Electrophysiologic vestibular evaluation in type 2 diabetic and prediabetic patients: Air conduction ocular and cervical vestibular evoked myogenic potentials

Cervical and Masseter Vestibular Evoked Myogenic Potentials in Diabetes Mellitus Type 2

PURPOSE

Diabetes affects the peripheral auditory and vestibular systems. Research suggests that both cervical vestibular evoked myogenic potentials (cVEMP) and ocular VEMP (oVEMP) are affected in individuals with diabetes. Masseter VEMP (mVEMP) is a new tool that assesses the vestibulomasseteric reflex pathways. The study aimed to characterize the cVEMP and mVEMP latency and amplitude parameters in diabetes mellitus type 2.

METHOD

The study included 21 participants with type 2 diabetes mellitus and 21 age- and gender-matched participants without diabetes aged 48-68 years. mVEMP and cVEMP were recorded using 500 Hz tone burst stimuli, presented at an intensity of 125 dB peSPL for both the groups.

RESULTS

The study suggests significantly prolonged P13 (p = .00) and P11 latencies (p = .00) in participants with diabetes (M for p11 = 15.81, M for p13 = 15.39) compared to participants without diabetes (M for p11 = 13.12, M for p13 = 14.19) for both cVEMP and mVEMP, respectively. No significant differences were observed in N23 (p = .4) and N21 latencies (p = .18) between the diabetes (M for N21 = 22.62, M for N23 = 22.61) and nondiabetes groups (M for N21 = 22.21, M for N23 = 22.40). Additionally, a significant reduction in cVEMP amplitude (P13-N23) was noted in the diabetes group (M for P13-N23 = 0.71, p = .00) than the nondiabetes group (M = 1.44), while mVEMP amplitudes (P11-N21) remained similar across groups (M for P11-N21 for diabetes = 0.72, (M for P11-N21 for nondiabetes = 0.77, p = .44). There were no significant correlations between the duration of diabetes and VEMP parameters, nor between cVEMP and mVEMP responses in either group.

CONCLUSIONS

The findings revealed notable differences in cVEMP and mVEMP findings in diabetes individuals. These results suggest that diabetes may lead to neural and labyrinthine impairments. The degree of vestibular impairment varies and affects different reflex pathways. Even though mVEMP has a similar saccular origin as cVEMP, the results between the two do not correlate with each other.

Vestibular and Balance Considerations in Type 2 Diabetes: A Tutorial on Pertinent Areas and Issues

PURPOSE

The purpose of this study is to describe the effects of diabetes mellitus (DM) on vestibular and balance system functions in humans. Because Type 2 diabetes (T2D) represents the majority of individuals affected by this condition, this subgroup is the main focus of this tutorial.

METHOD

Evidence of dysfunction is based on epidemiological, anatomical, physiological, neuroimaging, and clinical findings. Preventative measures, therapeutic interventions, and other mitigating factors are also given consideration.

RESULTS

Experimental and clinical findings support the notion that T2D damages vestibular and balance systems to the extent that these effects are more prevalent in patients with higher blood glucose levels and longer duration of the disease. Evidence indicates that T2D increases the occurrence and re-occurrence rates of benign paroxysmal positional vertigo, particularly when it occurs in conjunction with hypertension, osteoarthritis, and otologic disorders like Ménière's disease. Type 2 diabetes also impairs vestibular compensation, which is exacerbated by disease duration. Investigational and clinical studies suggest that galvanic stimulation of the vestibular system can be effective in reducing blood glucose levels and improving rehabilitation outcomes.

CONCLUSION

Because DM is a chronic metabolic condition affecting cochlear, vestibular, and balance system functions, lowering blood glucose levels through diet, pharmacological interventions, and exercise can be effective in mitigating dysfunction.

When, where, and why should we look for vestibular dysfunction in people with diabetes mellitus?

