Vestibular hypersensitivity to sound in superior canal dehiscence: large evoked responses in the legs produce little postural sway

OBJECTIVE

Patients with superior canal dehiscence (SCD) typically have enhanced sound-evoked vestibular reflexes, such as vestibulo-collic and vestibulo-ocular reflexes. We wished to investigate whether sound-evoked lower limb EMG responses and postural sway are also enhanced in this condition.

METHODS

Eight patients with CT confirmed SCD (11 affected ears) and 8 age-matched normal controls participated. Three sound-evoked responses were measured; vestibulo-collic reflexes (i.e. vestibular-evoked myogenic potentials, VEMPs), lower limb vestibulo-spinal reflexes and body sway (centre of pressure in mm). Sound stimuli were 500 Hz air-conducted tone bursts of varying lengths (VEMPs: 2 ms; vestibulo-spinal: 20 ms; sway: 1s and 200 ms) set at fixed levels above each subject's VEMP threshold.

RESULTS

SCD patients had very large VEMP and vestibulo-spinal responses following high intensity stimulation, but at the matched intensity of 15 dB above threshold amplitudes were similar in both SCD patients and controls. The amplitude of both responses increased linearly with increasing stimulus intensity in both groups. Large ( approximately 20mm), stereotyped sway responses were present in only one (atypical) patient with high intensity stimulation. Small ( approximately 2mm) sway responses were present in the remaining patients, and began immediately following the vestibulo-spinal responses.

CONCLUSIONS

Despite the presence of large vestibular reflexes, there is usually very little body sway in response to loud sounds in SCD patients.

SIGNIFICANCE

Large short-latency vestibulo-spinal reflexes in SCD do not necessarily evoke large sway responses.

A source analysis of short-latency vestibular evoked potentials produced by air- and bone-conducted sound

OBJECTIVE

To map short-latency vestibular evoked potentials (VsEPs) using air- (AC) and bone-conducted (BC) sound and to perform source analysis to determine their origin.

METHODS

Ten normal volunteers, chosen to have low-normal thresholds for acoustic vestibular activation, participated. In the first part, the subjects' individual thresholds for vestibular activation (V(T)) were established using vestibular evoked myogenic potentials (VEMPs) recorded from the sternocleidomastoid muscles. AC sound was delivered with headphones and BC sound with a commercial B71 bone vibrator. In the second part, VsEPs were recorded using Ag/AgCl scalp electrodes in a 10-20 montage supplemented by infra-ocular, mastoid and cerebellar electrodes. Stimuli were 2ms pips, consisting of a single cycle of 500 Hz, presented at +18 dB re V(T) ("vestibular" condition) and -3 dB re V(T) (control condition).

RESULTS

Following the control stimulus, auditory mid-latency responses (MLRs) were observed. In the vestibular condition, two dominant groups of non-MLR potentials of presumed vestibular origin appeared (vestibular evoked potentials, or VsEPs), which consisted of a P10-N17 complex maximal at Pz, and an N15-P21 complex maximal at Fpz. Large potentials were also recorded from the infra-ocular electrodes at similar latencies. Source analysis indicated that the two complexes were largely accounted for by a combination of ocular vestibular evoked myogenic potentials (OVEMPs) and sub-cortical sources (possibly vestibular cerebellum), with a smaller contribution from anterior cortical and other myogenic sources.

CONCLUSIONS

Both the N15 and P10 potentials appear to receive an ocular myogenic contribution but both appear also to receive a contribution from other central structures.

SIGNIFICANCE

The P10 and N15 complexes appear to represent the activity of otolith-dependent projections.

Ocular vestibular evoked myogenic potentials in superior canal dehiscence

OBJECTIVE

Patients with superior canal dehiscence (SCD) have large sound-evoked vestibular reflexes with pathologically low threshold. We wished to determine whether a recently discovered measure of the vestibulo-ocular reflex-the ocular vestibular evoked myogenic potential (OVEMP)-produced similar high-amplitude, low-threshold responses in SCD, and could differentiate patients with SCD from normal control patients.

