Diagnostic assessment of patients with Meniere's disease through caloric testing and the video-head-impulse test

The Role of Asymmetry Values, Gain, and Pathological Saccades of the Video Head Impulse Test (vHIT) in Sudden Sensorineural Hearing Loss

OBJECTIVE

The purpose of this study was to evaluate the value of asymmetry values, gain, and pathological saccades of the video head impulse test (vHIT) in sudden sensorineural hearing loss (SSNHL).

STUDY DESIGN

Retrospective study.

SETTING

Tertiary referral center.

PATIENTS

A total of 226 individuals diagnosed with unilateral definite SSNHL were hospitalized. The assessment included a comprehensive evaluation of medical history, pure-tone test, acoustic impedance, positional test, video nystagmography (VNG), vHIT, vestibular evoked myogenic potentials (VEMPs) and magnetic resonance.

INTERVENTIONS

vHIT, VNG, cVEMP, oVEMP. Statistical analysis was performed with SPSS version 22.0 for Windows.

MAIN OUTCOME MEASURES

The asymmetry values, gain, and pathological saccades of the vHIT.

RESULTS

The abnormal gain of vHIT in anterior, horizontal, and posterior canal in SSNHL patients with vertigo were revealed in 20 of 112 (17.9%), 24 of 112 (21.4%), and 60 of 112 (53.6%), respectively. The vHIT pathological saccades (overt + covert) of anterior, horizontal, and posterior canal in SSNHL patients with vertigo were observed in 5 of 112 (4.6%), 52 of 112 (46.4%), and 58 of 112 (51.8%), respectively. Multivariate analysis indicated that the prognosis of patients with vertigo was correlated with vHIT gain of posterior canal, pathological saccade in horizontal canal, asymmetric ratio of horizontal canal gain, asymmetric ratio of posterior canal gain, Canal paresis (%) on caloric test and spontaneous nystagmus.

CONCLUSION

In the vHIT of patients with SSNHL with vertigo, the posterior canal is most easily affected. Reduced gain of posterior canal, pathological saccade of horizontal canal, and larger asymmetric gain of posterior canal and horizontal canal may be negative prognostic factors.

Effect of Late-Stage Meniere's Disease and Vestibular Functional Impairment on Hippocampal Atrophy

OBJECTIVE

We investigated correlations among clinical features, degree of inner ear endolymphatic hydrops (EH), and hippocampal volume (HV) in different stages of Meniere's disease (MD).

METHODS

From February 2021 to April 2022, clinical data were collected from 99 patients (39 males, 60 females, mean age: 50.4 ± 10.0 [range: 26-69] years) with unilateral MD admitted to the Department of Vertigo Disease of Shandong ENT Hospital. The left and right ears were affected in 64 and 35 patients, respectively. There were 50 and 49 cases in early (Stages 1, 2) and late stages (Stages 3, 4), respectively. Fifty healthy participants were included as controls. Audiovestibular function test results, EH grading using gadolinium-enhanced magnetic resonance imaging (MRI), and HV determined on MRI were analyzed for patients at different stages of MD.

RESULTS

Between-group comparisons of early and late MD revealed significant differences in the disease course, vestibular function (VF), degree of EH, and HV. There were no significant between-group differences based on age, sex, affected side, subjective degree of dizziness, hospital anxiety, or depression. Mean HV in patients with early-stage MD was correlated with the canal paresis value of the caloric test and pure tone hearing threshold, HV in late-stage patients was correlated with vestibular EH.

CONCLUSION

Patients with late-stage MD exhibited severe auditory and VF impairments, increased EH, and atrophy of the HV. More advanced disease was associated with greater vestibular damage and degree of EH.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:410-418, 2024.

Meniere Disease treated with transcutaneous auricular vagus nerve stimulation combined with betahistine Mesylate: A randomized controlled trial

BACKGROUND

Meniere Disease is a clinical condition defined by hearing loss, tinnitus, and aural fullness symptoms, there are currently no any medications approved for its treatment.

OBJECTIVE

To determine whether taVNS as an adjunctive therapy could relieve symptoms and improve the quality of life in patients with Meniere disease.

