Abstract
We appreciate the comments by Dr. Tjell on our editorial.1 To our knowledge, the diagnostic accuracy of the proposed tests has not been compared with the head impulse test, nystagmus evaluation, and test of skew (HINTS) battery. There is evidence from Carmona et al.2 regarding the diagnostic value of truncal ataxia, but the same study found that the HINTS battery was far more sensitive and specific in distinguishing central from peripheral vestibulopathy. The evaluation of nystagmus only by its disruptive effect on smooth pursuit can lead to clinical errors because the pursuit performance requires visual attention, declines with age, can be influenced by a spontaneous nystagmus, and is particularly susceptible to the influence of medications. Although tragal compression, that is, the Hennebert test, can elicit vestibular nystagmus in some patients by changing the middle ear pressure, it is uncertain whether it might have a diagnostic value in the setting of acute vestibular syndrome. Finally, future automated predictive models combining the proposed test battery (excluding tragal compression) with HINTS may prove to be beneficial for remote screening of acute dizzy patients. However, a very large multicenter international collaboration would be required for such a study to create clinically impactful results.
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