Ocular vestibular evoked myogenic potentials induced by bone-conducted vibration in patients with unilateral inner ear disease

Development of a Subjective Visual Vertical Test System Using a Smartphone With Virtual Reality Goggles for Screening of Otolithic Dysfunction: Observational Study

BACKGROUND

The subjective visual vertical (SVV) test can evaluate otolith function and spatial awareness and is performed in dedicated vertigo centers using specialized equipment; however, it is not otherwise widely used because of the specific equipment and space requirements. An SVV test smartphone app was developed to easily perform assessments in outpatient facilities.

OBJECTIVE

This study aimed to verify whether the SVV test smartphone app with commercially available virtual reality goggles can be used in a clinical setting.

METHODS

The reference range was calculated for 15 healthy participants. We included 14 adult patients with unilateral vestibular neuritis, sudden sensorineural hearing loss with vertigo, and Meniere disease and investigated the correlation between the SVV test results and vestibular evoked myogenic potential (VEMP) results.

RESULTS

The SVV reference range of healthy participants for the sitting front-facing position was small, ranging from -2.6º to 2.3º. Among the 14 patients, 6 (43%) exceeded the reference range for healthy participants. The SVV of patients with vestibular neuritis and sudden sensorineural hearing loss tended to deviate to the affected side. A total of 9 (64%) had abnormal cervical VEMP (cVEMP) values and 6 (43%) had abnormal ocular VEMP (oVEMP) values. No significant difference was found between the presence or absence of abnormal SVV values and the presence or absence of abnormal cVEMP and oVEMP values; however, the odds ratios (ORs) suggested a higher likelihood of abnormal SVV values among those with abnormal cVEMP and oVEMP responses (OR 2.40, 95% CI 0.18-32.88; P>.99; and OR 2, 95% CI 0.90-4.45; P=.46, respectively).

CONCLUSIONS

The SVV app can be used anywhere and in a short period while reducing directional bias by using virtual reality goggles, thus making it highly versatile and useful as a practical otolith dysfunction screening tool.

Diagnostic and therapeutic strategies for vestibular neuritis of the Japan Society for Equilibrium Research

OBJECTIVE

To provide diagnostic and therapeutic strategies for vestibular neuritis in accordance with the Japanese Clinical Practice Guidelines for Vestibular Neuritis 2021.

METHODS

The Committee for Clinical Practice Guidelines for Vestibular Neuritis was entrusted with a review of the relevant scientific literature on the above topic. Clinical Questions (CQs) concerning the treatment of vestibular neuritis were produced, and a search of the literature was conducted to identify studies related to the CQs. The recommendations were based on the literature review and the expert opinion of a subcommittee.

RESULTS

We proposed the diagnostic criteria for vestibular neuritis, as well as answers to CQs, recommendations, and evidence levels for the treatment of vestibular neuritis.

CONCLUSION

The diagnostic criteria for vestibular neuritis were based on clinical history and examination findings after completing the differential diagnosis process. The treatment of vestibular neuritis was divided into acute, subacute, and chronic stages. The Japanese Clinical Practice Guidelines for Vestibular Neuritis 2021 should be used as a reference in the diagnosis and treatment of vestibular neuritis.

The value of vestibular graviceptive pathway evaluation in the diagnosis of unilateral peripheral vestibular dysfunction

BACKGROUND

Evaluation of vestibular graviceptive pathway (VGP) in patients with unilateral peripheral vestibular dysfunction (UPVD) has received increasing attention from researchers. The study aimed to investigate the value of VGP evaluation in the diagnosis of UPVD.

METHODS

Ninety-five UPVD patients were divided into attack and remission phase groups. VGP evaluation-related indicators, including subjective visual vertical (SVV), subjective visual horizontal (SVH), head tilt, ocular torsion (OT), and skew deviation (SD), were measured, and their correlations with cochleovestibular function test results were analyzed. The possible etiologies of contralesional VGP (c-VGP) were analyzed.

RESULTS

Positive rates of SVV, SVH, OT, and SD were significantly higher, and the degrees of SVV, SVH, and OT were significantly greater in the attack phase group than the remission phase group. The sides with abnormal VGP evaluation results were correlated with the sides with hearing loss, abnormal caloric, and video head impulse test (vHIT) results. A total of 14 patients showed c-VGP, and possible etiologies included contralateral benign paroxysmal positional vertigo (n = 4), bilateral hearing loss (n = 8), bilateral vHIT gain reduction (n = 1), autoimmune diseases (n = 6), vascular risk factors (n = 6), lacunar infarction (n = 3), and endolymphatic hydrops (n = 3).