METHODS

In this Single-center, single blind, randomized trial, participants were assigned to transcutaneous auricular vagus nerve stimulation (taVNS) group and sham taVNS group. The primary outcome measures comprised Tinnitus Handicap Inventory, Dizziness Handicap Inventory, Pure Tone Auditory, Visual analogue scale of aural fullness. Secondary outcome measures comprised the 36-Item Short Form Health Survey, video head impulse test, and the caloric test.

RESULTS

After 12 weeks, the THI (-11.00, 95%CI, -14.87 to -7.13; P < 0.001), DHI (-47.26, 95%CI, -50.23 to -44.29; P < 0.001), VAS of aural fullness (-2.22, 95%CI, -2.95 to -1.49; P<0.01), and Pure Tone Thresholds (-7.07, 95%CI, -9.07 to -5.06; P<0.001) were significantly differed between the two groups. In addition, SF36(14.72, 95%CI, 11.06 to 18.39; P < 0.001), vHIT (RD, 0.26, 95 % CI, -0.44 to -0.08, RR, 0.43, 95 % CI, 0.22 to 0.83, P < 0.01), and the caloric test (RD, -0.24, 95 % CI, -0.43 to -0.04, RR, 0.66, 95 % CI, 0.44 to 0.95, P = 0.02) have significant difference between two group, respectively.

CONCLUSIONS

These findings suggest that taVNS combined with Betahistine Mesylate relieve symptoms and improve the quality of life for patients with Meniere Disease. taVNS can be considered an adjunctive therapy in treatment of Meniere Disease.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05328895.

Dissociation between video head impulse test and caloric test: a marker of menière's disease? - A systematic review and meta-analysis

OBJECTIVE

To analyze, by means of a systematic review and meta-analysis, the proportion of patients with Meniere's disease who have altered caloric test and vHIT, as well as to determine the prevalence of altered caloric test and normal vHIT dissociation in the diagnosis of Meniere's disease.

METHODS

The literature search had no restriction regarding the period of publication on the following indexed data platforms: PubMed, PubMed PMC, BVS-Bireme, Web of Science, Embase and Cochrane Library. Articles that evaluated patients with Meniere's disease who underwent caloric test and vHIT were included. Two researchers independently conducted the analysis of the articles, promoting the selection and capture of data, following the recommendations of the PRISMA method, and complying with the criteria for articles inclusion and exclusion defined in the research protocol. In case of disagreement during the selection process, a third researcher was included for analysis.

RESULTS

From a total of 427 initial studies, the researchers selected 12 articles, published between 2014 and 2021, with a total of 708 patients evaluated, with a mean age of 52.72 years old. The prevalence of patients with Meniere's disease with altered caloric reflex test was 64% (95% CI 57%‒71%), while the prevalence of altered vHIT was only 28% (95% CI 16%-40%). The prevalence of the altered caloric test + normal vHIT dissociation was 47% (95% CI 37%-57%).

CONCLUSION

The video head impulse test and the caloric test are valuable tools for vestibular assessment. The dissociation of findings between these two tests in patients with Meniere's disease was more prevalent in this meta-analysis and may be a result of the tonotopy of specialized hair cells in the ampullary crest. The prevalence of altered caloric test was 64% and anormal vHIT was 28%. The dissociation caloric asymmetry and normal vHIT was observed in 47% of the patients.

LEVEL OF EVIDENCE: 1

Comparison of clinical characteristics and vestibular function test results in patients with vestibular migraine and Menière's disease

OBJECTIVES

The differentiation between Vestibular Migraine (VM) and Meniere's Disease (MD) is difficult because of overlapping symptoms. The study aimed to compare the clinical characteristics and vestibular function test results between VM and MD patients.

METHODS

Seventy-one patients with definite VM and 31 patients with definite unilateral MD were included. All patients received Caloric Test (CT), Video Head Impulse Test (vHIT) and Vestibular Evoked Myogenic Potential (VEMP) test within 7 days after visiting the hospital. Results of these tests were compared between groups.

RESULTS

Most VM patients (64.0%) experienced spontaneous internal vertigo, while most MD patients (66.7%) experienced spontaneous external vertigo. MD patients had more severe vestibular symptoms and autonomic responses compared to VM patients during attacks (p =  0.03, p = 0.00, respectively). The nystagmus intensity of CT-induced was greater in VM patients than in MD patients (p = 0.003). More VM patients had CT intolerance and Central Positional Nystagmus (CPN) compared to MD patients (p = 0.002, p = 0.006, respectively). More MD patients had CT(+) and vHIT saccades wave compared to VM patients (p < 0.001, p = 0.002, respectively). The non-elicitation rate of cervical VEMP was higher, and the ocular VEMP amplitudes were lower in MD patients than in VM patients (p = 0.002, p = 0.018).

