Assessment of Utricular Function in Individuals with Chronic Suppurative Otitis Media Using Subjective Visual Vertical Test and Dizziness Handicap Inventory

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Audiol Speech Res. 2026;22(1):54-61

Publication date (electronic) : 2026 January 30

doi : https://doi.org/10.21848/asr.250179

Aswin Ganesan, Praveena Jayakumar

Department of Audiology and Speech Language Pathology, SRM Medical College Hospital and Research Centre, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu, India

Correspondence: Praveena Jayakumar, MASLP Department of Audiology and Speech Language Pathology, SRM Medical College Hospital and Research Centre, SRM Institute of Science and Technology, Kattankulathur 603203, India Tel: +91-7418169586 Fax: +91-2745-2343 E-mail: praveenj@srmist.edu.in

Received 2025 January 31; Revised 2025 October 7; Accepted 2026 January 9.

Abstract

INTRODUCTION

Anatomically, hearing and balance are controlled by two exquisitely aligned systems located in the innermost part of the human ears. The vestibular apparatus controls posture and direction in the three-dimensional world, while the cochlea is responsible for the hearing mechanism. The semicircular canals, utricle, and saccule make up the vestibular apparatus, which senses both linear and angular acceleration. The vestibular nerve transmits impulses to the cerebellum and brainstem. Disruptions in the intricate system of the vestibular apparatus affect the gaze stability, balance, and spatial orientation. The peripheral lesions, such as vestibular neuritis or Meniere's disease, result in distorted sensory input. Central lesions, such as multiple sclerosis and stroke, impact the integration and processing of vestibular signals on both the ipsilateral and contralateral sides [1-4]. The vestibular disorders can occur along with middle ear dysfunctions such as chronic suppurative otitis media (CSOM).

CSOM is defined as “the presence of recurrent or persistent otorrhea lasting more than 6 weeks, in association with perforation of the tympanic membrane and signs of chronic, active inflammation of the middle ear (thickened granular middle ear mucosa, hyperemia, exudate, and mucosal polyps), with or without cholesteatoma” [5]. The vestibular dys-function, hearing loss and tinnitus are some of the inner-ear consequences due to CSOM [6]. Individuals with CSOM had a high prevalence 53.5% [4] and 72.5% [7] of vestibular symptoms, along with worsened postural balance control and abnormalities in vestibular tests i.e., in caloric tests and vestibular evoked myogenic potentials (VEMPs) [8]. A substantial loss of hair cells in the vestibular system was observed during histopathological examination of the temporal bone in individuals with CSOM [9,10]. The inflammatory mediators and bacterial products can spread throughout the labyrinth, causing damage to the cochlea through the round window membrane [11-14]. CSOM is primarily viewed as a middle ear pathology, but growing evidence suggests it may also affect the inner ear, particularly the vestibular system. Otolithic dysfunction, especially involving the utricle, often goes unnoticed due to its subtle symptoms. This research addresses a critical gap by evaluating vestibular involvement in CSOM patients.

In individuals with CSOM who present with vestibular symptoms, it is often difficult to administer traditional objective tests such as occular VEMP and cervical VEMP. These tests require input stimuli delivered through the air conduction pathway involving the outer, middle, and inner ear. However, in the presence of CSOM, the sound pressure level is insufficient to reach the inner ear, thereby failing to adequately stimulate the otolith organs [15]. By contrast, the subjective visual vertical (SVV) test directly evaluates utricular function by measuring an individual’s perception of verticality. During SVV testing, participants are seated and asked to align a visual reference to their perceived vertical, which is then compared against the true gravitational vertical (0°). This provides a straightforward and reliable measure of otolith integrity. Unlike VEMP, which requires careful interpretation to exclude lesions along complex reflex pathways, SVV is less affected by external variables such as sternocleidomastoid muscle tension, stimulus intensity, or middle ear pathology. Consequently, SVV offers greater consistency across patients. Therefore, when behavioural screening tests and VEMP cannot be reliably administered in individuals with CSOM. SVV serves as a more dependable alternative for assessing vestibular function, particularly when acoustic stimulation of the otolith organs is not feasible [7,16].

