The caloric test
Abstract Introduction and objective: Caloric test has been the most important test of vestibular function for the last century. A practical approach, including special recommendations for a more accurate completion and interpretation of this test are proposed. Method: Narrative statement. Results and discussion: The caloric test is limited to horizontal canal function and there are not absolute normative values. Thus, the procedures for administering the caloric test and for analysing the responses should be settled with caution. For accurate interpretation of the caloric test, the validity of the results must be stablished first, ruling out artefacts and technical errors. Conclusions: Caloric test is still a sensitive test for detecting common vestibular abnormalities, mainly due to its ability to point to the pathologic labyrinth. But the information from the caloric test must be used along with history, physical examination and other test to make a diagnosis and devise management plans.
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Alonso I, Chaparro P, Calvente R. Efecto de la secuencia de irrigación en los resultados de la paresia canalicular en la prueba calórica bitérmica. 2007;58(4):151–5.
Ansderson S. Caloric irrigators: air, open-loop water and closed-loop water. Br J Audiol. 1995;29(2):117–28.
https://doi.org/10.3109/03005369509086589
ANSI. Procedures for testing basic vestibular function. Am Natl Stand Inst. 1999;Revision of ANSI S3.45.
Baloh RW, Sills AW, Honrubia V. Caloric testing 3. Patients with peripheral and central vestibular lesions. Ann Otol Rhinol Laryngol. 1977;86 (suppl):24–30.
https://doi.org/10.1177/00034894770865S303
Baloh RW, Solingen L, Sills AW, Honrubia V. Caloric testing 1. Effect of different conditions of ocular fixation. Ann Otol Rhinol Laryngol. 1977;86 (Suppl):1–6.
https://doi.org/10.1177/00034894770865S301
Barin K. Background and Technique of caloric testing. In: N JG and S, editor. Balance Function Assessment and Management. San Diego, CA: Plural Publishing; 2008. p. 197–228.
Barin K. Interpretation and usefulness of caloric testing. In: Jacobson, Gary P SN, editor. Balance Function Assessment and Management. San Diego, CA: Plural Publishing; 2008. p. 229–52.
Batuecas-Caletrio A, Montes-Jovellar L, Boleas-Aguirre MS, Perez-Fernandez N. The ice-water caloric test. Acta Otolaryngol. 2009;129(12):1414–9.
https://doi.org/10.3109/00016480902791686
PMid:19922091
British Society of Audiology. Recommended procedure The caloric test. Br Soc Audiol. 2010;April:1–25.
Cartwright AD, Cremer PD, Halmagyi GM, Curthoys IS. Isolated directional preponderance of caloric nystagmus: II. A neural network model. Am J Otol. 2000;21(4):568–72.
PMid:10912704
Enticott JC, Dowell RC, O'Leary SJ. A comparison of the monothermal and bithermal caloric tests. J Vestib Res. 2003;13(2–3):113–9.
PMid:14757914
Furman JMR, Jacob RG. Jongkees' formula re-evaluated: order effects in response to alternate binaural bithermal caloric stimulation using closed-Loop irrigation. Acta Otolaryngol. 1993;113(1):3–10.
https://doi.org/10.3109/00016489309135759
Halmagyi GM, Cremer PD, Anderson J, Murofushi T, Curthoys IS. Isolated directional preponderance of caloric nystagmus: I. Clinical significance. Am J Otol. 2000;21(4):559–67.
PMid:10912703
Honrubia V. Evaluación vestibular cuantitativa. In: Suárez C, Gil- Carcedo LM, Medina J, Ortega P, Trinidad J, editors. Tratado de Otorrinolaringología y Cirugía de Cabeza y Cuello. San Fernando de Henares: Proyectos Médicos SL; 1999. p. 1011–55.