CONCLUSIONS

Alterations in SVV, SVH, OT, and SD were noted in UPVD patients in different phases, which are presumed to be related to dynamic vestibular compensation; correlations between VGP evaluation results and cochleovestibular function test results indicate that VGP evaluation may be helpful for the diagnosis of the side affected in UPVD; the presence of c-VGP may be related to bilateral labyrinth lesions or endolymphatic hydrops on the affected side; and the involvement of autoimmune mechanisms also deserves attention.

Subjective visual horizontal correlates better with ocular than with cervical vestibular evoked myogenic potentials

OBJECTIVE

To examine the relationship between widely used otolith function tests: the Subjective Visual Horizontal (SVH) and Vestibular Evoked Myogenic Potentials (VEMP).

METHODS

A retrospective analysis was performed on 301 patients who underwent SVH, ocular and cervical VEMP (oVEMP and cVEMP) tests on the same day. Correlations between the mean SVH tilt and amplitude asymmetry ratios for bone-conducted (BC) oVEMP and air-conducted (AC) cVEMP were examined. Diagnoses included vestibular neuritis, stroke, vestibular migraine, Meniere's disease, sudden sensorineural hearing loss (SSNHL) and vestibular schwannoma.

RESULTS

SVH results were concordant with the oVEMP in 64% of cases and the cVEMP in 51%. Across all patients, SVH demonstrated a significant moderate correlation with BC oVEMP amplitude asymmetry ratios (r = 0.55, p < 0.001) and a weak correlation with AC cVEMP amplitude asymmetry ratios (r = 0.35, p < 0.001). A stronger correlation between SVH and oVEMPs was observed in patients with vestibular neuritis (r = 0.67, p < 0.001) and SSNHL (r = 0.76, p = 0.001).

CONCLUSIONS

SVH correlates better with oVEMP than cVEMP symmetry.

SIGNIFICANCE

This finding reinforces the hypothesis of a common utricular origin for both SVH and oVEMPs which is distinct from the saccular origin of cVEMPs.

Vestibular function assessment in sudden hearing loss

OBJECTIVES

To perform vestibular assessment using cervical and ocular vestibular evoked myogenic potential, video head impulse test and caloric testing in patients with sudden hearing loss. Moreover, to evaluate the correlation of dizziness with vestibular tests and the correlation of vestibular tests with hearing prognosis.

METHODS

This is an observational, longitudinal and prospective study, including participants diagnosed with sudden hearing loss. The participants underwent cervical and ocular vestibular evoked myogenic potential, video head impulse test and caloric testing. The audiometric assessment was performed at the beginning and at the end of the follow-up. A value of p≤0.05 was considered statistically significant.

RESULTS

Seventeen patients were included in the study sample, with a mean age of 45.4±11.1 years. Five participants (29.41%) had dizziness and 15 (88.23%) had tinnitus. All participants underwent vestibular evaluation through cervical and ocular vestibular evoked myogenic potential and video head impulse test, and 13 of them were evaluated through caloric testing. The cervical vestibular evoked myogenic potential was considered altered in five (29.41%) participants, while 11 (64.71%) showed alterations at the ocular vestibular evoked myogenic potential. The video head impulse test and the caloric testing were considered altered in seven (41.18%) and five (38.46%) participants, respectively. There was no statistically significant correlation between the clinical data and the results of vestibular tests or hearing recovery, nor between the results of vestibular tests and hearing recovery.

CONCLUSION

The assessment through vestibular evoked myogenic potential, video head impulse test and caloric testing showed vestibular involvement in some participants. However, it cannot be stated that the results of the vestibular tests are related to the hearing prognosis of sudden hearing loss.

Differences in responsiveness of intratympanic steroid injection for intractable vertigo in Meniere's disease

OBJECTIVES

The efficacy of intratympanic steroid (ITS) injection for intractable Meniere's disease has been reported; however, its differences in responsiveness are not fully understood. This study investigated the clinical characteristics of patients who responded to ITS injection treatment.

