{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,6]],"date-time":"2026-03-06T16:02:18Z","timestamp":1772812938042,"version":"3.50.1"},"reference-count":20,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2026,3,6]],"date-time":"2026-03-06T00:00:00Z","timestamp":1772755200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Audiology Research"],"abstract":"<jats:p>Background: Acute vertigo is among the most frequent causes of access to the Emergency Department. In acute vestibular syndrome, differentiating peripheral from central causes remains challenging. The HINTS protocol provides high diagnostic accuracy but requires expertise and adequately informed physicians. The caloric ice-water test has recently been proposed as a bedside tool to aid this differential diagnosis. This study evaluates a novel approach: simultaneous bilateral ice-water irrigation in association with the HINTS protocol. Methods: One hundred consecutive patients presenting with acute vertigo and spontaneous unidirectional nystagmus were enrolled across three Italian centers. All patients underwent clinical assessment including among other the HINTS protocol and the simultaneous bilateral ice-water irrigation. Changes in spontaneous nystagmus during the ice test were recorded. Results: Eighty-six patients fulfilled HINTS criteria for acute unilateral peripheral vestibulopathy, all of whom demonstrated marked suppression\/abolition of nystagmus during the simultaneous ice test. In contrast, nystagmus persisted in all 12 patients classified as having central vestibular pathology. Conclusions: Simultaneous bilateral ice-water irrigation is a simple and well-tolerated bedside test that demonstrates strong concordance with the HINTS protocol. While it cannot replace comprehensive clinical assessment, it represents a valuable complementary tool to distinguish peripheral from central causes of acute vertigo.<\/jats:p>","DOI":"10.3390\/audiolres16020039","type":"journal-article","created":{"date-parts":[[2026,3,6]],"date-time":"2026-03-06T09:22:14Z","timestamp":1772788934000},"page":"39","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Bedside Approach to Acute Vertigo with Spontaneous Horizontal Nystagmus: The Role of Simultaneous Ice-Water Test Stimulation and Its Correlation with the HINTS Protocol in Differentiating Peripheral and Central Etiologies"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-4000-0024","authenticated-orcid":false,"given":"Luigi","family":"Califano","sequence":"first","affiliation":[{"name":"Audiology and Phoniatrics Department, AORN San Pio, Via dell\u2019Angelo 1, 82100 Benevento, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-7727-4249","authenticated-orcid":false,"given":"Cataldo","family":"Latorre","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, IRCCS San Raffaele Scientific Institute, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maria Grazia","family":"Melillo","sequence":"additional","affiliation":[{"name":"Audiology and Phoniatrics Department, AORN San Pio, Via dell\u2019Angelo 1, 82100 Benevento, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Iacopo","family":"Cangiano","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, IRCCS San Raffaele Scientific Institute, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0004-2376-7068","authenticated-orcid":false,"given":"Giuseppe","family":"Manna","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, San Leonardo Hospital, Viale Europa 79, 80053 Naples, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maria Gabriella","family":"Coppola","sequence":"additional","affiliation":[{"name":"Emergency Department, AORN San Pio, Via dell\u2019Angelo 1, 82100 Benevento, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2948-4638","authenticated-orcid":false,"given":"Roberto","family":"Teggi","sequence":"additional","affiliation":[{"name":"Department of Otolaryngology, IRCCS San Raffaele Scientific Institute, San Raffaele Hospital, Via Olgettina 60, 20132 Milan, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,6]]},"reference":[{"key":"ref_1","unstructured":"Graham, M.D., and Kemink, J.L. (1987). Facets of the life and work of Professor Robert B\u00e1r\u00e1ny (1886\u20131936). The Vestibular System: Neurophysiologic and Clinical Research, Raven Press."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"161","DOI":"10.3109\/00016488909127494","article-title":"Evidence of direct thermal action upon the vestibular receptors in the caloric test","volume":"107","author":"Hood","year":"1989","journal-title":"Acta Otolaryngol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1007\/BF00237741","article-title":"European vestibular experiments on the Spacelab-1 mission: 3 Caloric nystagmus in microgravity","volume":"64","author":"Scherer","year":"1986","journal-title":"Exp. Brain Res."},{"key":"ref_4","unstructured":"Barber, H.O., and Stockwell, C.W. (1980). Manual of Electronystagmography, CV Mosby Company. [2nd ed.]