Kondoh K, Kitahara T, Morihana T, Yamamoto K, Kubo T, Okumura S. Changes in caloric responses after temporal bone surgery with posterior tympanotomy. Auris Nasus Larynx. 2009;36(5):521–4.
https://doi.org/10.1016/j.anl.2008.11.004
PMid:19111414
Kondoh K, Kitahara T, Morihana T, Yamamoto K, Kubo T, Okumura S. Changes in caloric responses after temporal bone surgery with posterior tympanotomy. Auris Nasus Larynx. 2009;36(5):521–4.
https://doi.org/10.1016/j.anl.2008.11.004
PMid:19111414
Lightfoot G, Barker F, Belcher K, Kennedy V, Nassar G, Tweedy F. The derivation of optimum criteria for use in the monothermal caloric screening test. Ear Hear. 2009;30(1):54–62.
https://doi.org/10.1097/AUD.0b013e31818f006c
PMid:19125027
Lightfoot GR. The origin of order effects in the results of the bi-thermal caloric test. Int J Audiol. 2004;43(5):276–82.
https://doi.org/10.1080/14992020400050037
PMid:15357411
Maes L, Dhooge I, De Vel E, D'haenens W, Bockstael A, Vinck BM. Water irrigation versus air insufflation: A comparison of two caloric test protocols. Int J Audiol. 2007;46(5):263–9.
https://doi.org/10.1080/14992020601178147
PMid:17487674
McGovern TN, Fitzgerald JE. The effect of mental alerting on peripheral vestibular nystagmus during spontaneous, gaze (30 degrees left, 30 degrees right) and body positional (left & right lateral lying) testing using electronystagmography (ENG). Int J Audiol. 2008;47(10):601–6.
https://doi.org/10.1080/14992020802123579
PMid:18923981
Molina MI, Zapata C, Palma MJ, López-Escámez JA. Valores poblacionales de referencia para videooculografía en el test de agitación cefálica y la prueba calórica bitérmica. Acta Otorrinolaringológica Espa-ola. 2006;57(1):34–40.
https://doi.org/10.1016/S0001-6519(06)78660-5
Nishizawa S. Observations on conduction of caloric stimulation to the middle ear cavity by thermoscanning. Laryngoscope. 2002;12(3):504–8.
https://doi.org/10.1097/00005537-200203000-00018
PMid:12148862
Pau HW, Just T, Sievert U, Wild W. Heat radiation during caloric vestibular test: thermographic demonstration in temporal bone experiments. Ann Otol Rhinol laryngol. 2001;110(11):1041–4.
https://doi.org/10.1177/000348940111001109
PMid:11713915
Schmäl F, Lübben B, Weiberg K, Stoll W. The minimal ice water caloric test compared with established vestibular caloric test procedures. J Vestib Res.2005;15(4):215–24
PMid:16286703
Sills AW, Balow RW, Honrubia V. Caloric testing 2. Results in normal subjects. Ann Otol Rhinol Laryngol. 1977;86 (Suppl):7–23.
https://doi.org/10.1177/00034894770865S302
Spoelstra HAA, Wit HP SH. Mechanism of caloric stimulation of the pidgeon's vestibular system. Acta Otolaryngol. 1991;481(Suppl):94.
https://doi.org/10.3109/00016489109131355
Strupp M, Kim J-S, Murofushi T, Straumann D, Jen JC, Rosengren SM, et al. Bilateral vestibulopathy: Diagnostic criteria Consensus document of the Classification Committee of the Barany Society. J Vestib Res. 2017;27(4):177–89.
https://doi.org/10.3233/VES-170619
PMid:29081426
Takenouchi T, Suzuki M, Furuya M, Otsuka K, Ogawa Y. Contribution of endolymphatic fluid shift to caloric response in plugged semicircular canals. ORL J Otorhinolaryngol Relat Spec. 2005;67(5):266–71.
https://doi.org/10.1159/000089406
PMid:16374058
Valli P, Buizza A, Botta L, Zucca G, Ghezzi L, Valli S. Convection, buoyancy or endolymph expansion: what is the actual mechanism responsible for the caloric response of semicircular canals? J Vestib Res. 2003;12(4):155–65.