The biochemistry of diabetes mellitus results in multi-system tissue compromise that reduces functional mobility and interferes with disease management. Sensory system compromise, such as peripheral neuropathy and retinopathy, are specific examples of tissue compromise detrimental to functional mobility. There is lack of clarity regarding if, when, and where parallel changes in the peripheral vestibular system, an additional essential sensory system for functional mobility, occur as a result of diabetes. Given the systemic nature of diabetes and the plasticity of the vestibular system, there is even less clarity regarding if potential vestibular system changes impact functional mobility in a meaningful fashion. This commentary will provide insight as to when we should employ diagnostic vestibular function tests in people with diabetes, where in the periphery we should look, and why testing may or may not matter. The commentary concludes with recommendations for future research and clinical care.

The impact of vestibular dysfunction on falls and postural instability in individuals with type 2 diabetes with and without diabetic polyneuropathy

Aim

This study aimed to determine the association between vestibular dysfunction, falls, and postural instability in individuals with type 2 diabetes (T2D) compared to healthy control individuals and to examine the impact of diabetic polyneuropathy (DPN).

Methods

This cross-sectional study included individuals with T2D with DPN (n = 43), without DPN (n = 32), and healthy controls (n = 32). Cervical and ocular vestibular evoked myogenic potentials (VEMP) were recorded, and latencies and amplitudes were determined. DPN was diagnosed based on nerve conduction studies and clinical scores. Postural instability was examined using a static posturographic balance system and calculated as an instability index (ST). Falls were recorded retrospectively during the past year. Group comparisons were conducted by using univariate and bivariate statistics.

Results

Individuals with T2D experienced more falls than healthy controls (T2D with DPN n = 12[38%], T2D without DPN n = 15[35%], controls n = 5[16%], p = 0.04). Individuals with T2D had decreased postural stability, T2D with DPN, ST (median of 52[iqi = 33; 77]), T2D without DPN, ST (median of 31[iqi = 24; 39]), controls ST (median of 26[iqi = 19; 33], p = 0.01), when comparing all three groups. Individuals with T2D had a greater number of no-responses in oVEMP compared to controls (T2D with DPN, n = 15[46.9%] T2D without DPN n = 25[58.1%], controls n = 9[28.1%], p = 0.04). No difference was found in cVEMP and oVEMP amplitudes in any of the groups. Irrespectively of DPN, fallers with T2D had decreased oVEMP and cVEMP latencies on the right ears, when comparing to non-fallers, respectively, n10 (fallers [median of 16, iqi=15;19 ms.] vs. non-fallers [median of 25 iqi=16;35 ms]); p13 (fallers [median of 16, iqi=15;17 ms.] vs. non-fallers [median of 15, iqi=8;16 ms.], p < 0.05).

Conclusion

Falls and postural instability were more frequent in individuals with T2D compared to healthy controls. Fallers with T2D had vestibular end-organ impairments based on the oVEMP and cVEMP latencies on the right but not the left ears, irrespective of DPN. Individuals with T2D had more frequent no-response of the oVEMP, indicating impaired vestibular nerve function.

Cervical and ocular vestibular evoked myogenic potentials in patients with Diabetic Peripheral Neuropathy

BACKGROUND

Diabetes causes impaired microarterial blood flow, demyelination and neuronal damage, which may lead to cochlear damage and vestibular malfunction. Vestibular evoked myogenic potentials (VEMP) is a simple, reproducible test. Cervical and ocular vestibular evoked myogenic potentials (cVEMP and oVEMP) can be explored in the saccadic-spinal and utriculo-ocular pathways in regular clinical practice.

OBJECTIVE

To evaluate possible vestibular evoked myogenic potential (VEMP) abnormalities in patients with diabetic peripheral neuropathy.

