Role of dorsal neck proprioceptive inputs to vestibular compensation in humans

High-frequency skull vibration-induced nystagmus test in partial vestibular lesions

OBJECTIVES

To establish the effectiveness of the skull vibration-induced nystagmus test (SVINT) as a rapid high-frequency stimulation test, in the evaluation of partial unilateral vestibular lesions (pUVL).

METHODS

SVINT (30, 60, and 100 Hz), caloric, and head-shaking tests were performed in 99 patients with pUVL. These results were compared with those in 9 patients with symmetrical partial bilateral labyrinthine malformations, 131 patients with total unilateral vestibular lesions (tUVL), and 95 control subjects.

RESULTS

A skull vibratory nystagmus (SVN) was found in 75% of patients with pUVL and 98% with tUVL. In pUVL: SVINT revealed asymmetric responses in 20% of patients where other tests were normal; SVN direction at 100 Hz was opposite to the head-shaking nystagmus direction in 30% and opposite to SVN at 30 Hz in 10% of cases. At 100 Hz, SVN beat toward the safe side in 91% of cases; SVN values at 60 and 100 Hz were higher than those at 30 Hz (p < 0.005). SVN was found in unilateral superior canal dehiscences. Partial bilateral labyrinthine malformations revealed no nystagmus.

CONCLUSION

SVINT complements head-shaking and caloric tests in multifrequency assessment of patients with pUVL, as a global vestibular test. In contrast with tUVL results, SVINT does not always indicate the side of partial lesions, neither does it locate their level on the vestibulo-ocular pathway. This test is useful to reveal a vestibular asymmetry as a bedside examination test and may be used as a "vestibular Weber."

Nystagmus induced by high frequency vibrations of the skull in total unilateral peripheral vestibular lesions

CONCLUSION

The skull vibration-induced nystagmus test (SVINT) is a useful complementary test to the caloric test, which evaluates very low frequencies, and the head shaking test (HST), which explores medium range frequencies. These three tests are fully correlated in total unilateral vestibular lesions (tUVL) with a sensitivity of 98% and a specificity of 94% for the SVINT. The results of the interference of the SVINT with the cold caloric test on the intact ear suggest that different vestibular sensory cells are involved in these two tests. The stimulus location optimization suggests that vibrations directly stimulate the inner ear on the intact side.

OBJECTIVES

The aim of this study was to establish the effectiveness of a rapid, non-invasive test used to detect vestibular asymmetry at 30, 60 and 100 Hz stimulation in tUVL.

PATIENTS AND METHODS

The high frequency vibration test applied to the skull using the SVINT was compared to the results of HST and caloric test in 134 patients and 95 normal subjects: 131 patients had a total unilateral vestibular dysfunction and 3 had a bilateral total lesion (tBVL). The effects of stimulus frequency, topography and head position were studied using a video-nystagmograph.

RESULTS

In tUVL, the SVINT always revealed a lesional nystagmus beating toward the healthy side at all frequencies. The mastoid site was more efficient than the cervical and vertex sites (p0.005). The mean skull vibratory nystagmus (SVN) slow phase velocity (SPV) is 10.7 degrees (SD =7.5; n=20). Mastoid stimulation efficiency was not correlated with the side of stimulation. SVN SPV was correlated with the total caloric efficiency on the healthy ear (p=0.03). The interference of the SVINT during the cold caloric test on the intact ear demonstrated a reversal of the caloric nystagmus at each application of the vibrator. In tBVL, SVINT revealed no nystagmus.

[Skull vibration induced nystagmus test]

OBJECTIVES

To establish during a consensus meeting the fundamental basis, the validity criteria, the main indications and results of the skull vibration induced nystagmus test (SVINT) which explores the vestibule high frequencies.

