Cervical vestibular evoked myogenic potential tuning properties of patients with recurrent peripheral vestibulopathy: Is it Meniere’s disease without hearing loss?

Vestibular migraine or Meniere's disease: a diagnostic dilemma

Meniere's disease (MD) represents one of the vertigo disorders characterized by triad symptoms (recurrent vertigo, fluctuating hearing loss, tinnitus or ear fullness). The diagnosis of MD relies on the accurate and detailed taking of medical history, and the differentiation between MD and vestibular migraine (VM) is of critical importance from the perspective of the treatment efficacy. VM is a highly prevalent vertigo condition and its typical symptoms (headache, vestibular symptoms, cochlear symptoms) mimic those of MD. Furthermore, the misdiagnosis in MD and VM could lead to VM patients mistakenly receiving the traumatic treatment protocol designed for MD, and sustaining unnecessary damage to the inner ear. Fortunately, thanks to the advances in examination technologies, the barriers to their differentiation are being gradually removed. These advances enhance the diagnostic accuracy of vertigo diseases, especially VM and MD. This review focused on the differentiation of VM and MD, with an attempt to synthesize existing data on the relevant battery of differentiation diagnosis (covering core symptoms, auxiliary tests [audiometry, vestibular tests, endolymphatic hydrops tests]) and longitudinal follow-up. Since the two illnesses are overlapped in all aspects, no single test is sufficiently specific on its own, however, patterns containing all or at least some features boost specificity.

Skull Vibration-Induced Nystagmus Test (SVINT) in Vestibular Migraine and Menière's Disease

BACKGROUND

Vestibular migraine (VM) and Menière's disease (MD) are the two most frequent episodic vertigo apart from Benign Paroxysmal Positional Vertigo (BPPV) differential diagnosis for them may be troublesome in the early stages. SVINT is a newly proposed vestibular test, which demonstrated to be fast and reliable in diagnoses above all of peripheral vestibular deficits.

METHODS

We retrieved clinical data from two groups of subjects (200 VM and 605 MD), enrolled between 2010 and 2020. Among others, these subjects were included when performing a SVINT. The purpose of the study is to assess if SVINT can be useful to differentiate the two episodic disorders.

RESULTS

59.2% of MD subjects presented as positive with SVINT while only 6% did so with VM; among other tests, only video HIT demonstrated a different frequency in the two groups (13.1% and 0.5%, respectively), but the low sensitivity in these subjects makes the test unaffordable for diagnostic purposes.

CONCLUSIONS

Since SVINT demonstrated to be positive in a peripheral vestibular deficit in previous works, we think that our data are consistent with the hypothesis that, in the pathophysiology of VM attacks, the central vestibular pathways are mainly involved.

Cervical Vestibular Evoked Myogenic Potentials That Are Absent at 500 Hz But Present at 1000 Hz Are Characteristic of Endolymphatic Hydrops-Related Disease

OBJECTIVES

It remains unclear whether the dominance of 1000 Hz responses over responses at 500 Hz in cervical vestibular evoked myogenic potentials (cVEMPs) are characteristic of endolymphatic hydrops (EH), due to the presence of patients with absent responses at both frequencies. The purpose of the present study is to examine whether the dominant cVEMP responses at 1000 Hz over 500 Hz are characteristic findings of EH-related diseases among patients who show various cVEMP findings.

DESIGN

We retrospectively reviewed the medical records of 470 consecutive patients who underwent cVEMP testing with short-tone bursts at both 500 Hz and 1000 Hz. We categorized the cVEMP responses of these 470 patients into the following five groups: (group 1) present responses at both frequencies bilaterally, (group 2) present responses at 500 Hz but absent at 1000 Hz on at least one side, (group 3) absent responses at 500 Hz but present at 1000 Hz on at least one side, (group 4) absent responses at both frequencies on one side and present at both frequencies on the other side, and (group 5) absent responses at both frequencies bilaterally. We compared the proportion of EH-related diseases between each group and the other four groups and then investigated any increased or decreased disease incidence in each group.

RESULTS

In group 3, the proportion of EH-related disease was significantly higher (p < 0.01), and the incidence of an EH-related disease was greatly increased (standard residual value > 3).

CONCLUSIONS

cVEMPs that are absent at 500 Hz and present at 1000 Hz may be characteristic of EH-related disease.

Association of cervical vestibular-evoked myogenic potential tuning property test results with MRI findings of endolymphatic hydrops in Meniere's disease

PURPOSE

To examine the concordance between cervical vestibular-evoked myogenic potential (cVEMP) tuning property test results and MRI findings of endolymphatic hydrops (EH).

METHODS

Fourteen subjects (age 24-76 years) that had been diagnosed with unilateral definite Meniere's disease (MD) (N = 8) or unilateral probable MD (N = 6) were enrolled. All of the subjects underwent cVEMP tests (using 500 Hz and 1000 Hz tone bursts), pure-tone audiometry, and gadolinium-enhanced 3 T-MRI. To examine tuning properties of cVEMP, the 500-1000 Hz amplitude ratio was calculated as the SLOPE. The results of the cVEMP tuning property test results were compared with EH-related MRI findings.

RESULTS

EH positivity in both the cochlea and vestibule on MRI was observed in 7 of the 8 affected ears of definite MD and 3 of the 6 affected ears of probable MD, although it was only in one of the 14 unaffected ears. EH(+) or no response (NR) in cVEMP tuning property test was significantly associated with EH positivity on MRI, while EH(-) in the cVEMP tuning property test was significantly associated with EH-negativity on MRI (p = 0.0016 Fisher's exact test test).

CONCLUSION

EH(+) or NR in the cVEMP tuning property test correspond well to EH positivity in the MRI findings. The cVEMP tuning property test is useful for screening and following up EH.

