BACKGROUND The visual and vestibular systems interact to maintain visual clarity of objects during head movement.

The reflex that makes this possible is known as the vestibuloocular reflex (VOR). It permits individuals to perform such routine activities as reading street signs while walking down a sidewalk. Like many other systems in the body, most individuals are unaware of the VOR and its basic functioning until it does not function properly. Vertigo, dizziness, imbalance, nausea, vomiting, and other similar symptoms often characterize dysfunction of the vestibular system. Patients who present with symptoms of vestibular dysfunction often undergo a detailed diagnostic workup including a standard electronystagmography (ENG) battery, posturography, and audiometry. Caloric testing is routinely performed in most vestibular laboratories as part of a vestibular dysfunction workup. VOR system on a daily basis and may not identify dysfunction at higher frequencies. In addition, caloric results may be abnormal in individuals with congenital abnormalities such as atretic or stenotic external auditory canals, with anatomic variations such as a thickened temporal bone, or with certain acquired disorders such as a severely atelectatic or absent tympanic membrane or fluid in the middle ear. Thus, an additional test is needed to assess the integrity of the VOR. VOR testing is often performed with the use of a rotary chair. Rotational chair testing was first introduced by Brny in 1907. He initially designed the chair for VOR testing with impulsive rotation in mind. The test consisted of manual rotation of the chair 10 times over 20 seconds followed by a sudden stop of the chair to analyze the postrotary nystagmus. Rotational chair testing has undergone numerous changes since that time and now has additional applications, including testing of visual-vestibular interaction, optokinetic after-nystagmus (OKAN), high-velocity sinusoidal testing, and off-vertical axis rotation (OVAR). Some of the newer applications require more sophisticated equipment than that developed by Brny. The purpose of rotational chair testing is to determine whether or not dizziness may be due to a disorder of inner ear or brain. This tests measures the dizziness (nystagmus) while slowly being turned in a chair that rotates back and forth. Rotational chair testing is usually ordered in addition to ENG/VNG (caloric) testing to confirm a diagnosis and increase accuracy.

THEORY The purpose of the vestibular system is to keep tabs on the position and motion of your head in space. There are really two components to monitoring motion, however. You must be able to detect rotation, such as what happens when you shake or nod your head. In physics, this is called angular acceleration. You must also be able to detect motion along a line - such as what happens when the elevator drops beneath you, or on a more subtle note, what happens when your body begins to lean to one side. This is called linear acceleration.

The semicircular canals: The 3 semicircular canals (anterior, posterior, lateral) are small ringlike structures; each form two thirds of a circle with a diameter of about 6.5 mm and a luminal cross-sectional diameter of 0.4 mm. One end of each canal is dilated to form the ampulla, which contains a saddle-shaped ridge termed the crista ampullaris, on which lies the sensory epithelium. The vestibular sensory epithelium is located on the maculae of the saccule and utricle and the cristae of the semicircular canals. The sensory cells are surrounded by supporting cells; therefore, they do not come into direct contact with the bony base of the cristae.

The crista ampullaris consists of a crest of sensory epithelium supported on a mound of connective tissue, lying at right angles to the longitudinal axis of the canal. A bulbous, wedgeshaped, gelatinous mass called the cupula surmounts the crista. Cilia of the sensory cells project into the cupula. The cupula extends from the surface of the cristae to the roof and lateral walls of the membranous labyrinth, forming a fluid-tight partition. The semicircular canals detect angular acceleration. There are 3 canals, corresponding to the three dimensions in which you move, so that each canal detects motion in a single plane. Each canal is set up as shown below, as a continuous endolymph-filled hoop. The actual hair cells sit in a small swelling at the base called the ampula.

The hair cells are arranged as a single tuft that projects up into a gelatinous mass, the cupula. When you turn your head in the plane of the canal, the inertia of the endolymph causes it to slosh against the cupula, deflecting the hair cells. Now, if you were to keep turning in circles, eventually the fluid would catch up with the canal, and there would be no more pressure on the cupula. If you stopped spinning, the moving fluid would slosh up against a suddenly still cupula, and you would feel as though you were turning in the other direction. This is the explanation for the phenomenon you discovered when you were 5. Naturally, you have the same arrangement (mirrored) on both sides of the head. Each tuft of hair cells is polarized - if you push it one way, it will be excited, but if you push it the other way, it will be inhibited. This means that the canals on either side of the head will generally be operating in a push-pull rhythm; when one is excited, the other is inhibited. It is important that both sides agree as to what the head is doing. If there is disagreement, if both sides push at once,

then you will feel debilitating vertigo and nausea. This is the reason that infections of the endolymph or damage to the inner ear can cause vertigo. However, if one vestibular nerve is cut, the brain will gradually get used to only listening to one side - this can actually be a treatment for intractable vertigo.