METHODS

Nine patients with CT-confirmed SCD and 10 normal controls were stimulated with 500 Hz, 2 ms tone bursts and 0.1 ms clicks at intensities up to 142 dB peak SPL. Conventional VEMPs were recorded from the ipsilateral sternocleidomastoid muscle to determine threshold, and OVEMPs were recorded from electrode pairs placed superior and inferior to the eyes. Three-dimensional eye movements were measured with scleral dual-search coils.

RESULTS

In patients with SCD, OVEMP amplitudes were significantly larger than normal (p<0.001) and thresholds were pathologically low. The n10 OVEMP in the contralateral inferior electrode became particularly large with increasing stimulus intensity (up to 25 microV) and with up-gaze (up to 40 microV). Sound-evoked (slow-phase) eye movements were present in all patients with SCD (vertical: upward; torsional: upper pole away from the affected side; and horizontal: towards or away from the affected side), but began only as the OVEMP response became maximal, which is consistent with the surface potentials being produced by activation of the extraocular muscles that generated the eye movements.

CONCLUSIONS

OVEMP amplitude and threshold (particularly the contralateral inferior n10 response) differentiated patients with SCD from normal controls. Our findings suggest that both the OVEMPs and induced eye movements in SCD are a result of intense saccular activation in addition to superior canal stimulation.

Delayed vestibular evoked responses to the eyes and neck in a patient with an isolated brainstem lesion

OBJECTIVE

Two recently described tests of the vestibular system, vestibular evoked myogenic potentials (VEMPs) and ocular vestibular evoked myogenic potentials (OVEMPs), test the descending and ascending vestibular brainstem pathways, respectively. We describe a case of a patient in whom these investigations localised the lesion and suggested its nature.

METHODS

VEMPs (to clicks and short duration galvanic stimulation) and OVEMPs (to clicks) were recorded.

RESULTS

Click- and galvanic-evoked VEMPs were delayed on the left side (by approximately 5-6 ms), and click-evoked OVEMPs were similarly delayed (by approximately 4 ms) following left-sided stimulation. Repeat testing 21 months later showed partial resolution.

CONCLUSIONS

The observed delays in evoked potentials suggested a demyelinating lesion. Furthermore, the similarity in delayed responses to neck and extraocular muscles was suggestive of a lesion at the root entry zone of the vestibulocochlear nerve.

SIGNIFICANCE

VEMPs and OVEMPS may thus provide information about the location and nature of lesions affecting central vestibular pathways.

Ocular vestibular evoked myogenic potentials (OVEMPs) produced by air- and bone-conducted sound

OBJECTIVE

To determine the origin and properties of short latency extraocular potentials produced by activation of the vestibular apparatus using two modes of acoustic stimulation.

METHODS

Extraocular potentials were measured in 10 normal subjects using a bipolar montage to increase selectivity. Three dimensional eye movements were also recorded in five subjects. The subjects were stimulated with both air-conducted (AC) and bone-conducted (BC) sound using a single cycle of a 500Hz sine wave.

RESULTS

Short latency positive and negative potentials that peaked at 8.1-12.7ms for AC and 7.5-13.9ms for BC stimulation were recorded, which were distinct for the two eyes and for the two modes of stimulation. The extraocular potentials began prior to the onset of eye movements, which peaked at 16.5-20.1ms for AC, 17.8-25.0ms for BC stimulation.

CONCLUSIONS

The pattern of short latency eye movements and extraocular potentials induced by AC and BC vestibular stimulation are distinct. As the potentials preceded the eye movements and were not correlated morphologically with them, the source of the observed potentials is not an eye movement and thus we refer to them as ocular vestibular evoked myogenic potentials (OVEMPs).

SIGNIFICANCE

The potentials had properties consistent with modulation of the electromyogenic activity of the extraocular muscles and if interpreted as originating from displacement of the eye will give misleading results. AC and BC acoustic stimulation are likely to activate differing profiles of vestibular end organs.

Vestibular evoked potentials (VsEPs) in patients with severe to profound bilateral hearing loss

OBJECTIVE

To confirm the exclusive vestibular dependence of the evoked potentials (P10 and N15) recorded in normal subjects, by recording the potentials evoked in response to bone-conducted sound stimulation in patients with bilateral hearing loss.

