochlear division
- Whisper test: mask the other ear by rubbing the tragus, whisper a number at arm’s length
- Rinne and Weber with a 512 Hz fork, to classify any loss as conductive or sensorineural
- Otoscopy to complete
Vestibular division
- Nystagmus on eye movement testing
- Romberg’s test and gait
- Dix-Hallpike manoeuvre for benign paroxysmal positional vertigo. A positive test gives upbeating torsional nystagmus after a latency of a few seconds, lasting under a minute and fatiguing on repetition, and is treated with the Epley manoeuvre
- Head impulse test, part of HINTS
HINTS, in acute continuous vertigo:
- HI - Head Impulse: an abnormal test, with a corrective saccade, indicates a peripheral lesion. A normal test in a patient with acute vertigo is worrying
- N - Nystagmus: unidirectional and horizontal is peripheral. Direction changing, vertical or torsional is central
- TS - Test of Skew: any vertical skew deviation on cover testing is central
A “benign” HINTS pattern is more sensitive for stroke in the first 48 hours than early diffusion weighted MRI, which can be falsely negative in small posterior fossa infarcts.
Sudden sensorineural hearing loss is an otological emergency and requires urgent steroids and ENT referral.