Wit, HP, Spoelstra AA SJ. Bárány's theory is right, but imcomplete. Acta Otolaryngol. 1990;110(1-2):1–6.
https://doi.org/10.3109/00016489009122507
PMid:2386023
Zapala D, Olsholt KF, Lundy LB. A comparison of water and air caloric responses and their ability to distinguish between patients with normal and impaired ears. Ear Hear. 2008;29(4):585–600.
https://doi.org/10.1097/AUD.0b013e3181734ed0
PMid:18600135
Ansderson S. Caloric irrigators: air, open-loop water and closed-loop water. Br J Audiol. 1995;29(2):117–28.
https://doi.org/10.3109/03005369509086589
ANSI. Procedures for testing basic vestibular function. Am Natl Stand Inst. 1999;Revision of ANSI S3.45.
Baloh RW, Sills AW, Honrubia V. Caloric testing 3. Patients with peripheral and central vestibular lesions. Ann Otol Rhinol Laryngol. 1977;86 (suppl):24–30.
https://doi.org/10.1177/00034894770865S303
Baloh RW, Solingen L, Sills AW, Honrubia V. Caloric testing 1. Effect of different conditions of ocular fixation. Ann Otol Rhinol Laryngol. 1977;86 (Suppl):1–6.
https://doi.org/10.1177/00034894770865S301
Barin K. Background and Technique of caloric testing. In: N JG and S, editor. Balance Function Assessment and Management. San Diego, CA: Plural Publishing; 2008. p. 197–228.
Barin K. Interpretation and usefulness of caloric testing. In: Jacobson, Gary P SN, editor. Balance Function Assessment and Management. San Diego, CA: Plural Publishing; 2008. p. 229–52.
Batuecas-Caletrio A, Montes-Jovellar L, Boleas-Aguirre MS, Perez-Fernandez N. The ice-water caloric test. Acta Otolaryngol. 2009;129(12):1414–9.
https://doi.org/10.3109/00016480902791686
PMid:19922091
British Society of Audiology. Recommended procedure The caloric test. Br Soc Audiol. 2010;April:1–25.
Cartwright AD, Cremer PD, Halmagyi GM, Curthoys IS. Isolated directional preponderance of caloric nystagmus: II. A neural network model. Am J Otol. 2000;21(4):568–72.
PMid:10912704
Enticott JC, Dowell RC, O'Leary SJ. A comparison of the monothermal and bithermal caloric tests. J Vestib Res. 2003;13(2–3):113–9.
PMid:14757914
Furman JMR, Jacob RG. Jongkees' formula re-evaluated: order effects in response to alternate binaural bithermal caloric stimulation using closed-Loop irrigation. Acta Otolaryngol. 1993;113(1):3–10.
https://doi.org/10.3109/00016489309135759
Halmagyi GM, Cremer PD, Anderson J, Murofushi T, Curthoys IS. Isolated directional preponderance of caloric nystagmus: I. Clinical significance. Am J Otol. 2000;21(4):559–67.
PMid:10912703
Honrubia V. Evaluación vestibular cuantitativa. In: Suárez C, Gil- Carcedo LM, Medina J, Ortega P, Trinidad J, editors. Tratado de Otorrinolaringología y Cirugía de Cabeza y Cuello. San Fernando de Henares: Proyectos Médicos SL; 1999. p. 1011–55.
Kondoh K, Kitahara T, Morihana T, Yamamoto K, Kubo T, Okumura S. Changes in caloric responses after temporal bone surgery with posterior tympanotomy. Auris Nasus Larynx. 2009;36(5):521–4.
https://doi.org/10.1016/j.anl.2008.11.004
PMid:19111414
Kondoh K, Kitahara T, Morihana T, Yamamoto K, Kubo T, Okumura S. Changes in caloric responses after temporal bone surgery with posterior tympanotomy. Auris Nasus Larynx. 2009;36(5):521–4.
https://doi.org/10.1016/j.anl.2008.11.004
PMid:19111414
Lightfoot G, Barker F, Belcher K, Kennedy V, Nassar G, Tweedy F. The derivation of optimum criteria for use in the monothermal caloric screening test. Ear Hear. 2009;30(1):54–62.