Cervical vestibular evoked myogenic potential with chirp sounds

BACKGROUND

There are only a few reports concerning cervical vestibular evoked myogenic potential (cVEMP) using chirp sound, and clinical indications/advantages of it are still unclear.

OBJECTIVE

To compare cVEMP using CE-chirp LS® with cVEMP using 500 Hz and 1000 Hz tone bursts (TB) and to investigate clinical indications/advantages of CE-chirp LS® for recording cVEMP.

METHODS

Sixteen patients with vestibular disorders (2men and 14 women) (18∼62, mean 42.9 years of age) were enrolled in this study. Participants underwent cVEMP testing using 500 Hz and 1000 Hz tone bursts (TB) and CE-chirp LS®. Response rate of P1-N1, corrected/normalized amplitude of P1-N1, latencies of P1 and N1, asymmetry ratio, and correlation of P1 latency to SLOPE in tuning property test (an index of endolymphatic hydrops) were compared.

RESULTS

Corrected/normalized amplitude of P1-N1 to CE-chirp LS® was smaller than corrected/normalized amplitude of P1-N1 to 500 Hz TB. Peak latencies to CE-chirp LS® were the shortest among the 3 types of stimulation. EH-positive ears according to the tuning property test had tendency of prolonged P1 latencies to CE-chirp LS®.

CONCLUSION

CE-chirp LS® is applicable for recording cVEMP with a similar diagnostic accuracy to TB. Prolongation of P1 latency in CE-chirp LS® might be an indicator of endolymphatic hydrops in the saccule.

Vestibular Migraine Patients Show Lack of Habituation in Auditory Middle Latency Responses to Repetitive Stimuli: Comparison With Meniere's Disease Patients

Objectives: To compare habituation in auditory middle latency response (AMLR) to repetitive stimuli of vestibular migraine (VM) patients with Meniere's disease (MD) patients and healthy controls (HC) and to assess usefulness of AMLR for diagnosis of VM. Subjects: Thirteen unilateral definite MD patients (2 men, 11 women, mean age 50.6), 13 definite VM patients (3 men, 10 women, mean age 45.5), and 8 HC subjects (2 men, 6 women, mean age 37.1) were enrolled. Methods: The electrodes were placed on the vertex and the spinal process of the fifth cervical vertebra. Binaural click stimulation (0.1 ms, 70 dBnHL) was presented. A total of 800 responses were averaged. Averaged responses were divided into four sets (S1 to S4) according to the temporal order. No, Po, Na, and Pa were identified, and amplitudes and latencies were measured. Results: Concerning latencies, HC subjects showed a tendency of shorter latencies. However, there was no clear effect of repetitive stimulation. Concerning No-Po amplitudes, no significant differences were observed. Raw amplitudes of Na-Pa showed statistically significant differences in S1 and S2 among the groups (p < 0.01 one-way ANOVA). Differences were shown in MD vs. VM and HC vs. VM in S1 (smaller in VM) (p < 0.01 Bonferroni's test) and in MD vs. VM in S2 (smaller in VM) (p < 0.01 Bonferroni test). Relative amplitudes of Na-Pa to S1 showed statistically significant differences in S4 (p < 0.01 one-way ANOVA). Differences were shown in MD vs. VM and HC vs. VM (larger in VM) (p < 0.01 Bonferroni's test). Differences of Na-Pa amplitudes in S2 to S4 from Na-Pa amplitude in S1 were significant in S4 of VM patients (Dunnett's test). Conclusions: VM patients showed lack of habituation (potentiation) of Na-Pa amplitude in AMLR to repetitive stimuli while MD patients and HC subjects showed habituation. Observation of lack of habituation has high diagnostic accuracy for differential diagnosis of VM from MD.

Simultaneous Presentation of Definite Vestibular Migraine and Definite Ménière's Disease: Overlapping Syndrome of Two Diseases

Objectives: To review the clinical records of patients that exhibited the clinical features of both vestibular migraine (VM) and Ménière's disease (MD) during each episodic vertigo attack and to discuss the possible pathophysiology of such combination of symptoms.

Subjects: Ten patients that were selected according to criteria based on a combination of the diagnostic criteria for definite MD and VM (9 females and one male, age: 22–54 years) were enrolled. They were required to show features of both diseases in each vertigo attack.

Methods: The patients' medical histories and pure-tone audiometry, cervical vestibular evoked myogenic potential (cVEMP), video head-impulse test (vHIT), and caloric test results were examined. cVEMP was recorded using 500 and 1,000 Hz short tone bursts (125dBSPL, air-conducted), 500 Hz-1,000 Hz cVEMP slope, an index of endolymphatic hydrops in the saccule was calculated using normalized amplitudes of p13-n23. For performing vHIT, each subject was seated 1.5 m in front of a target and asked to keep watching it as their head was passively rotated by the examiner. Their eye movements were evaluated using video-oculography while their head movements were recorded using inertial sensors.

Results: The patients were predominantly female. On average, the onset of migrainous headaches occurred 9 years earlier than the onset of vertigo attacks. All of the patients but one had migraines with auras. Five of the 10 patients had a family history of vertigo attacks accompanied by both migrainous and auditory symptoms. The patients mainly displayed hearing loss at low frequencies. Nine patients exhibited 500–1,000 Hz cVEMP slope < −19.9, which was suggestive of endolymphatic hydrops. None of the patients who underwent vHIT showed abnormal canal function. One patient showed unilaterally decreased caloric responses.

Conclusions: These patients presented with simultaneous MD and VM signs/symptoms might be referred to “VM/MD overlapping syndrome (VM/MD-OS)” as a new clinical syndrome.