METHODS

This retrospective study included 32 patients with Meniere's disease who were unable to control frequent vertigo attacks despite conservative treatment for at least 3 months. They received an intratympanic injection of dexamethasone (3.3 mg/mL) in the affected side at least three times. We measured hearing threshold, subjective symptom scores, cervical and ocular vestibular evoked myogenic potential (cVEMP and oVEMP), and performed glycerol and bithermal caloric tests.

RESULTS

Satisfactory control of vertigo for 1 year after the first round of injection was found in 18 patients (56.3%; the response group). However, the injections failed to control vertigo in the other 14 patients (43.8%; the non-response group), and they were then treated with middle ear micropressure therapy. The response group showed improvement in low-frequency hearing, whereas hearing acuity did not change in the non-response group. Significantly reduced amplitude of cVEMP on the affected side was found in 62.5% of patients in the response group; however, no patients in the non-response group showed reduced amplitude of cVEMP.

CONCLUSIONS

ITS injection significantly improved the subjective symptoms for intractable Meniere's disease; however, the long-term effects were heterogeneous. Our results suggest that reduced amplitude in cVEMP is associated with the effectiveness of ITS injection treatment.

Independent Measures of Utricular Function: Ocular Vestibular Evoked Myogenic Potentials Do Not Correlate With Subjective Visual Vertical or Fundus Photographic Binocular Cyclorotation

Ocular vestibular evoked myogenic potentials (oVEMPs), subjective visual vertical (SVV), and fundus photographically measured binocular cyclorotation (BCR) are diagnostic tests to assess utricular function in patients with vertigo or dizziness. In 138 patients with chronic vertigo or dizziness, we asked whether the asymmetry ratio of oVEMP (normal, right side pathological, left side pathological) could predict the SVV deviation (normal, rightward deviation, leftward deviation) or BCR (normal, cyclorotation to the right, cyclorotation to the left). There was no correlation between oVEMP and SVV and between oVEMP and BCR, while SVV and BCR correlated highly. Although both oVEMP and SVV measure aspects of utricular function, our findings demonstrate that oVEMP and SVV are not redundant and may reflect different utricular pathologies. The role of fundus photographic BCR may be relegated to only confirm unclear SVV results in vestibular diagnostic workup.

Association Between Hearing Characteristics/Prognosis and Vestibular Function in Sudden Sensorineural Hearing Loss With Vertigo

Sudden sensorineural hearing loss (SSNHL) patients with vertigo have a poorer prognosis. However, the factors associated with hearing recovery remain uncertain. This retrospective study was to evaluate the association between hearing characteristics/hearing recovery and the patterns of vestibulocochlear lesions in SSNHL patients with vertigo. Patients were classified into groups according to the patterns of vestibular dysfunction. We not only compared hearing characteristics and prognosis among subgroups but also determined the potential association between vestibular lesion location and hearing recovery. The shapes of the audiogram differed significantly between patients with normal vestibular function and patients with vestibular dysfunction (p = 0.022). Patients whose audiogram indicated profound hearing loss were 3.89 times more likely to have vestibular dysfunction than those whose audiogram shape indicated low-frequency hearing loss (95% CI, 1.02–14.86, p = 0.047). Patients who had saccule dysfunction were 0.11 times as likely to have hearing recovery than those who had normal saccule function (95% CI, 0.11–0.31, p = 0.001). When adjusted for sex and age, patients who had saccule dysfunction were 0.07 times as likely to have hearing recovery than those who had normal saccule function (95% CI, 0.02–0.22, p = 0.001). Abnormal results following cVEMP testing may be a potential predictive factor for poor hearing recovery.

Vestibular evoked myogenic potentials in the prognosis of sudden hearing loss ‒ a systematic review

INTRODUCTION

Sudden hearing loss is an otorhinolaryngological emergency that often leads to severe damage to the auditory and vestibular function. The vestibular evoked myogenic potential is a test that allows a noninvasive evaluation of the otolithic system function and vestibulospinal and vestibulo-ocular pathways.

OBJECTIVE

To evaluate the importance of vestibular evoked myogenic potential in determining the prognosis of patients with sudden hearing loss.

METHODS

A search for articles published up to December 2018 was performed in the PubMed, Cochrane, VHL and LILACS databases using MeSH descriptors. Retrospective and prospective articles were included containing cervical or ocular vestibular evoked myogenic potential in sudden hearing loss patients and information on associated vertigo and/or dizziness.

