Tympanic membrane temperature in a patient with vertigo

Tympanic membrane temperature (TMT) is greatly influenced by the internal carotid artery and the jugular vein. Average human brain temperature is influenced by the differences between the temperature of the internal carotid artery and of the jugular vein. TMT has been used extensively as an indicator of brain temperature. Tympanic membrane temperature was measured in six healthy men (control group) and one patient with vertigo. In the control group, TMT showed considerable circadian changes parallel to the core temperature. In the patient with vertigo, TMT varied widely after the attack of vertigo. These data can provide a basis for the understanding of vertigo attacks.

Vestibular compensation in vestibular neuronitis: evaluation of positional nystagmus and caloric nystagmus

We evaluated the vestibular functions, especially for positional nystagmus and caloric nystagmus, in 43 cases of vestibular neuronitis for long periods after its onset. It is shown that in the cases of vestibular neuronitis that were studied more than 10 years after the onset of the disease, the completed vestibular compensation changed or the vestibular compensation was still incomplete.

Progress of caloric response of vestibular neuronitis

Progress of caloric response and subjective symptoms of 60 patients with vestibular neuronitis was evaluated by a long term follow-up study. Normalization of caloric responses was confirmed in 25 (41.7%) out of 60 patients, 20 of whom had recovered within 2 years of the onset of vertigo. The rate of the patients with canal paresis was about 90% after 1 month of the onset, and 80% after 6 months, while 50% of them still showed canal paresis after 5 or 10 years had passed. Complete relief from subjective symptoms was recognized in 34 (56.7%) cases during the follow-up period. We conclude that the prognosis of vestibular neuronitis is not always good, because vestibular function did not recover within normal levels in about half of the patients in spite of complete relief from subjective symptoms in many of them.

Clinical observation of 32 cases of vestibular neuronitis

Clinical observations were made on 32 patients with vestibular neuronitis in the last 5 years: 14 male and 18 female, ranging from 15-76 years, the average being 46.3. Within the age distribution of the cases, two peaks were observed: a younger and an older group. Five patients (15%) had recently contracted infection of the upper respiratory tract before the onset of the disease, and two developed benign paroxysmal positional vertigo during the recovery period. Spontaneous nystagmus was observed in 19 cases (59%) in the first medical examination. There were several patients in whom there was the possibility of central lesions based upon the findings of equilibrium examinations. No relation was found between the degree of canal paresis and the time required for recuperation; however, the older patients took much longer to recover from the disease. Our results showed that there were considerable individual variations regarding the clinical findings, which may suggest that the pathological entity that creates this disease is not simple.

Relationship between GBST and equilibrium examination in vestibular neuronitis

Eleven patients with vestibular neuronitis were followed up from 1988 to 1990. The relationship between the GBST and other vestibular examinations was investigated. Vertiginous symptoms showed relative improvement, but in the last medical examination 4 out of 11 cases (36.4%) complained of unsteadiness when their head was rotated and fatigued. Seven patients (63.6%) presented spontaneous and positional nystagmus at the first consultation, but only one patient (9.1%) at the last one. Seven patients (63.6%) showed canal paresis to caloric stimulation, while 3 (27.3%) showed normal responses. In the galvanic body sway test (GBST), 9 patients (81.8%) showed abnormal thresholds. There was no significant relationship between vertiginous symptoms in the last medical examination and prodromes, vertigo type, nystagmus, righting reflex, caloric stimulation or the results of the GBST.

Prolonged dysequilibrium in three cases with vestibular neuronitis: efficacy of vestibular rehabilitation

The clinical course of acute unilateral vestibular disturbance in 3 cases with vestibular neuronitis and a case with labyrinthine destruction was surveyed for a long-term period. Vestibular training with a modified Cawthorne-Cooksey's exercise was done in 2 of 3 cases with vestibular neuronitis and a case of labyrinthine destruction. All had no severe troubles in activities of their daily lives over one year after the onset of the disease, but the central compensation was not completed, even in a young patient, in a case of labyrinthine destruction and in a well trained case. Spontaneous nystagmus to the affected side and increase of body sway with eyes closed were revealed by examinations in all cases. Physical exercise was found to be effective for relief from vestibular ataxia, but it was difficult to keep the effect even after training.

Vestibular neuronitis evaluated by the combined galvanic test

Forty-two patients with unilateral vestibular neuronitis were examined by the combined galvanic test (CGT), consisting of the galvanic eye movement test (GEMT) and the galvanic body sway test (GBST). Results of the CGT were evaluated with respect to the time period from the onset of vestibular neuronitis. A favorable recovery was observed earlier with the GBST than the GEMT. We believe that this discrepancy may be due to the difference in compensation between the vestibulo-ocular reflex and the vestibulo-spinal reflex.