A large role of the semicircular canal system is to keep your eyes still in space while your head moves around them. If you nod and shake and swivel your head, you will find that you have no trouble staying focused on this page. But hold a piece of paper in front of you and shake it around, and your eyes will not be able to keep up with the quick movements. The reason is that the semicircular canals exert direct control over the eyes, so they can directly compensate for head movements. Recall that the eye is controlled by three pairs of muscles; the medial and lateral rectus, the superior and inferior rectus, and the inferior and superior oblique. You may also remember that their directions of motion seemed to be at crazy diagonals. Those same crazy diagonals are matched closely by the three planes of the semicircular canals, so that a single canal (in general) interacts with a single muscle pair. The entire compensatory reflex is called the vestibulo-ocular reflex (VOR). The maculae and cristae are innervated by bipolar neurons of the vestibular ganglion. The central processes of these cells form the vestibular nerve which enters the brain stem at the cerebellopontine angle medial to the cochlear nerve. The vestibular nerve bifurcates into short ascending and long descending branches which are distributed to the vestibular nuclei. Some vestibular nerve fibers continue without interruption to the ipsilateral cerebellar cortex and one of the deep cerebellar nuclei. Most primary vestibular fibers terminate differentially in the four main vestibular nuclei in the floor of the fourth ventricle. The vestibular nuclei give rise to

secondary vestibular fibers which project to specific portions of the cerebellum, certain motor cranial nerve nuclei and to all levels of the spinal cord. Most afferent fibers from the hair cells terminate in the vestibular nuclei, which lie on the floor of the fourth ventricle. They are bound medially by the pontine reticular formation, laterally by the restiform body, rostrally by the brachium conjunctivum, and ventrally by the nucleus and spinal tract of the trigeminal nerve. The central processes of the primary afferent vestibular neurons divide into an ascending and descending branch after entering the brain stem at the inner aspect of the restiform body. Some primary vestibular neurons pass directly to the cerebellum, in particular the flocculonodular lobe and the vermis. No primary vestibular afferent neurons cross the midline. The first-order vestibular afferents have their cell bodies in the vestibular (Scarpas) ganglion, which is found at the distal end of the internal auditory meatus. Their axons travel in the vestibular portion of the VIIIth cranial nerve through the internal auditory meatus and enter the brain stem at the junction between the pons and the medulla where the IVth ventricle is the widest. Most of these afferents project to one of the four nearby vestibular nuclei in the rostral medulla and caudal pons. A few of the vestibular afferents go directly to the cerebellum through the inferior cerebellar peduncle. The cerebellum coordinates the movements that maintain balance. The 1st order vestibular afferents arise in Scarpa's ganglion, which is in the distal portion of the internal auditory meatus. The axons travel in the vestibular portion of the VIIth cranial nerve and enter the brain stem at the pontomedullary junction. There are four 2nd order vestibular nuclei: the inferior, medial, lateral (Deiters) and superior vestibular nuclei. All four nuclei are found beneath the floor of the fourth ventricle in the medulla and pons, lateral to the sulcus limitans. The main projections from these nuclei are to the spinal cord (controlling head and body position), to the three, extraocular motor nuclei (III, IV, VI, controlling eye movements), to the thalamus (VPI, eventually reaching the cortex and conscious perception of movement and gravity), and to the cerebellum (coordinating postural adjustments).

The main descending tracts are the lateral vestibulospinal tract from the lateral vestibular nucleus and the medial vestibulospinal tract from the medial vestibular nucleus. The lateral vestibular tract starts in the lateral vestibular nucleus and descends the length of the spinal cord on the same side. This pathway helps us walk upright. The medial vestibular tract starts in the medial vestibular nucleus and extends bilaterally through mid-thoracic levels of the spinal cord in the MLF. This tract affects head movements and helps integrate head and eye movements. In summary, remember that the lateral vestibulo-spinal tract is ipsilateral and long; the medial vestibulo-spinal tract is bilateral but shorter. The main ascending tracts are from the superior and medial vestibular nuclei to the extraocular muscles through the medial longitudinal fasciculus (MLF).