RESULTS

Sixteen of 62 initially selected articles met the inclusion criteria and were analyzed. Regarding the methodology of the evaluated studies, 8 studies were prospective, six were retrospective, one contained part of the data from a retrospective analysis and another part from a prospective analysis, and one study was cross-sectional. A total of 872 patients were evaluated (50.22% males and 49.77% females) with a mean age of 51.26 years. Four hundred and twenty-six patients (50.35%) had vertigo and/or dizziness associated with sudden hearing loss. The cervical vestibular evoked myogenic potential was performed in all studies, but only seven assessed the ocular vestibular evoked myogenic potential. The cervical vestibular evoked myogenic potential showed alterations in 38.65% of 846 evaluated ears, whereas ocular vestibular evoked myogenic potential showed alterations in 47.88% of 368 evaluated ears. The hearing recovery rate was analyzed by 8 articles, with 63.4% of 410 evaluated ears showing hearing recovery.

CONCLUSIONS

The studies suggest that the assessment of the vestibular system using vestibular evoked myogenic potential seems to be important in the prognosis of sudden hearing loss. For better follow-up of patients with sudden hearing loss, the emphasis should not be limited to the cochlea, but also include the diagnosis and treatment of vestibular abnormalities, regardless of the presence of vertigo.

Cervical VEMP tuning changes by Meniere's disease stages

Objective

To determine if changes in cervical vestibular-evoked myogenic potential (cVEMP) testing reflect the different stages of cochlea-saccular hydrops in Meniere's disease (MD).

Methods

This is a case-control retrospective series. Forty-seven patients with unilateral MD by American Academy of Otolaryngology-Head and Neck Surgery diagnostic and staging criteria, and 30 with non-MD vertigo as control. Meniere patients were further classified based on symptoms at the time of testing as active or stable. Subsequently, patients underwent cVEMP testing by tone-burst stimuli at 500 and 1,000 Hz. The main outcome measure was to compare the cVEMP 1,000 and 500 Hz amplitude ratio in ears with MD and non-MD vertigo, and in active versus stable MD.

Results

The cVEMP 1,000/500 Hz amplitude ratio was higher in Meniere's ears (mean = 1.14 μV, SD = 0.25) than in non-Meniere's ears (mean = 0.96 μV, SD = 0.2) (Student's t test, P = .001), and higher in active (mean = 1.22 μV, SD = 0.25) than in stable MD (mean = 1.00 μV, SD = 0.18) (P = .0035). The diagnostic value of cVEMP 1,000/500 Hz amplitude ratio to differentiate MD versus non-MD vertigo was evaluated with a receiver-operating characteristics (ROC) curve and the area under the curve (AUC) was 0.716 (95% confidence interval [CI] [0.591, 0.829]). The ideal cutoff point was 0.9435 with sensitivity and specificity values of 83% and 53%, respectively. The sensitivity and specificity values for this test to differentiate active versus stable MD were 68% and 81%, respectively, with AUC 0.746 (95% CI [0.607, 0.885]) and cutoff value of 1.048. In all ears, the 1,000/500 Hz amplitude ratio increased by a decrease of the 500 Hz amplitude with increasing age.

Conclusion

The cVEMP 1,000/500 Hz amplitude ratio is elevated in ears with MD but not in those with non-MD vertigo. After corrected by age, this ratio is higher in active but not in stable MD, probably reflecting dynamic changes in saccular membrane motion mechanics in hydrops, and may be a useful marker of disease progression and the effect of therapy.

Level of Evidence

IV.

Comparison of cervical vestibular evoked potentials evoked by air-conducted sound and bone-conducted vibration in vestibular Schwannoma patients

OBJECTIVE

The vestibular evoked myogenic potential (VEMP) is associated with otolithic afferents and can be used to evaluate the function of the saccule and utricle. In this study, we compared cervical VEMP evoked by stimulation with Air-conducted sound (ACS) and bone-conducted vibration (BCV) to the forehead and investigated whether BCV can be used as a substitute for ACS.

METHODS

Data were obtained from 33 patients with vestibular schwannoma. Vestibular examinations were performed preoperatively. VEMP was obtained upon stimulation with ACS (ACS cVEMP) and BCV to the forehead using a minishaker (BCV cVEMP). Vestibular function was also analyzed using the caloric test and ocular VEMP (oVEMP) testing. oVEMP was measured using bone-conductive vibration to the forehead. The results of BCV cVEMP, ACS cVEMP, and oVEMP were compared by the caloric test.