MATERIALS AND METHODS

89 patients with Type 2 Diabetes in the present study consisted of three groups: 29 patients with no peripheral neuropathy (NDPN group), 26 patients with asymptomatic neuropathy (SDPN group), 34 patients with symptomatic neuropathy (DPN group). Meanwhile, 42 healthy subjects were recruited as controls. The clinical characteristics (including gender, age, body mass index (BMI), and illness duration), as well as lipids (including triglyceride (TG), cholesterol (TC), low-density lipoprotein (LDL), and high-density lipoprotein (HDL)), uric acid, fasting blood glucose (FBG), and glycated hemoglobin (HbA1c) were compared among the four groups. Four groups were assessed using two vestibular tests including oVEMP and cVEMP. Latency and amplitude parameters were analyzed from VEMP plots.

RESULTS

The latency of n10, p15 (oVEMP), p13, n23 (cVEMP) were significantly prolonged in the SDPN and DPN groups compared with the control and NDPN groups (p < 0.01), whereas latencies were similar in NDPN and the control groups. The amplitudes were not significantly different (p > 0.05). oVEMP latency p15 and cVEMP latency (p13, n23) were positively correlated with HbA1c, FBG, and illness duration, and oVEMP latency n10 was positively correlated with HbA1c and FBG. A nomogram, including FBG, HbA1C, HDL, TG, TC, LDL and group, was constructed to predict VEMP parameters and p13 was found to be independently associated with diabetic subgroups. Receiver operating characteristic curve (ROC) analysis showed good accuracy in predicting p13 in this nomogram. A user-friendly website has been created to facilitate the application of this prediction model ( https://fyey.shinyapps.io/VEMP_Model/ ).

CONCLUSION

Patients with diabetic peripheral neuropathy may have vestibular dysfunction. VEMP may be useful in assessing vestibular impairment in diabetic patients.

Vestibular evoked potential response in adults with type 1 diabetes

Purpose

Vestibular system is critical for maintaining balance. This study aimed to determine the function of the saccule of the otolith organ in adults with type 1 diabetes (T1D) using cervical vestibular evoked myogenic potential (cVEMP) and its independently associated demographic, clinical and laboratory variables.

Method

This case-control cross-sectional study included 60 patients (male = 15; female = 45) and 30 healthy adults. They underwent cVEMP.

Results

Patients had mean age of 30.63 ± 4.20 years and duration of illness of 14.68 ± 3.65 years. More than 50% had frequent diabetic ketoacidosis (DKA), 30% had frequent hypoglycaemic attack, 35% had comorbid hyperlipidaemia, and 40% had peripheral neuropathy. Dizziness was reported in 30%. Compared to controls, 40% of patients had significantly delayed absolute latencies of P1 and N1 (p = 0.01) either unilateral or bilateral and 80% had reduced P1-N1 amplitudes (p = 0.001). Higher frequencies of abnormalities were present bilaterally. Asymmetry ratio (AR) was reported in 25%. Patients with longer duration of diabetes (>5 year), dizziness, HbA1c (>7%), frequent DKA or hypoglycaemic attacks and peripheral neuropathy had significantly prolonged P1 and N1 latencies and reduced P1-N1 amplitudes compared to those with shorter duration of diabetes, without dizziness, with HbA1c% ≤7%, low frequency of DKA hypoglycaemic attacks and those without peripheral neuropathy. Multiple regression analysis showed that presence of delayed P1 latencies and reduced P1-N1 amplitudes were significantly correlated with duration of diabetes > 5 years [OR = 3.60 (95%CI = 1.80–6.44), p = 0.01; OR = 4.56 (95%CI = 2.80–7.80), p = 0.01] and HbA1c levels >7% [OR = 5.26(95%CI = 3.83–8.05), p = 0.001; OR = 4.55(95%CI = 2.45–8.55), p = 0.001].

Conclusion

The dysfunctions of the saccule of otolith organ and/or its pathway are prevalent in adults with T1D and correlated with duration and severity of diabetes. Therefore, optimal control of glycemic control is essential.