https://doi.org/10.1097/AUD.0b013e31818f006c
PMid:19125027
Lightfoot GR. The origin of order effects in the results of the bi-thermal caloric test. Int J Audiol. 2004;43(5):276–82.
https://doi.org/10.1080/14992020400050037
PMid:15357411
Maes L, Dhooge I, De Vel E, D'haenens W, Bockstael A, Vinck BM. Water irrigation versus air insufflation: A comparison of two caloric test protocols. Int J Audiol. 2007;46(5):263–9.
https://doi.org/10.1080/14992020601178147
PMid:17487674
McGovern TN, Fitzgerald JE. The effect of mental alerting on peripheral vestibular nystagmus during spontaneous, gaze (30 degrees left, 30 degrees right) and body positional (left & right lateral lying) testing using electronystagmography (ENG). Int J Audiol. 2008;47(10):601–6.
https://doi.org/10.1080/14992020802123579
PMid:18923981
Molina MI, Zapata C, Palma MJ, López-Escámez JA. Valores poblacionales de referencia para videooculografía en el test de agitación cefálica y la prueba calórica bitérmica. Acta Otorrinolaringológica Espa-ola. 2006;57(1):34–40.
https://doi.org/10.1016/S0001-6519(06)78660-5
Nishizawa S. Observations on conduction of caloric stimulation to the middle ear cavity by thermoscanning. Laryngoscope. 2002;12(3):504–8.
https://doi.org/10.1097/00005537-200203000-00018
PMid:12148862
Pau HW, Just T, Sievert U, Wild W. Heat radiation during caloric vestibular test: thermographic demonstration in temporal bone experiments. Ann Otol Rhinol laryngol. 2001;110(11):1041–4.
https://doi.org/10.1177/000348940111001109
PMid:11713915
Schmäl F, Lübben B, Weiberg K, Stoll W. The minimal ice water caloric test compared with established vestibular caloric test procedures. J Vestib Res.2005;15(4):215–24
PMid:16286703
Sills AW, Balow RW, Honrubia V. Caloric testing 2. Results in normal subjects. Ann Otol Rhinol Laryngol. 1977;86 (Suppl):7–23.
https://doi.org/10.1177/00034894770865S302
Spoelstra HAA, Wit HP SH. Mechanism of caloric stimulation of the pidgeon's vestibular system. Acta Otolaryngol. 1991;481(Suppl):94.
https://doi.org/10.3109/00016489109131355
Strupp M, Kim J-S, Murofushi T, Straumann D, Jen JC, Rosengren SM, et al. Bilateral vestibulopathy: Diagnostic criteria Consensus document of the Classification Committee of the Barany Society. J Vestib Res. 2017;27(4):177–89.
https://doi.org/10.3233/VES-170619
PMid:29081426
Takenouchi T, Suzuki M, Furuya M, Otsuka K, Ogawa Y. Contribution of endolymphatic fluid shift to caloric response in plugged semicircular canals. ORL J Otorhinolaryngol Relat Spec. 2005;67(5):266–71.
https://doi.org/10.1159/000089406
PMid:16374058
Valli P, Buizza A, Botta L, Zucca G, Ghezzi L, Valli S. Convection, buoyancy or endolymph expansion: what is the actual mechanism responsible for the caloric response of semicircular canals? J Vestib Res. 2003;12(4):155–65.
Wit, HP, Spoelstra AA SJ. Bárány's theory is right, but imcomplete. Acta Otolaryngol. 1990;110(1-2):1–6.
https://doi.org/10.3109/00016489009122507
PMid:2386023
Zapala D, Olsholt KF, Lundy LB. A comparison of water and air caloric responses and their ability to distinguish between patients with normal and impaired ears. Ear Hear. 2008;29(4):585–600.
https://doi.org/10.1097/AUD.0b013e3181734ed0
PMid:18600135
Pérez-Vázquez, P., & Franco-Gutiérrez, V. (2018). The caloric test. Revista ORL, 9(3), 193–213. https://doi.org/10.14201/orl.17699
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