METHODS

Fourteen patients with severe to profound bilateral hearing loss were stimulated via a B71 bone-vibrator above the mastoid with bone-conducted tone bursts (500 Hz, 6 ms) at fixed levels above their individual vestibular evoked myogenic potential (VEMP) thresholds. Surface potentials were recorded from scalp electrodes at F7, F3, Fpz, F4, F8, T3, Cz, and T4 and referred to linked earlobes.

RESULTS

Seven of 14 patients had suitable VEMPs to the maximal stimulus. P10 and N15 potentials were present in each of these 7 patients, but were absent in patients with absent VEMP responses. The potentials were only detected above VEMP threshold, and were similar in size, shape and latency to those recorded in normal controls at a matched intensity above VEMP threshold.

CONCLUSIONS

Normal P10 and N15 potentials can be recorded from patients with profound bilateral hearing loss using bone-conducted acoustic stimulation of the vestibular apparatus.

SIGNIFICANCE

The P10 and N15 appear to be dependent purely upon vestibular activation.

Cervical dystonia responsive to acoustic and galvanic vestibular stimulation

We examined the effects of acoustic and galvanic vestibular stimulation in a patient with cervical dystonia. Acoustic stimulation consisted of three conditions: "baseline" (no stimulation), "vestibular" (500 Hz bone-conducted tone bursts), and "control" (5,000 Hz tone bursts). Rectified electromyographic activity in the sternocleidomastoid was measured. Galvanic stimulation (1.5-2.5 mA current steps) was delivered to the mastoids, and head acceleration was measured. Vestibular acoustic stimulation reduced neck muscle activity between 16% and 44% (P < 0.001), and galvanic stimulation reduced head acceleration by 22.5% (P = 0.028). The patient reported subjective improvement in head control. Vestibular stimulation can reduce neck muscle activity in cervical dystonia and give symptomatic relief.

Vestibular-evoked extraocular potentials produced by stimulation with bone-conducted sound

OBJECTIVE

To investigate the origin, whether ocular or extraocular, of the short latency frontal potential (N15) reported by following vestibular stimulation.

METHODS

Fourteen subjects with low VEMP thresholds (V(T)) and 9 patients with vestibular or ocular disorders were stimulated at the mastoid with bone-conducted tone bursts (500 Hz, 8 ms) above vestibular threshold, using a B71 bone vibrator. Surface potentials were recorded from Fpz and around the eyes and referred to linked earlobes.

RESULTS

The N15 was present at Fpz, but was largest around the eyes (mean amplitude 2.6 microV, peak latency 13.4 ms, with stimulation at +18 dB above threshold) and was generally in phase above and below the eyes. The response was vestibular-dependent and modulated by alteration of gaze direction. The potentials were delayed in a patient with Miller Fisher syndrome and were larger in patients with superior canal dehiscence than in controls.

CONCLUSIONS

We report a new vestibular-evoked extraocular potential. Its properties are not consistent with an eye movement. It is likely to be produced, mainly or exclusively, by synchronous activity in extraocular muscles (i.e. a myogenic potential).

SIGNIFICANCE

Vestibular-evoked extraocular potentials extend the range of vestibular pathways that can be assessed electrophysiologically, and may be a useful additional test of vestibular function.

A short latency vestibular evoked potential (VsEP) produced by bone-conducted acoustic stimulation