."},{"key":"ref_5","unstructured":"Jacobson, G.P., and Shepard, N.T. (2008). Balance Function Assessment and Management, Plural Publishing."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1414","DOI":"10.3109\/00016480902791686","article-title":"The ice-water caloric test","volume":"129","year":"2009","journal-title":"Acta Otolaryngol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"577","DOI":"10.1016\/j.ncl.2015.04.011","article-title":"TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo","volume":"33","author":"Edlow","year":"2015","journal-title":"Neurol. Clin."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"161","DOI":"10.3988\/jcn.2025.0105","article-title":"Usefulness of Nystagmus Patterns in Distinguishing Peripheral From Central Acute Vestibular Syndromes at the Bedside: A Critical Review","volume":"21","author":"Lee","year":"2025","journal-title":"J. Clin. Neurol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1329","DOI":"10.4065\/82.11.1329","article-title":"Imprecision in patient reports of dizziness symptom quality: A cross-sectional study conducted in an acute care setting","volume":"82","author":"Cannon","year":"2007","journal-title":"Mayo Clin. Proc."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"3504","DOI":"10.1161\/STROKEAHA.109.551234","article-title":"HINTS to diagnose stroke in the acute vestibular syndrome: Three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging","volume":"40","author":"Kattah","year":"2009","journal-title":"Stroke"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"190","DOI":"10.1136\/svn-2018-000160","article-title":"Use of HINTS in the acute vestibular syndrome. An Overview","volume":"3","author":"Kattah","year":"2018","journal-title":"Stroke Vasc. Neurol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"56","DOI":"10.14639\/0392-100X-N2283","article-title":"The role of vestibular cold caloric tests in the presence of spontaneous nystagmus","volume":"43","author":"Gufoni","year":"2023","journal-title":"Acta Otorhinolaryngol. Ital."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1112","DOI":"10.1212\/WNL.0000000000207740","article-title":"Pediatric and Adult Brain Death\/Death by Neurologic Criteria Consensus Guideline","volume":"101","author":"Greer","year":"2023","journal-title":"Neurology"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"389","DOI":"10.3233\/VES-220201","article-title":"Acute unilateral vestibulopathy\/vestibular neuritis: Diagnostic criteria","volume":"32","author":"Strupp","year":"2022","journal-title":"J. Vestib. Res."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"737","DOI":"10.1001\/archneur.1988.00520310043015","article-title":"A clinical sign of canal paresis","volume":"45","author":"Halmagyi","year":"1988","journal-title":"Arch. Neurol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1002\/ana.24532","article-title":"Missed stroke in acute vertigo and dizziness: It is time for action, not debate","volume":"79","year":"2016","journal-title":"Ann. Neurol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"E571","DOI":"10.1503\/cmaj.100174","article-title":"Does my dizzy patient have a stroke? A systematic review of bedside diagnosis in acute vestibular syndrome","volume":"183","author":"Tarnutzer","year":"2011","journal-title":"Can. Med. Assoc. J."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Spencer, R., Gandhi, J., Tepe, J., Li, C., Kulzer, M., O\u2019nEill, J., Eisenmenger, L., Goldberg, M., Chien, A., and Chang, W. (2025). Low incidence of acute actionable imaging findings in emergency department patients imaged for vertigo: Retrospective analysis and proposed guidelines. Emerg Radiol., 1\u201311.","DOI":"10.1007\/s10140-025-02426-2"},{"key":"ref_19","first-page":"CD015089","article-title":"Head impulse, nystagmus, and test of skew examination for diagnosing central causes of acute vestibular syndrome","volume":"11","author":"Gottlieb","year":"2023","journal-title":"Cochrane Database Syst Rev."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"440","DOI":"10.1016\/S1808-8694(15)30580-2","article-title":"Interpretation and use of caloric testing","volume":"74","author":"Felipe","year":"2008","journal-title":"Braz. J. Otorhinolaryngol."}],"container-title":["Audiology Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2039-4349\/16\/2\/39\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,6]],"date-time":"2026-03-06T10:20:04Z","timestamp":1772792404000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2039-4349\/16\/2\/39"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,6]]},"references-count":20,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,4]]}},"alternative-id":["audiolres16020039"],"URL":"https:\/\/doi.org\/10.3390\/audiolres16020039","relation":{},"ISSN":["2039-4349"],"issn-type":[{"value":"2039-4349","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,6]]}}}