Journal of
eISSN: 2379-6359
Submit manuscript...
Review Article Volume 18 Issue 2
Bedside oculomotor examination in the acute vestibular syndrome: what hints can and cannot do for the otolaryngologist
Dr Anirudda Deshpande, Dr Supriya Khardenavis, Dr Gayatri Godse, Dr Vikram Khardenavis
Received: August 03, 2026 | Published: August 24, 2026
Citation: Deshpande A, Khardenavis S, Khardenavis V, et al. Bedside oculomotor examination in the acute vestibular syndrome: what hints can and cannot do for the otolaryngologist. J Otolaryngol ENT. 2026;18(2):66-72. DOI: 10.15406/joentr.2026.18.00590
Abstract
The acute vestibular syndrome is one of the few presentations in medicine where a selflimiting disorder and a life-threatening one produce an almost identical history. Vestibular neuritis and infarction in the posterior circulation both present with sudden, continuous vertigo, nausea, intolerance of head movement and spontaneous nystagmus, and neither the character of the dizziness nor the presence of vascular risk factors reliably separates them. The three-step HINTS battery — horizontal head impulse test, characterisation of nystagmus, and test of skew — was shown in 2009 to exceed early diffusion-weighted magnetic resonance imaging in sensitivity for stroke in this population, a result that has been quoted ever since as evidence that a competent bedside examination outperforms a scanner. That claim is defensible, but only under conditions that are rarely reproduced in routine practice. This narrative review sets out the physiological basis of each component, examines the accuracy data critically, and argues that the gap between the original figures and the performance achieved in general emergency and outpatient settings reflects examiner skill, patient selection and case mix rather than any intrinsic limitation of the test. Two boundaries are emphasised throughout. First, the battery is validated only in patients who genuinely meet the definition of an acute vestibular syndrome, and its operating characteristics are unknown in any other group; applying it to episodic or triggered dizziness is a taxonomic error, not merely a technical one. Second, findings consistent with a peripheral vestibulopathy reduce the probability of stroke but do not exclude it, and this remains true even when the examination is performed by a trained and experienced clinician; the examination should therefore be interpreted alongside the wider history, the general neurological assessment and the clinical course rather than used as a standalone rule-out test. Particular attention is given to the situations in which otolaryngologists encounter these patients, which are often days after the index event and after a working diagnosis has already been recorded. We conclude with the practical implications for departmental pathways and with the questions the field still needs to answer.
Keywords: acute vestibular syndrome, HINTS examination, vertigo, posterior circulation stroke, head impulse test, nystagmus, skew deviation, vestibular neuritis
©2026 Deshpande, et al. This is an open access article distributed under the terms of the, which permits unrestricted use, distribution, and build upon your work non-commercially.