In this paper data are presented from an experiment which provides evidence for the existence of a short latency, acoustically evoked potential of probable vestibular origin. The experiment was conducted in two phases using bone-conducted acoustic stimulation. In the first phase subjects were stimulated with 6-ms, 500-Hz tone bursts in order to obtain the threshold V(T) for vestibular evoked myogenic potentials (VEMP). It was confirmed that the difference between bone-conducted auditory and acoustic vestibular thresholds was slightly over 30 dB. The estimated threshold was then used as a reference value in the second part of the experiment to stimulate subjects over a range of intensities from -6 to +18 dB (re: V(T)). Averaged EEG recordings were made with eight Ag/AgCl electrodes placed on the scalp at Fpz, F3, F4, F7, F8, Cz, T3, and T4 according to the 10-20 system. Below V(T) auditory midlatency responses (MLRs) were observed. Above V(T) two additional potentials appeared: a positivity at about 10 ms (P10) which was maximal at Cz, and a negativity at about 15 ms (N15) which was maximal at Fpz. Extrapolation of the growth functions for the P10 and N15 indicated a threshold close to V(T), consistent with a vestibular origin of these potentials. Given the low threshold of vestibular acoustic sensitivity it is possible that this mode may make a contribution to the detection of and affective responses to loud low frequency sounds. The evoked potentials may also have application as a noninvasive and nontraumatic test of vestibular projections to the cortex.

Vestibular activation by bone conducted sound

OBJECTIVE

To examine the properties and potential clinical uses of myogenic potentials to bone conducted sound.

METHODS

Myogenic potentials were recorded from normal volunteers, using bone conducted tone bursts of 7 ms duration and 250-2000 Hz frequencies delivered over the mastoid processes by a B 71 clinical bone vibrator. Biphasic positive-negative (p1n1) responses were recorded from both sternocleidomastoid (SCM) muscles using averaged unrectified EMG. The best location for stimulus delivery, optimum stimulus frequency, stimulus thresholds, and the effect of aging on evoked response amplitudes and thresholds were systematically examined. Subjects with specific lesions were studied. Vestibular evoked myogenic potentials (VEMP) to air conducted 0.1 ms clicks, 7 ms/250-2000 Hz tones, and forehead taps were measured for comparison.

RESULTS

Bone conducted sound evoked short latency p1n1 responses in both SCM muscles. Ipsilateral responses occurred earlier and were usually larger. Mean (SD) p1 and n1 latencies were 13.6 (1.8) and 22.3 (1.2) ms ipsilaterally and 14.9 (2.1) and 23.7 (2.7) ms contralaterally. Stimuli of 250 Hz delivered over the mastoid process, posterosuperior to the external acoustic meatus, yielded the largest amplitude responses. Like VEMP in response to air conducted clicks and tones, p1n1 responses were absent ipsilaterally in subjects with selective vestibular neurectomy and preserved in those with severe sensorineural hearing loss. However, p1n1 responses were preserved in conductive hearing loss, whereas VEMP to air conducted sound were abolished or attenuated. Bone conducted response thresholds were 97.5 (3.9) dB SPL/30.5 dB HL, significantly lower than thresholds to air conducted clicks (131.7 (4.9) dB SPL/86.7 dB HL) and tones (114.0 (5.3) dB SPL/106 dB HL).

CONCLUSIONS

Bone conducted sound evokes p1n1 responses (bone conducted VEMP) which are a useful measure of vestibular function, especially in the presence of conductive hearing loss. For a given perceptual intensity, bone conducted sound activates the vestibular apparatus more effectively than air conducted sound.

Differential effect of current rise time on short and medium latency vestibulospinal reflexes

OBJECTIVES

To investigate the effect of varying current rise time on galvanic-evoked short (SL) and medium (ML) latency vestibulospinal reflexes.

METHODS

We recorded the soleus EMG of standing subjects in response to 3 mA direct current transmastoid stimulation with a series of current ramps with rise times of 0-300 ms.

RESULTS

Longer current rise times significantly delayed the onset of both SL (P<<0.001) and ML (P<<0.001) vestibulospinal responses, by approximately 20 and 39 ms, respectively. The SL response amplitude was reduced with increasing rise time (P<<0.001), whereas the ML response amplitude was relatively unaffected by stimulus rise time. With very slow rise times a prolonged ML response alone was evoked.

CONCLUSIONS

Both SL and ML reflexes can be evoked by changes in vestibular activity produced by transmastoid galvanic stimulation with a ramp onset. We found a differential effect of current rise time on SL and ML vestibulospinal reflexes, suggesting different potential functional roles for the two reflexes. SL reflexes can participate in the response to abrupt disturbances only. ML reflexes are evoked by both fast and slow changes in vestibular discharge and may be particularly effective for slowly-changing disturbances.