Vestibular neuronitis in children

Seventeen cases of vestibular neuronitis in children, including 11 cases from the questionnaires of an epidemiological survey in Japan and 6 patients in our clinic, were examined. Sex and age distribution was 11 males and 6 females, ranging in age from 3 to 15 years. Bilateral and recurrent cases were not encountered. Fifty-three percent of children had had a preceding episode of an upper respiratory tract infection and this ratio was higher than that in adults. The etiology of vestibular neuronitis is probably many-faceted, but it is thought that upper respiratory tract infections play an important role especially in children. Vertiginous symptoms had almost subsided among children at the last visit. However, among adults, 24% of patients felt persisting unsteadiness. The disappearance of positional and positioning nystagmus was observed in 71% of children at the last visit. Caloric CP failed to recover in only 14% of all cases who were re-examined. As shown in this study, the prognosis in children is better than in adults for nystagmus and caloric response. The results of this study thus indicate that not only central compensation but also recovery of the peripheral vestibular function is more effective for bringing recovery from the vestibular disorder in children than in adults.

Bilateral vestibular neuronitis

Bilateral vestibular neuronitis with a different onset time for each affected side was reported in two cases among 74 cases observed. The first case appeared 3 weeks and the other 5 years before involvement of the second ear. In the case with a short period before the second attack, the direction of nystagmus was unchanged throughout the clinical course. It is suggested that the direction of nystagmus depends upon the severity of each vestibular dysfunction. In the case with a long period when the vestibular compensation has been completed, paralytic nystagmus was observed and its direction corresponded with the side affected by canal.

The intravenously administered glycerol test

Three different methods of performing the glycerol dehydration test were evaluated. Method one involved the oral administration of 50 g of 50% glycerol solution; method two was the intravenous administration of 500 ml of 10% glycerol in saline with 5% fructose; and method three involved the administration of 200 ml of the same solution. It was found that intravenous administration was safe and did not give any unpleasant side effects. Both intravenously administered methods appeared to give similar rates of positive diagnosis for Menière's disease.

Vestibular neuronitis in aged patients: results from an epidemiological survey by questionnaire in Japan

An epidemiological survey of vestibular neuronitis in Japan was done using a questionnaire. Answer sheets were obtained from 619 patients with vestibular neuronitis. In order to evaluate data from aged patients, 74 cases were singled out. The following results were obtained: i) There was no sexual difference and no laterality of affected side; ii) There was no case of bilateral vestibular neuronitis; iii) Ten cases were reported as recurrent. Aged patients had a relatively high rate of recurrence; iv) About 10% of 74 cases had had an upper respiratory tract infection, and this rate was lower than that for patients under 65 years of age; v) Thirty-five cases had complications. Hypertension was the most common complication; vi) The caloric test was re-used in 28 cases. The continued existence of caloric CP was observed in 23 cases upon re-examination.

Body sway response to experimental unbalance in normal subjects and patients with unilateral vestibular disorders

The function of maintaining posture during temporary unbalance caused by experimental vestibular asymmetry was studied. Galvanic stimulation to the vestibular nerve causing body deviation to the stimulated ear was given to 31 normal subjects and 16 patients with peripheral vestibular disorders. The velocity of spontaneous body sway and that during body deviation caused by the galvanic stimulation were compared. The spontaneous body sway velocity was significantly higher than that of normal subjects. In normal subjects, the body sway velocity during body deviation remarkably increased, while that in patients did not. It is considered that large body sway in patients might conceal the fine compensatory body sway during the body deviation and that patients with unilateral vestibular dysfunction who have large body sway are always in a dysfunction state similar to that which normal subjects experience during body deviation caused by galvanic stimulation.

Furosemide VOR test for the detection of endolymphatic hydrops

In order to detect endolymphatic hydrops, we applied three neuro-otologic examination methods, including the furosemide VOR test, the glycerol dehydration test, and electrocochleography in 61 patients with unilateral Menière's disease, 21 patients with delayed endolymphatic hydrops, and 10 patients with syphilitic labyrinthitis. The positive rate of the furosemide VOR test in patients with endolymphatic hydrops was more than 50%. Inconsistencies were observed between the results of the furosemide VOR test, the glycerol test and/or electrocochleography. Therefore, combined test battery of these tests is useful clinically for detecting endolymphatic hydrops in the vestibular and cochlear systems.