EQUIPMENT 1. Barany chair 2. Semicircular canals model The operation of Barany chair is controlled by an inverter. The inverter control speed of rotation, and also stops the Barany chair. To operate the Barany chair, you must be familiar with the program in the inverter. Please ask the supervisor.

PREPARATION OF TESTING Prior to rotational chair testing, the subject is asked to refrain from use of alcohol or caffeine for 48 hours. In addition, certain medications, including antihistamine,

antihypertensives, sedatives/hypnotics, and anxiolytics, are withheld. Eating for 2 hours prior to the examination is discouraged because this may exacerbate nausea and emesis. Student may only participate once in an experiment as a subject. For another experiment, use another student. Before you make any experiment, you should observe the model of vetibular system to know the position of horizontal, lateral, and superior semicircular canals.

EXPERIMENT 1 (NYSTAGMUS) 1. Choose a student to be a subject 2. Let the subject sitting on Barany chair with his/her eyes are closed with a handkerchief, and his/her head is bent down 300 3. All the other students take a position in front of the subject when the Barany chair is stopped and ready to observe nystagmus of the subjects eyes 4. Rotate the Barany chair 10 times over 20 seconds 5. After 20 seconds make a sudden stop to the Barany chair 6. Analyse the postrotatory nystagmus of the subjects eyes

RESULT After post rotation, the subjects eyes move quickly parallel to the medial and lateral intermittently.

QUESTION What is nystagmus? Nystagmus refers to the involuntary oscillations of one or, more commonly, both eyeballs. These oscillations are usually rhythmic and may be horizontal, vertical, rotary, or mixed. They may be transient or sustained and may occur spontaneously or on deviation or fixation of the eyes. Minor degrees of nystagmus at the extremes of gaze are normal. Nystagmus when the eyes are stationary and looking straight ahead is always abnormal. The visual and vestibular systems interact to maintain visual clarity of objects during locomotion and other head movement. The fovea is the part of the eye that has the greatest density of photoreceptors and therefore is the area with the best visual acuity. An object is most

clearly viewed when it is centered on the fovea. During motion, the image of the viewed object tends to slip from the fovea, causing it to blur. In fact, visual acuity declines to 50% when an object is 2 from the center of the fovea. To maintain an object on the fovea, the eye must make corrective responses. These corrective eye movements, known as nystagmus, have a slow phase and a quick phase. The vestibuloocular reflex (VOR) slow phase keeps the eyes on the foveal vision (opposite direction to head movement). Here are the mechanisms: Although the vestibulo-ocular reflex works on all three muscle pairs, the medial-lateral rectus pair, coupled to the horizontal canal, is geometrically the easiest to draw. Here is the setup, looking down at a person's head:

The lateral rectus muscle will pull the eye laterally, and the medial rectus will pull the eye medially, both in the horizontal plane. The horizontal canal detects rotation in the horizontal plane. If you move your head to the left, you will excite the left horizontal canal, inhibiting the right. To keep your eyes fixed on a stationary point, you need to fire the right lateral rectus and the left medial rectus, to move the eyes to the right.

The pathway is as follows: the vestibular nerve enters the brainstem and synapses in the vestibular nucleus. Cells that received information from the left horizontal canal project to the abducens nucleus on the right side, to stimulate the lateral rectus. They also project to the oculomotor nucleus on the left side, to stimulate the medial rectus. Although not shown on the diagram, the same vestibular cells also inhibit the opposing muscles (in this case, the right medial rectus, and the left lateral rectus). On the other hand, the right horizontal canal is wired to the complementary set of muscles. Since it is inhibited, it will not excite its target muscles (the right medial rectus and the left lateral rectus), nor will it inhibit the muscles you want to use (the right lateral rectus and the left medial rectus). A great deal of the VOR axon traffic travels via a fiber highway called the MLF (medial longitudinal fasciculus). The integrity of this tract is crucial for the VOR to work properly.