A ‘‘bucket test’’ is a simple and low-cost effective test to evaluate SVV [16]. A bucket is altered in this test to determine the SVV. The intra-test and inter-test reliability of bucket test was 90% [16-18]. The computer software based SVV test which has been recently implemented, made the test simple to perform. The modified version of the static SVV, called as the dynamic SVV test in which the background rotates continuously unlike the static SVV in which the background is kept stable. When the background rotates, the peripheral visual field produces a perception that the individual himself/herself rotates which results in replacement of vestibular signals with visual signals [19,20]. In SVV dynamic the background rotation be in both clockwise and counterclockwise directions. Traditional vestibular assessments can be expensive, time-consuming, or unavailable in many clinical settings. The SVV-bucket test and computerized SVV (static and dynamic) offer low-cost, non-invasive, and reliable alternatives for detecting utricular dysfunction. Validating these tools in CSOM populations could enhance early diagnosis and management of the vestibular dysfunction.

Otolithic dysfunction exhibits milder symptoms than any other types of vestibular dysfunction [21]. The dizziness handicap inventory (DHI) is a questionnaire that assesses a person's self-perception of dizziness. The DHI developed by Jacobson and Newman [22] to evaluate the physical factors associated with dizziness as well as the functional and emotional consequences of vestibular system. Objective tests alone may not capture the full impact of vestibular dysfunction. The DHI complements SVV testing by assessing the emotional, functional, and physical consequences of dizziness from the patient’s perspective. This dual approach strengthens the clinical relevance of the findings. The present study aimed to utilize the SVV-bucket test, computerized SVV (static and dynamic) to assess the utricular function in individuals with CSOM and also aimed at using DHI to evaluate patient’s self-perception of dizziness. By identifying vestibular deficits early in CSOM patients, clinicians can tailor rehabilitation strategies, reduce fall risk, and improve quality of life. This research could lead to more comprehensive care protocols for a condition often treated solely as an auditory issue.

MATERIALS AND METHODS

The study was approved by Institutional Scientific Committee and Ethical Committee. A cross-sectional study design was adapted. A total of 70 individuals in the age range of 18 to 45 years (31.7 ± 8.26) were included in the study. The participants were classified into two groups, the control group (group I) consists of 35 individuals with normal vestibular functioning and the study group (group II) consists of 35 individuals with CSOM. The subject selection into the groups were based on the following inclusion exclusion criteria.

Group I included individuals with a hearing threshold of ≤ 15 dB HL in the frequency range of 250 Hz to 8 KHz (ANSI S3.6,1996), normal findings in behavioural vestibular tests, normal vision or corrected impaired vision through contact lenses/spectacles. However, individuals with middle ear pathology were excluded from group I. The experimental group included individuals with a confirmed diagnosis of CSOM either in one ear or both the ears by an otorhinolaryngologist. Both active and non-active CSOM individuals were chosen for the group II. Individuals with sensorineural hearing loss, treated chronic otitis media, history of surgeries to the ear, usage of ototoxic medications, severe head injury, complete visual impairment or limitations, benign paroxysmal positional vertigo, perilymphatic fistula, clinical otosclerosis, Meniere’s disease, other inner ear disorders and any other medical conditions like diabetes mellitus, definite or probable migraine were excluded from both the groups.

All the test protocols were explained and the informed consents were received from each participant before initiating the test procedure. Following which, a detailed case history (demographic data, family history, severity and duration) was completed. A calibrated dual channel diagnostic audiometer (Madsen Astera2; Natus Medical, Taastrup, Denmark) was used for tracking the hearing threshold. A calibrated middle ear analyser Granson - Standler Tynpstar Pro (Tymp Star Pro; Granson Stadler, Eden Prairie, MN, USA) was used for evaluating middle ear status through a tympanogram.

All the participants were subjected to vestibular evaluation through the SVV-bucket test and computerized SVV (dynamic and static). Behavioral vestibular evaluation (Robmerg & Sharpened Romberg test, finger to nose pointing test, gaze test, heel to knee, spontaneous nystagmus, Fukuda stepping test and tandem gait test) were administered only on the individuals with normal vestibular functioning. The DHI [22] was administered for individuals with CSOM and for individuals with normal vestibular system.