Clinical evaluation of the monothermal caloric test

The Torok Monothermal Caloric Test has been described as offering a strong advantage over bithermal caloric testing because it can distinguish labyrinthine from retrolabyrinthine lesions. Weak and strong irrigations of room-temperature water are administered to each ear and the ratios of strong to weak nystagmus responses compared to those of normal individuals. Ratios that fall below normal are said to represent decruitment and to denote retrolabyrinthine disease. Ratios that exceed normal are said to represent recruitment and to denote labyrinthine lesions. We attempted to verify the clinical value of the Monothermal Caloric Test by examining patients with known labyrinthine (N = 9) and retrolabyrinthine (N = 25) lesions. Ten patients with dysequilibrium and nonlocalizing testing were also examined. The test was performed exactly as described by the originator. Decruitment was found either unilaterally or bilaterally in 56% of patients with retrolabyrinthine lesions. However, it occurred on the side of the lesion in only 42%. Decruitment was also found in 47% of patients without retrolabyrinthine lesions, including 63% of those with unilateral Meniere's disease. Recruitment was never found on the side of a labyrinthine lesion. A description of the test and a summary of our results are presented. We conclude that the Monothermal Caloric Test is moderately sensitive to the presence of retrolabyrinthine lesions, but lateralizes poorly and is not highly selective. The test was found to be insensitive to the presence of labyrinthine disease.

[Nystagmus reactions after rotatory vestibular stimulation (modified Veits extended rotation method) in patients with normal equilibrium. Part II: Directional preponderance in nystagmus reactions]

Based on the absolute values of the different nystagmus reactions, measured after having used the rotational test on 70 healthy subjects, the directional preponderance (DP) was calculated in the present study according to the equation of Jongkees and Philippszoon. It could be shown that a DP of less than +/- 30% can be regarded as a normal standard only if it refers to the summarised nystagmic reaction of the per- and first postrotatory phase (Per+PI) of the test. Depending on the different parameters (frequency, amplitude or slow phase velocity of the nystagmus reactions), higher standard values have to be accepted for the different phases of the rotational test. The differentiation between healthy persons on the one hand and patients with an acute loss of vestibular function on the other can be best achieved by evaluating the nystagmographic reactions via the amplitude. Summing up, the modified rotational test also proved to be a very sensitive method in follow-up examinations of patients with vestibular lesions to differentiate between acute and compensated or regenerated stages of the disease.

[Correlation between audiometric and electronystagmographic results in Menière's disease]

Cochlear and vestibular functions of 30 patients suffering from Méniere's disease have been analyzed through audiometric and electronystagmographic studies. Auditive thresholds in low, medium and high frequencies have been correlated with the results of the caloric and pendular tests. Statistical analysis has demonstrated that there is no significant relationship between caloric and pendular reflectivity and hearing loss in the mentioned frequencies. In conclusion, in Méniere's disease hearing losses and vestibular alterations follow a different pathologic pattern.

Hearing results following posterior semicircular canal injury during antesigmoid retrolabyrinthine selective vestibular nerve section

The disastrous hearing results in six patients whose posterior semicircular canal was entered during antesigmoid mastoid craniotomy for retrolabyrinthine selective vestibular nerve section were reviewed. The injury occurred during skeletonization of the posterior semicircular canal to maximize intracranial exposure of the eighth nerve. All patients had Meniere's disease. Four patients were deafened, and in two, there was either no serviceable hearing or severe hearing impairment in the operated ear. Caution is urged in posterior semicircular canal labyrinthotomy for vertigo and attempted hearing preservation if a patient has symptoms of endolymphatic hydrops.

[Experimental defects of the round window membrane]

Previous and current studies of experimentally induced fistulas in the round window membrane (RWM) are reviewed. After puncture (or "micro-perforation") of the RWM leaking perilymph was not been observed and auditory evoked potentials have remained unaltered. In contrast, most publications have reported that gross incisions ("macro-perforations") of the RWM have resulted in the deterioration of auditory evoked potentials, with leaking perilymph and/or cerebrospinal fluid and/or with entrance of air bubbles into the scala tympani depending on the site of the perforation. Spontaneous healing was then observed within 4 to 8 days and was associated with normalization of the auditory evoked potentials. In a very few experimental studies pathophysiological mechanisms were simulated that may be involved clinically in patients with RWM fistulas, i.e. implosive rupture of the RWM due to an acute increase in middle ear pressure or explosive rupture of the RWM that may occur in patients trying to use forced Valsalva maneuvers to equalize decreased middle ear pressures due to blocked Eustachian tubes.