Cervical Vestibular-Evoked Myogenic Potentials in Individuals with Diabetes Mellitus: A Systematic Review and Meta-Analysis

Vestibular evoked myogenic potentials (VEMPs) in individuals with diabetes mellitus (DM) provide evidence as how diabetes can bring about changes in the peripheral nervous system. Cervical VEMP (cVEMP) evaluates the function and integrity of the sacullo- collic pathway and ocular VEMP (oVEMP) evaluates the utriculo-collic pathway. cVEMP is an ipsilateral inhibitory response of the sternocleidomastoid muscle. cVEMP is recorded at higher intensity above 80-85 dBnHL with biphasic waveforms having initial peak positivity P13 followed by a negativity N23. We performed a systematic review following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines to evaluate cVEMP in diabetes mellitus. The search was conducted in the databases: PubMed, Cumulative Index of Nursing and Allied Health Literature, Scopus, and Cochrane library using the keywords "diabetes mellitus" and "vestibular evoked myogenic potential" or "cVEMP." A two-phase selection process was used for the final inclusion of studies, and the methodological quality of these studies was assessed using the Newcastle Ottawa scale (NCOS). Meta-analysis was performed using a random-effects model. For comparisons between DM and healthy controls, a significant difference was observed for cVEMP amplitude (P = 0.01). Our meta-analysis's results suggest peripheral vestibular dysfunction can be observed in DM. It appears that cVEMPs may be useful in the early detection of neuropathy in DM.

Role of Vestibular Evoked Myogenic Potential (VEMP) in diagnosis of vestibular abnormalities in patients with type 2 diabetes mellitus

Objectives

To evaluate the role of ocular vestibular evoked myogenic potentials (oVEMP) in diagnosis of vestibular abnormalities among patients with type 2 diabetes mellitus (T2DM).

Methods

Eighty T2DM patients were selected for the study plus a group of 30 normal non-diabetic individuals. Both groups were assessed regarding oVEMP latency and amplitude.

Results

There were statistically significant differences in the latencies of N1 and P1 in patients with DM in comparison to controls in both the right and left ears although there was no significant difference between both groups regarding the amplitude of N1 and P1. We found that there were statistically significant differences in the latencies of N1 and P1 in patients with DPN in comparison with patients without DPN. Also, we found that there was no significant relation between duration of diabetes and VEMP latency. According to type of treatment, there was significant difference between diabetic patients on insulin therapy and those on hypoglycemic medications regarding latency of N1 and P1 (Table 6).

Conclusion

In patients with type 2 DM receiving primary health care, who are not seeking medical care due to sensory or balance decline, utricular function may be impaired even without history of falls.

Vestibular function for children with insulin dependent diabetes using cervical vestibular evoked myogenic potentials testing

BACKGROUND

Healthy vestibular system adjusts balance during static and dynamic conditions. This is important for normal development (standing up and walking). Vestipulopathies (central and peripheral) are common complications of diabetes in adult population. Related studies are scare in children with type 1 diabetes (T1D).

AIM

To assess saccular function of otolith organ in children with T1D and predictors for its dysfunction.

METHODS

Cervical vestibular evoked myogenic potential (cVEMP) was used for objective evaluation.

RESULTS

The study included 40 patients (boys = 15; girls = 25). Patients had mean age of 13.63 ± 1.50 years, duration of diabetes of 5.62 ± 2.80 years, frequent attacks of diabetic ketoacidosis (55%) and hypoglycemia (30%), hyperlipidemia (20%), hypertension (12.5%) and peripheral neuropathy (40%). Dizziness was found in 10%. Compared to healthy children (n = 25), patients had prolonged cVEMP P1 and N1 latencies and reduced P1-N1 amplitude. Bilateral cVEMP abnormalities were found in 60% (vs 25% for unilateral abnormalities). Higher frequencies and severe vestibulopathies were found with chronic diabetes of > 5 years, hemoglobin A1c values > 7%, frequent diabetic ketoacidosis and hypoglycemic attacks and presence of dizziness. Regression analyses showed that predictors for prolonged P1 latencies and reduced P1-N1 amplitudes were only chronic diabetes (> 5 years) {odds ratio (OR) = 2.80 [95% confidence interval (CI): 1.80-5.33], P = 0.01; OR = 3.42 (95%CI: 2.82-6.81)} and its severity (hemoglobin A1c > 7%) [OR = 3.05 (95%CI: 2.55-6.82), P = 0.01; OR = 4.20 (95%CI: 3.55-8.50), P = 0.001].