A 15.0-L bucket (rim diameter = 29 cm; depth = 30 cm; bottom diameter = 19 cm) was modified to perform the SVV-bucket test. A vertical line was drawn with fluorescent tape in the bucket's internal base and a thread with slight weight was attached in the centre point of the buckets outside base. A protractor scale was taped to the rim of the bucket's external base, with 0º corresponding to the straight line drawn inside the bucket. The 0º location is defined as the true vertical. The patients were requested to place their heads inside the bucket and align the fluorescent tape in their perception of vertical position. As the bucket rotates, the thread with light weight giving the angle of divergence (in degrees) from the true vertical [16].

In computerized SVV (static and dynamic), to avoid visual cues, the testing was carried out in a dark room and goggles were provided for all the participants. The chair's height was adjusted such that the subject's eye level corresponded to the centre of the screen. The stimulus was displayed on a screen directly in front of the patient. A software from the SVV equipment (BalanceEye, Cyclops MedTech, Hyderabad, India) projected an illuminated "line" on the screen. The “line” was presented at different pre-set angle. The participants were asked to use a remote to move the "line" vertically. The background was rotated clockwise and counter-clockwise for the dynamic assessment. The test was performed five times each for static, dynamic (clockwise) and dynamic (counter-clockwise) condition. These values were displayed as either positive or negative depending on the direction of deviation.

DHI is a self-perceived handicap scale were used to quantify the impact of vertigo in everyday life situations. It consists of 25 items designed to assess the effect of dizziness and unsteadiness on quality of life. The items are grouped into three subscales: which includes 9-emotional, 9-functional, and 7-physical aspects of daily living. Each item included three possible choices: no, sometimes, and yes with the score of 0, 2, and 4 points respectively. A total score of 0 indicates the absence of handicap. The DHI scores were categorized as physical (28 points), emotional (36 points) and functional (36 points). The DHI scores were divided into four categories: minimal (0~14), mild (16~34), moderate (36~52), and severe (≥ 54).

The data obtained was tabulated using the assistance of Statistical Package for the Social Sciences (SPSS) software version 21 (IBM Corporation, Armonk, NY, USA) and subjected to analysis. The combination of descriptive and inferential statistics ensured that the research aims summarizing SVV performance, comparing groups, evaluating within subject changes, and exploring associations with perceived handicap. Descriptive statistics was performed to estimate the mean and standard deviation for SVV results in both the groups. Inferential statistics was done to measure the mean difference between the individuals with and without CSOM. As the SVV results didn’t show normal distribution the Mann-Whitney U-test was used to compare the results of SVV test in individuals with normal vestibular functioning and individuals with CSOM, p-value < 0.05 were considered as statistically significant differences. Wilcoxon signed-rank test was administered to compare the bucket test, static and dynamic SVV within the group of individuals with CSOM. To correlate DHI scores with the SVV test findings in individuals with CSOM, Spearman’s rho correlation coefficient was used.

RESULTS

The study recruited 35 individuals with normal vestibular functioning (18 male and 17 female) with the mean and standard deviation (SD) age of 27.23 ± 6.21 years and 35 individuals with CSOM (14 male and 21 female) with the mean and SD age of 36.17 ± 7.67 years (n = 70) were recruited based on the inclusion and the exclusion criteria of the study. The normality test using Shapiro-Wilk test revealed that the data were not distributed normally (p < 0.05). Hence further inferential statistics, non-parametric tests were used.

The mean, SD values of deviation in degrees is given in Figure 1. The results revealed that there is an increased deviation in SVV-bucket, static SVV, dynamic SVV (clockwise) and dynamic SVV (counter-clockwise) for the study group when compared to the control group.

Figure 1.

Overall median and standard deviation of SVV-bucket test, static SVV and dynamic SVV for group I and group II. CSOM: chronic suppurative otitis media, SVV: subjective visual vertical, CW: clockwise, CCW: counter clockwise.

The deviation in the perception of visual vertical among individuals with CSOM is significantly higher in both the static (Z = 2.85; p = 0.004) and dynamic (Z = 4.00; p = 0.000; Z = 2.94; p = 0.003) measure of SVV compared to individuals with normal vestibular functioning (Table 1).

Table 1.