RESULTS

Rates of patients with abnormal ACS cVEMP, BCV cVEMP, oVEMP, and caloric test results were 78.8%, 75.8%, 78.8%, and 69.7%, respectively. BCV cVEMP did not correlate with ACS cVEMP, but correlated with oVEMP and caloric test results.

CONCLUSION

BCV cVEMP did not correlate with ACS cVEMP. Therefore, BCV cVEMP cannot be used as a substitute for ACS cVEMP.

Vestibular-evoked myogenic potentials

The vestibular-evoked myogenic potential (VEMP) is a short-latency potential evoked through activation of vestibular receptors using sound or vibration. It is generated by modulated electromyographic signals either from the sternocleidomastoid muscle for the cervical VEMP (cVEMP) or the inferior oblique muscle for the ocular VEMP (oVEMP). These reflexes appear to originate from the otolith organs and thus complement existing methods of vestibular assessment, which are mainly based upon canal function. This review considers the basis, methodology, and current applications of the cVEMP and oVEMP in the assessment and diagnosis of vestibular disorders, both peripheral and central.

The relationship between hearing loss and vestibular dysfunction in patients with sudden sensorineural hearing loss

OBJECTIVE

To investigate the relationship between hearing loss and vestibular dysfunction in patients with sudden sensorineural hearing loss (SSHL).

METHODS

Clinical data including the symptom of vertigo of 149 SSHL patients were investigated retrospectively. Pure tone audiometry, ocular vestibular-evoked myogenic potential (oVEMP) and cervical vestibular-evoked myogenic potential (cVEMP) evoked by air-conducted sound (ACS), and caloric test were employed for cochlear and vestibular function assessment. The relationship between hearing level and vestibular dysfunction was analyzed.

RESULTS

The pure tone averages (PTAs) (mean ± SD) of SSHL patients with and without vertigo were 88.81 ± 21.74 dB HL and 72.49 ± 21.88 dB HL (Z = -4.411, p = 0.000), respectively. The PTAs of SSHL patients with abnormal and normal caloric test were 84.71 ± 22.54 dB HL and 70.41 ± 24.07 dB HL (t = -2.665, p = 0.009), respectively. Conversely, vertigo and abnormal caloric results also happened more frequently in patients with profound hearing loss. However, no consistent tendency could be found among vestibular evoked myogenic potentials (VEMPs) responses or hearing loss.

CONCLUSIONS

SSHL patients with vertigo or abnormal caloric test displayed worse hearing loss; and vice versa, vertigo and abnormal caloric results happened more frequently in SSHL patients with profound hearing loss.

Vestibular-evoked myogenic potentials and subjective visual vertical testing in patients with vitamin D deficiency/insufficiency

Otolith function in subjects with vitamin D deficiency/insufficiency is investigated through vestibular-evoked myogenic potentials (VEMP) and subjective visual vertical (SVV) testing. The study group included 62 patients with vitamin D deficiency/insufficiency (30 females, 32 males), with age range 24-56 years (40.6 ± 9.1). The control group included 44 healthy volunteers of similar age and gender distribution. The entire study group had: (1) serum level of 25-hydroxyvitamin D <30 ng/ml; (2) normal bone mineral density as indicated by dual-energy X-ray absorptiometry with T-score >-1; (3) normal middle ear function; (4) Age is ≤60 years. All subjects enrolled in the current study underwent audiovestibular evaluation consisting of pure-tone audiometry, immittancemetry, cervical VEMP (cVEMP), ocular VEMP (oVEMP), and SSV. The entire control group had normal cVEMP, two subjects had abnormal oVEMP. Thirty-three subjects (53%) in the study group had abnormal oVEMP and 31 subjects (50%) had abnormal cVEMP. Forty-one (66%) had abnormal VEMP when abnormal VEMP was considered as either abnormal oVEMP or cVEMP. The entire control and study groups had normal SSV test results. Vitamin D deficiency may be associated with development of otolith dysfunction affecting both the utricle and saccule. This was suggested by the high prevalence of abnormal ocular vestibular-evoked myogenic potentials (oVEMP) and cervical vestibular-evoked myogenic potentials (cVEMP) in the study group.