CONCLUSION

Dysfunction or injury of the saccular macula and its pathways is prevalent in children with T1D. Optimum glycemic control is important to prevent diabetes related vestipulopathies.

Auditory and Vestibular Functioning in Individuals with Type-2 Diabetes Mellitus: A Systematic Review

Introduction  Diabetes mellitus is a metabolic disease associated with a rise in the level of blood glucose. Individuals with diabetes mellitus are more likely to develop hearing loss, tinnitus, and dizziness due to macro- and microvascular complications. The extent to which auditory and vestibular functions are impaired in individuals with type-2 diabetes mellitus is still under debate.

Objective  To systematically review studies focusing on auditory and vestibular functions in individuals with type-2 diabetes mellitus.

Data Synthesis  A search was conducted in the PubMed, MedlinePlus, Ingenta Connect and Google Scholar databases for articles published until June 2019. A total of 15,980 articles were primarily retrieved, 33 of which were shortlisted based on the inclusion criteria set by the investigators for the systematic review. Out of 33 full-length articles, 26 evaluated the functioning of the auditory system, while 7 evaluated the functioning of the vestibular system. Most studies related to auditory functioning reported a significant effect of type-2 diabetes mellitus on the peripheral auditory system, whereas studies on vestibular functioning reported no significant effect of diabetes mellitus on the functioning of the peripheral vestibular end-organ.

Conclusion  Overall, the results of various audiological and peripheral vestibular tests reveal distinctive peripheral and/or central auditory and vestibular end-organ impairments in individuals with type-2 diabetes mellitus.

Cardiovascular Risk Factors and Benign Paroxysmal Positional Vertigo in Community Otolaryngology-Head and Neck Surgery

OBJECTIVE

Cardiovascular risk factors have been associated with benign paroxysmal positional vertigo (BPPV), possibly causing degeneration of the utricular epithelium and subepithelium, but supportive evidence is mixed. This is the first study to examine the association between cardiovascular risk factors and BPPV as they present in the community practice of comprehensive otolaryngology-head and neck surgery.

STUDY DESIGN

Cross-sectional case-matched case-control series.

SETTING

A community practice of otolaryngology-head and neck surgery with 3 clinical offices and a socioeconomically diverse patient population.

SUBJECTS AND METHODS

Clinical data were collected retrospectively from the electronic health records of a continuous 4-year series of 628 patients with BPPV and age- and sex-matched controls.

RESULTS

There were no statistically significant associations found between BPPV and diabetes, hypertension, dyslipidemia, or body mass index in the study population in pairwise comparisons or multivariable modeling.

CONCLUSION

This study suggests that BPPV as encountered in a community ear, nose, and throat practice is not generally associated with cardiovascular risk factors. The possibility that these or other cardiovascular risk factors may be causative in some cases cannot be excluded, though most cases of BPPV appear to be caused primarily by shedding of otoconia from the utricle that is idiopathic or at least in part by unconfirmed noncardiovascular factors.

Diabetes and the Vestibular System

Falls are among the most injurious, costly, and feared conditions affecting older adults. Patients with diabetes have a significantly greater risk for falling due to complications affecting the sensory systems required for balance: vision, proprioception, and vestibular. The effects of diabetes mellitus on the vestibular system are perhaps the least understood of these systems. The vestibular system is complex, includes multiple structures, and is difficult and expensive to thoroughly assess. There is pathophysiologic evidence suggesting a direct effect of diabetes mellitus complications on the vestibular system, but there is limited clinical evidence regarding which specific vestibular structures are most adversely affected. Nevertheless, large population-based studies show that patients with diabetes are more likely to have vestibular loss, have a high prevalence of a specific vestibular disorder called benign paroxysmal positional vertigo, and are at a greater risk for falling. Based on the available evidence, a balance screening and an evaluation of benign paroxysmal positional vertigo, a common but easy to treat pathology, in patients with diabetes is recommended as well as counseling on falls risk and home modifications.