Comparison of SVV findings between group I and group II

Comparison of visual vertical perception among individuals with CSOM

The measure of visual vertical, static and SVV-bucket measures was highly significant when compared to the dynamic SVV measures (clockwise and counter-clockwise). However, between the static and SVV-bucket as well as within the dynamic measure of visual vertical there were no significant differences (Table 2).

Table 2.

Comparison of SVV measures among individuals with CSOM

There is a variation in the degrees of deviation mean, standard deviation and median SVV by right, left and both ears CSOM. In the SVV-bucket test and static SVV, the right and left ear CSOM exhibited an equal deviation concerning the pathological ears. However, dynamic SVV clockwise scores were found to be deviant in individuals with right ear CSOM. However, increased dynamic SVV (counterclockwise) scores were observed in individuals with left ear CSOM. In case of CSOM in both ears, SVV mean values showed deviation only in the dynamic SVV (clockwise and counterclockwise), but not in SVV-bucket test and static SVV (Figure 2).

Figure 2.

Median and standard deviation for the measure of visual vertical in CSOM for right, left and both ears. SVV: subjective visual vertical, CW: clockwise, CCW: counter clockwise, CSOM: chronic suppurative otitis media.

Correlation of DHI with the measure of visual vertical in the individual with CSOM

Individuals with a normal vestibular system had a score of 0 on the DHI measures. Therefore, these results were excluded during test statistics. The mean value revealed comparatively higher scores in the functional and physical parameters of DHI in individuals with CSOM. However, the emotional aspects seem to exhibit the least scores (Figure 3). The Table 3 depicts the comparison of DHI scores with the SVV tests.

Figure 3.

Median and standard deviation of DHI findings in individuals with giddiness among CSOM. DHI: dizziness handicap inventory, CSOM: chronic suppurative otitis media.

Table 3.

Correlation between DHI and SVV findings in individuals with CSOM

DISCUSSIONS

In the present study, the prevalence of dizziness among individuals with CSOM was found to be 46%. This is similar to the findings observed earlier by several researchers, where the prevalence of dizziness was 40~60% of individuals with CSOM [4,13,21]. However, da Costa Monsanto, et al. [7] observed a higher prevalence of dizziness about 72.5% among individuals with CSOM. The possibility of variation in prevalence rate in different researches can be due to differences in the inclusion criteria. da Costa Monsanto, et al. [7] in their study had only individuals who had active CSOM. However, in the present study, both active and inactive CSOM were included. In individuals with inactive CSOM, there is a possibility of probable vestibular compensation which could have altered the prevalence rate in the present study.

The SVV findings in the present study showed a deviation in the perception of visual vertical among individuals with CSOM which were significantly higher (p < 0.005) when compared to those without CSOM. The percentage of population who had deviations in the SVV-bucket test was 34.28%, in static SVV was 34.28%, dynamic SVV (clockwise) was 48.57% and dynamic SVV (counterclockwise) was 42.85%. These findings are similar to Lee, et al. [23] study who had observed a deviation of 20% in the static SVV measures in individuals with CSOM. da Costa Monsanto, et al. [7] have reported around 68.6% of individuals with active CSOM had deviation in the SVV-bucket test. This difference in the deviation in da Costa Monsanto, et al. [7] study can be probably due to the inclusion of only active CSOM.

The dynamic SVV measures were found to be significantly affected more compared to static SVV and SVV-bucket tests. This difference in SVV measures was probably because the static SVV compensates relatively quicker compared to dynamic SVV [24,25]. In individuals with CSOM, there was no significant difference in the test measure of SVV static, dynamic and SVV-bucket test. This is indicating that both the SVV-bucket test and static SVV assess are able to detect the deviations similarly. In both the static and dynamic SVV, the deviances were observed congruent to the pathological ear. The same trend was observed by da Costa Monsanto, et al. [7] in their study, that all the patients with CSOM had deviation towards the affected ear. Individuals with CSOM the dynamic SVV were affected more than the SVV-bucket test and static SVV. This is cab be because the dynamic SVV are even more sensitive to rule out deviation in the utricular function even in a compensated vestibular system. In the dynamic SVV, the movement of background is continuous during testing this will make the participants experience a rotating sensation [8]. In turn the dynamic SVV test becomes more difficulty to perform than the SVV static and SVV-bucket test. Therefore, dynamic SVV depicts a process in which vestibular signals are influenced by the visual inputs [3] and can detect both the late and early onset vestibular symptoms in the utricular pathway [24]. Kessler, et al. [25] stated that the SVV test may be less sensitive in diagnosing bilateral symmetrical otolith dysfunction and patients who have developed central compensation over time. The duration of the CSOM in our investigation ranged from 3 months to 15 years, and these variations in duration could have also been reflected in the difference in static and dynamic SVV measures. Moreover, the dynamic test is more effective than the static test in the 90 days following the onset of impairment. The sensitivity of the static SVV is 59.5% and dynamic SVV is 78.1% [26]. This variations in sensitivity are observed in the current study.