MATERIAL AND METHODS

The SVINT is applied on the mastoid process (right and left sides) at 100 Hz during 10 seconds on a sitting upright subject. Total unilateral peripheral lesions (tUVL: operated vestibular shwannomas, vestibular neurectomies) and partial unilateral peripheral lesions (pUVL: preoperative neuromas, Meniere's disease, vestibular neuritis, chemical labyrinthectomies) were studied. Thirty-six patients had brainstem lesions and 173 normal subjects were used as controls.

RESULTS

The SVINT is considered positive when the application of the vibrator produces a reproducible sustained nystagmus always beating in the same direction following several trials in various stimulation topographies (on the right and left mastoid). The skull vibratory nystagmus (SVN) begins and ends with the stimulation; the direction of the nystagmus has no secondary reversal. The slow phase velocity (SPV) is>2 degrees /second. In tUVL the SVINT always reveals a lesional nystagmus beating toward the safe side at all frequencies. The mean SVN SPV is 10.8 degrees /s+/-7.5 SD (N=45). The mastoid site was more efficient than the cervical or vertex sites. Mastoïd stimulation efficiency is not correlated with the side of stimulation. The SVN SPV is correlated with the total caloric efficiency on the healthy ear. In pUVL the SVINT is positive in 71 to 76% of cases; the mean SVN. SPV (6.7 degrees /s+/-4.7 SD)(N=30) is significantly lower than in tUVL (P=0.0004). SVINT is positive in 6 to 10% of the normal population, 31% of brain stem lesions and negative in total bilateral vestibular peripheral lesions.

CONCLUSIONS

SVINT is an effective, rapid and non invasive test used to detect vestibular asymmetry between 20 to 150 Hz stimulation. This test used in important cohorts of patients during the ten last years has demonstrated no observable adverse effect. SVINT complements other tests which evaluate lower frequencies (caloric test: 0,003 Hz) and the medium frequencies (Head-Shaking-Test (HST): 2 Hz; the head impulse test (HIT): 6 Hz). SVINT is useful in the diagnosis of labyrinthine hydrops or detection of acoustic neuromas. It is useful when the caloric test can not be practised because of middle ear problems. SVINT has its limits: in pUVL, the nystagmus direction is not always specific of the pathologic side and can change with the stimulus frequency. This test does not precisely point out the level of the lesion on the vestibular pathway.

Convergence defects in patients with temporomandibular disorders

The aim of this study is to show the presence of a correlation between ocular convergence defects (OCD) and temporomandibular disorders (TMD) among a group of adult subjects. The group studied was made up of 48 subjects (12 males and 36 females). The average age was 35 with a range of 19-45 years of age. The subjects presented with TMD and muscular pain and/or dysfunction. Forty-eight subjects with TMD for the case study were matched by gender and age to 48 control subjects seeking routine dental care (control group). All the subjects were examined by the same orthoptist who classified the ocular convergence degree using two tests. The first test evaluated the distances (in centimeters) of the convergence near point (3-4 cm: normal; 5-7 cm: sufficient; > 7 cm: insufficient). The second test assessed the fusional convergence using a Berens prism test (> 25 diopters: normal; between 18-25: sufficient; < 18 diopters: insufficient). In the TMD group, 36 subjects (75%) showed a compromise of convergence: 13 (36%) were classified in the 5-7 degree range and 23 (48%) in the > 7 cm degree range. The Berens test showed ten subjects (28%) in the group < 18D and 26 (72%) in the group 18-25D. The control-group presented ten (21%) subjects with compromise of convergence: three classified in the group < 18D and seven in the group 18-25D. The TMD subjects presented a higher statistical percentage (p < 0.0001) of ocular convergence defects. The TMD patients also reported a strong association referred to specific signs and symptoms, i.e., limited maximal opening or myofascial pain. There were some subjective reports also of headaches and torcicollis (neck stiffness) which appeared significantly more frequently in subjects with a compromise of convergence. The study showed a much higher prevalence of ocular convergence defects in patients with head, neck, and shoulder pain.