Vestibular evoked myogenic potentials in patients with diabetes mellitus

Although the exact mechanism and most involved region of the vestibular system have not yet been fully clarified, vestibular dysfunction has been demonstrated in patients with diabetes mellitus (DM). Vestibular evoked myogenic potential (VEMP) is a short latency electromyographic response to sound or vibration stimuli that may reflect otolith organ or related reflex functions. Since its first description in 1992, VEMP has become a significant part of the vestibular test battery as an objective measurement tool. In diabetic patients, VEMP responses have been studied in order to determine any otolith organ or related reflex dysfunctions. Here, we review the literature with regard to VEMP findings representing any peripheral vestibular end-organ dysfunction in patients with DM. Distinctive vestibular end-organ impairments seem to be demonstrated in patients with DM either with or without DNP via objective vestibular testing tools including VEMP recordings according to relevant studies. However, further studies with larger sample sizes are required to reveal the more definitive findings of VEMP recordings regarding the vestibular pathologies in patients with DM.

Diabetes in the practice of otolaryngology

Diabetes mellitus is the most common endocrine disease, characterized by chronic hyperglycemia. The hyperglycemic milieu leads to endothelial injury in blood vessels of variant size, which results in microangiopathy and macroangiopathy (atherosclerosis). Consequential ischemia of nerves and hyperglycemia by itself lead to nerve degeneration and generalized neuropathy, affecting most often the sensory peripheral nerves and the autonomic nervous system. Auditory, vestibular and olfactory sensorium may be compromised by DM. People with DM have an increased susceptibility to infection, as a result of neutrophil dysfunction and impaired humoral immunity. Therefore DM predisposes to certain infectious diseases, such as fungal sinusitis or malignant otitis externa, which are rare in general population. Recovery from infections or from injuries may be compromised by coexisting DM. In this review we discuss complications of DM in the head and neck region. Otolaryngologists and general practitioners should be alert to specific conditions related to DM and be minded of the relevant complications and consequences.

Hyperglycemia and diabetes mellitus are related to vestibular organs dysfunction: truth or suggestion? A literature review

Diabetes mellitus is an independent risk factor for falling, particularly in the elderly. Due to chronic hyperglycemia and hyperinsulinemia patients with diabetes mellitus may have neurological deficits as peripheral neuropathy that is a debilitating micro-vascular complication affecting the proximal and distal peripheral sensory and motor nerves. Sensory neuropathy is prominent and represents the chief contributor to postural instability in diabetic subjects. Diabetic retinopathy is another complication consequent to a breakdown of the inner blood-retinal barrier with accumulation of extracellular fluids in the macula and growth of new vessels causing retinal detachment. Together peripheral neuropathy and retinopathy contribute to increase the risk of falls in diabetic patients, but a certain vestibular organs impairment should not be underestimated. Nevertheless, the exact mechanism and localization of peripheral vestibular damage consequent to chronic hyperglycemia and hyperinsulinemia are currently not still understood. Moreover it is not defined the possible role of these two blood conditions in worsening the prognosis of typical vestibular pathologies like "benign paroxysmal positional vertigo" and "Meniere disease". The aim of this review was to retrieve all studies investigating about the balance system alterations in patients suffering of diabetes. A search thorough Ovid MEDLINE was performed to enroll all eligible articles. Fourteen studies comprising a total of 1364 patients were included and analyzed in detail. On the basis of data reported in our review it appears plausible to hypothesize a direct connection among chronic hyperglycemic/hyperinsulinemic damage and peripheral vestibular organ dysfunction.