The deviations in SVV should correlate with the side of the vestibular dysfunction. In individuals with unilateral CSOM, the SVV-bucket test and static SVV test deviation observed was in concordance to the pathological side. The right ear CSOM had deviation towards the right and left ear CSOM had deviation towards left. With in the dynamic SVV the clockwise and counterclockwise presentations, in individuals with the right ear CSOM the dynamic SVV clockwise was affected and in the left ear CSOM dynamic SVV counter-clockwise was affected. These findings are similar to Miller and Crane [27] results, when dynamic SVV line was rotated counter-clockwise, migraine participants showed more deviation than controls. Therefore, these findings suggest that the majority of migraine patients deviated in one direction, indicating asymmetric vestibular function [23]. In case of bilateral CSOM, SVV mean values showed deviation only in the dynamic SVV in both clockwise and counter-clockwise, but not in SVV-bucket test and static SVV. It could be associated with reductions in bilateral otolithic inputs causing decrease in the neuronal activity of the vestibular nuclei. Funabashi, et al. [28] documented a larger deviation in both clockwise and counter-clockwise direction in individuals with bilateral vestibular disorder. da Costa Monsanto, et al. [7] reported that all the patients with unilateral CSOM had deviation towards the affected ear and in bilateral CSOM the results were less consistent in SVV-bucket method. Moreover, the static SVV findings showed no significant difference between individuals with bilateral vestibular disorder and normal individuals [25,29,30].

On administering the DHI on individuals with CSOM, the mean and SD values were 35.63 ± 15.39. The individual with CSOM perceived their dizziness to be mild handicap. Kalaycık Ertugay, et al. [31] studied DHI scores in individuals with CSOM and found DHI score of 38.00 ± 17.41 and 39.83 ± 21.17 for preoperative tympanoplasty and mastoidectomy group respectively. The symptoms of otolithic dysfunction are usually milder than those of other types of vestibular dysfunction [11] and compensated by the central nervous system [26].

On comparing the DHI scores with the Bucket test, static and dynamic SVV. There was no significant difference (p > 0.005) in the findings in the dizziness severity rating and the SVV deviations. This might be due to ear specific deviation for dynamic SVV tests and static SVV is not sensitive for chronic condition and bilateral vestibular dysfunctions. However, most of the patient had abnormal deviation in SVV findings among which only 46% of them reported dizziness. Similar result was found by Ho, et al. [3] reported that no significant correlation between the symptoms of dizziness and vestibular test findings in individuals with CSOM. This can be due to compensation of the central mechanism on vestibular dysfunction [3]. Therefore, the individuals with CSOM had abnormal SVV findings irrespective of the complaint of dizziness.

These findings suggests that the SVV test can be done for all the CSOM individuals to rule out earlier vestibular dysfunction. SVV testing offers a practical, non-invasive method to detect vestibular dysfunction in CSOM, unaffected by conductive hearing loss. Its integration into otorhinolaryngology practice could enhance early diagnosis and guide rehabilitation. Future research should validate SVV against objective measures and assess its role across CSOM subtypes. These findings may inform updates to clinical guidelines for dizziness evaluation.

As all the researches documented have their own pits and pearls, the present study has a limitation of not subdividing the experimental group as having active and inactive CSOM. A modest sample size and lack of stratification by CSOM activity. Future studies should incorporate objective tests like VEMP and explore longitudinal outcomes.

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