[Nystagmus reactions after rotatory vestibular stimulation (modified Veits long-term rotation) in patients with normal equilibrium. Part I: Absolute values of the nystagmus reactions]

In this study the nystagmographic findings of 70 healthy subjects--obtained after having used the rotatory test (modified method of Veits)--are summarised and visualised by means of easily appreciated graphs. In accordance with the recommendations of the ADANO, the test was carried out as a continuous turning of the chair, first clockwise and then counterclockwise, with an accelerating stimulus of 3 degrees/s2 and a sudden stop after a period of constant rotation with a speed of 90 degrees/s (trapezoidal stimulus). This was done for the absolute values of the following nystagmus parameters: frequency, amplitude and slow phase velocity of the nystagmus reaction. The limits of a normal nystagmus reaction are evaluated by the 5%- or 95%-percentiles on the one side and the mean values combined with the standard deviation mean value +/- 2 standard deviations on the other. It is shown that the rotatory test with its different phases enables very sensitive selection between healthy subjects and patients with an acute peripheral vestibular lesion. The intraindividual variability of the nystagmus reactions proved to be lower than that between our control persons (interindividual variability). By our method of employing the rotatory test it can be shown that the interfering phenomenon of habituation does not influence the nystagmographic results.

Endolymphatic hydrops induced by immune response of the endolymphatic sac: relation to perilymph antibody levels

This study investigated the effect of a secondary immune response in the endolymphatic sac on the development of endolymphatic hydrops in guinea pigs. Following secondary keyhole limpet hemocyanin (KLH) challenge directly to the sac in systemically presensitized animals, hydrops rapidly developed within 1 week, then gradually reduced by 4 weeks. After 5 weeks, hydrops gradually recurred and developed again. Mean perilymph anti-KLH antibody levels rose from day 1 to 4 weeks and then decreased. The elevation of perilymph anti-KLH antibody levels on day 2 was due to an increased vascular permeability and there was a local regeneration by the challenge of the sac after day 7. The development of hydrops correlated well with mean perilymph anti-KLH antibody levels in the period from day 1 to day 7. After 2 weeks, there was no correlation between them. These results suggest that an immune response of the sac may induce an excess secretion of endolymph in the initial stage and may further lead to irreversible dysfunction of the sac at a later stage.

Bilateral electrocochleographic findings in unilateral Menière's disease

At present, electrocochleography is the only proven investigation that can demonstrate objectively the presence of endolymphatic hydrops. The electrophysiologic recordings in response to sound stimuli show an enhancement of the negative summating potential in these cases. It is well established that patients with unilateral Meniere's disease have a high likelihood of development of the disease bilaterally in the fullness of time. Using transtympanic electrocochleography in 40 patients who manifested unilateral clinical Meniere's disease, we have recorded bilateral abnormalities indicative of endolymphatic hydrops in 35% of cases. The early recognition of incipient Meniere's disease in the asymptomatic contralateral ear of a patient with known unilateral disease has obvious profound implications for patient management.

Cochleovestibular nerve compression syndrome. II. Vestibular nerve histopathology and theory of pathophysiology

The present study was undertaken to systematically examine and characterize pathological changes in vestibular nerve specimens obtained at surgery in patients with symptomatic cochleovestibular nerve compression syndrome (CNCS). Vestibular nerves were obtained in six cases of CNCS and were intermingled with vestibular nerves obtained in cases of Meniere's disease. All of the nerve specimens were coded and reviewed microscopically in a blind-study fashion by the neuropathologist. The vestibular nerves obtained from CNCS cases showed significant endoneurial fibrosis, compared to controls (specimens from patients with Meniere's disease). Based on observations in this study, as well as the clinical symptoms and audiovestibular test findings in these patients, a theory of pathophysiology in CNCS of the cochleovestibular nerve is proposed. The implications of this theory are discussed with respect to the diagnosis of CNCS.

[Progressing cases from low tone sudden deafness to Menière's disease--cochlear impairment in the so-called pre-Menière's disease period]

Among 80 patients with low tone sudden deafness (LTSD) who visited our department over the past 15 years, there were 6 cases (7.5%) who subsequently progressed to Menière's disease. The clinical and audiological processes of the 6 patients were studied in detail and the following results were obtained. (1) In these 6 patients, the time between onset of LTSD and the diagnosis of Menière's disease ranged from 4 months at the shortest to 6 years and 8 months at the longest, 2 years and 9 months on average. (2) Two pattern types were seen in the change from LTSD to Menière's disease: changing within a short period of time after recurrence of an LTSD-like attack, and changing after more than one year without recurrent attack. (3) The monoattack-nonrecovered type of LTSD and the recurrent type of LTSD within three months after the onset (short-term prognosis) frequently progressed to Menière's disease. (4) There were no close relationships between subjective symptoms and audiological features in the pre-Menière's disease period (from the onset of LTSD to the recurrence of vertigo with cochlear symptoms). (5) The 6 patients showed various audiogram shapes at the time of progression to Meniere's disease; 3 cases with the slightly rising type, 1 with the high frequency-impaired type, and 2 with the moderate, gradual and flat type. (6) Of the 6 patients, 3 had good hearing during long term observation. At least 2 patients seemed to have the mild type of Menière's disease.(ABSTRACT TRUNCATED AT 250 WORDS)