Balance Screening of Vestibular Function in Subjects Aged 4 Years and Older: A Living Laboratory Experience

To better understand the various individual factors that contribute to balance and the relation to fall risk, we performed the modified Romberg Test of Standing Balance on Firm and Compliant Support, with 1,174 participants between 4 and 83 years of age. This research was conducted in the Living Laboratory^® at the Museum of Science, Boston. We specifically focus on balance test condition 4, in which individuals stand on memory foam with eyes closed, and must rely on their vestibular system; therefore, performance in this balance test condition provides a proxy for vestibular function. We looked for balance variations associated with sex, race/ethnicity, health factors, and age. We found that balance test performance was stable between 10 and 39 years of age, with a slight increase in the failure rate for participants 4-9 years of age, suggesting a period of balance development in younger children. For participants 40 years and older, the balance test failure rate increased progressively with age. Diabetes and obesity are the two main health factors we found associated with poor balance, with test condition 4 failure rates of 57 and 19%, respectively. An increase in the odds of having fallen in the last year was associated with a decrease in the time to failure; once individuals dropped below a time to failure of 10 s, there was a significant 5.5-fold increase in the odds of having fallen in the last 12 months. These data alert us to screen for poor vestibular function in individuals 40 years and older or suffering from diabetes, in order to undertake the necessary diagnostic and rehabilitation measures, with a focus on reducing the morbidity and mortality of falls.

Otolith Dysfunction in Persons With Both Diabetes and Benign Paroxysmal Positional Vertigo

OBJECTIVE

Vestibular dysfunction is a well-recognized complication of type 2 diabetes (DM) that may contribute to increased fall risk. The prevalence of benign paroxysmal positional vertigo (BPPV) is higher in people with DM. The impact of DM on the otolith organs of the vestibular system in people with BPPV is unknown. The purpose of this study was to analyze otolith function using vestibular-evoked myogenic potential (VEMP) tests in people with DM and concurrent BPPV (BPPV + DM), and to examine the relationships between VEMP variables and diabetes-related variables.

STUDY DESIGN

Prospective, cross-sectional study.

SETTING

Tertiary academic medical center.

SUBJECTS AND METHODS

Participants 40 to 65 years were recruited in four groups: controls (n = 20), people with DM (n = 19), BPPV (n = 18), and BPPV + DM (n = 14). Saccule and utricle function were examined using cervical VEMP (cVEMP) and ocular VEMP (oVEMP), respectively. Diabetes-related variables such as HbA1c, duration of diabetes, and presence of sensory impairment due to diabetes were collected.

RESULTS

The frequency of abnormal cVEMP responses was higher in the DM (p = 0.005), BPPV (p = 0.003), and BPPV + DM (p <0.001) groups compared with controls. In the participants with diabetes, higher HbA1c levels were correlated with prolonged P1 (p = 0.03) and N1 latencies (p = 0.03). The frequency of abnormal oVEMP responses was not different between groups (p = 0.2).

CONCLUSION

Although BPPV and DM may independently affect utricle and saccule function, they do not seem to have a distinct cumulative effect.

Vascular and Neuroepithelial Histopathology of the Saccule in Humans With Diabetes Mellitus

HYPOTHESIS

This study aimed to determine if there are quantitative differences in the neuroepithelium and microvasculature of the saccule between subjects with and without diabetes mellitus (DM).

BACKGROUND

Histopathologic changes that may underlie the association between DM and vestibular dysfunction have not been characterized in humans.

METHODS

Human temporal bones (HTBs) from 39 subjects with DM (n = 16 type I DM [T1DM], n = 23 type II DM [T2DM]) were compared with 40 group age-matched controls. Vessel wall thickness was measured from the saccular arteriole. Type I and type II vestibular hair cell (VHC) counts were performed on perpendicularly oriented saccular maculae using differential interference contrast microscopy (T1DM: 5HTB/3 subjects; T2DM: 9HTB/8 subjects; controls: 25HTB/20 subjects).

RESULTS

The mean density of type I VHCs was 16 to 17% lower in the DM groups compared to controls (T1DM 52.21 [4.26], T2DM 53.3 [5.34], control 63.14 [2.49] cells/mm, p = 0.02). There were no differences between T1DM, T2DM, and control groups in type II VHC density (T1DM 40.89 [5.17], T2DM 40.44 [6.93], control 42.80 [1.79] cells/mm, p = 0.92) or in mean vessel wall thickness (T1DM 2.23 [0.62], T2DM 2.18 [0.53], control 2.00 [0.53] μm, p = 0.26).

CONCLUSION

Neuroepithelial pathology, manifested as lower density of type I VHCs, was observed in the saccules of subjects with DM. Saccular microangiopathy, expressed as alterations in arteriole thickness, was not observed. These findings are consistent with histologic observations in animals with experimentally induced diabetes. DM may have a selective and deleterious effect on human vestibular sensory epithelia.

The impact of diabetes on mobility, balance, and recovery after repositioning maneuvers in individuals with benign paroxysmal positional vertigo

AIM

The prevalence of benign paroxysmal positional vertigo (BPPV) is higher in people with type 2 diabetes (DM). The impact of DM on mobility, balance, and management of BPPV is unknown. This prospective study compared symptom severity, mobility and balance before and after the canalith repositioning maneuver (CRM) in people with posterior canal BPPV canalithiasis, with and without DM.

METHODS

Fifty participants, BPPV (n=34) and BPPV+DM (n=16) were examined for symptom severity (dizziness handicap inventory, DHI), mobility (functional gait assessment, FGA), and postural sway (using an accelerometer in five conditions) before and after the CRM. The number of maneuvers required for symptom resolution was recorded.

RESULTS

At baseline, no differences in DHI or FGA scores were seen between groups, however, people with BPPV+DM had higher sway velocity in the medio-lateral direction in tandem stance (p<0.01). After treatment, both groups improved in DHI and FGA scores (p<0.01), with no differences between groups. Decrease in sway velocity in the mediolateral direction (p=0.003) were seen in tandem stance in persons with BPPV+DM. There were no differences between the groups in the number of CRMs provided.

CONCLUSIONS

This pilot study showed no differences in symptom severity, mobility deficits or efficacy of CRM treatments in people with posterior canal BPPV canalithiasis with and without DM. Future studies examining the impact of the severity and duration of diabetes, as well as the influence of diabetic peripheral neuropathy on functional performance are essential.

Postural sway in individuals with type 2 diabetes and concurrent benign paroxysmal positional vertigo

BACKGROUND AND PURPOSE

diabetes has been shown to affect the peripheral vestibular end organs and is associated with an increase in the frequency of benign paroxysmal positional vertigo (BPPV). People with diabetes have higher postural sway; however, the impact of symptomatic BPPV on postural sway in individuals with diabetes is unclear. The purpose of this cross-sectional study was to examine postural sway in people with type 2 diabetes who have symptomatic, untreated BPPV (BPPVDM).

METHODS

fifty-two participants (mean age 56.9 ± 5.6 years) were enrolled: controls (n = 14), diabetes (n = 14), BPPV only (n = 13) and BPPVDM (n = 11). An inertial motion sensor was used to detect pelvic acceleration across five standing conditions with eyes open/closed on firm/foam surfaces. Range of acceleration (cm/s²), peak velocity (cm/s) and variability of sway [root mean square (RMS)] in the anterior-posterior (AP) and medial-lateral (ML) directions were used to compare postural sway between groups across conditions.

RESULTS

participants with BPPVDM had higher ranges of acceleration in the AP (p = 0.02) and ML (p = 0.02) directions, as well as higher peak velocity (p < 0.001) and RMS values (p = 0.006) in the AP direction compared to the control and diabetes groups. Standing on foam with eyes closed and tandem stance were challenging conditions for people with BPPVDM.

CONCLUSION

clinicians may consider using standing on foam with eyes closed and tandem standing with eyes open to assess postural control in people with BPPVDM to identify postural instability.