CONCLUSIONS

Vestibular symptoms during attacks combined with the results of vestibular function tests may be used to differentiate between VM and MD. The diverse nature of vestibular symptoms (especially internal vertigo), history of motion sickness and CT intolerance may provide clues to the diagnosis of VM, whereas spontaneous external vertigo, CT(+) with vHIT(-), and the presence of saccades may provide clues to the diagnosis of MD.

LEVEL OF EVIDENCE: 4

Cross-Sectional Analysis of Videonystagmography (VNG) Findings in Balance Disorders

OBJECTIVE

To understand the videonystagmography (VNG) findings in various balance disorders in 67 patients who presented to the outpatient department of an otorhinolaryngology clinic.

MATERIALS AND METHODS

This cross-sectional study was conducted in the outpatient department of the otorhinolaryngology clinic of a tertiary care center. A total of 67 patients between the age group of 18 and 70 years with balance disorders were included in the study. VNG findings in different balance disorders were observed and analyzed.

RESULTS

A total of 67 patients were enrolled in the study. Findings like caloric inversion and optokinetic nystagmus do not always indicate a central balance disorder due to technical errors and other limitations during the test. However, abnormal saccades seem to be a more relevant finding in central disorders. Rare variants of benign paroxysmal positional vertigo (BPPV) like multiple canal BPPV were also diagnosed using VNG.

CONCLUSION

VNG has come out as a very useful test in our study aiding in 75% of diagnoses. The overall benefits of VNG in balance disorders are immense and necessitate their inclusion in every vertigo clinic.

Dissociation between Caloric and Video Head Impulse Tests in Dizziness Clinics

Vestibular assessment tests such as the video head impulse test (vHIT) for the horizontal semicircular canal, and caloric test (Cal), both evaluate horizontal canal function. One would assume that the outcomes for these tests should lead to concordant results, yet several studies have suggested that dissociation can occur in certain pathological conditions. As this topic remains inconclusive, this review aims to analyze the scientific evidence regarding the patterns of hypofunction observed in vHIT and Cal in different otoneurological diseases. A comprehensive review of the literature regarding dissociation between these tests in common neurotological diseases was carried out. Articles were analyzed when data for vHIT and Cal were described in a way that it was possible to calculate discordance rates; both retrospective and prospective studies were analyzed. In this review, the discordance rates were as follows: 56% in Ménière’s disease, 51.5% in vestibular migraine, 37.2% in vestibular schwannoma, and 20.8% in vestibular neuritis. These results highlight the benefit of using both Cal and vHIT, and that they are complementary tests.

The Relationship between Meniere's Disease and Acute Low-Tone Sensorineural Hearing Loss

Objective

To analyse the vestibular function characteristics of patients with Meniere's disease and acute hypophonic sensorineural hearing loss in order to find more reliable and objective ancillary tests that will reduce misdiagnosis and missed diagnoses.

Methods

From January 2021 to December 2021, 60 healthy adults who underwent physical examination in our hospital were included in the control group, 60 patients with Meniere's disease were included in Study Group A, and 60 patients with acute low-tone sensorineural hearing loss were recruited in Study Group B. All participants underwent the caloric test (CT), video-head impulse test (vHIT), headshaking test (HST), and vestibular-evoked myogenic potential (VEMP) testing, which includes ocular vestibular-evoked myogenic potential (oVEMP) and cervical vestibular-evoked myogenic potential (cVEMP).

Results

Statistical analyses of unilateral weakness and directional preponderance (DP) in the two groups of patients found no significant differences between the two groups (P > 0.05). There was no statistically significant difference in the abnormal rate of vHIT and HST results between the two study groups (P > 0.05). There was no significant difference in the wave latencies, interwave intervals, and amplitudes of cVEMP and oVEMP, among the three groups (P > 0.05).

Conclusion

This study found that factors affecting CT, vHIT, HST, and VEMP results included age, head posture and position during testing, stimulus type, manipulation method, and control of muscle tone, and also those that are related to the testing instrument, statistical software, and manipulation procedures, resulting in different excitation rates and testing parameters. The small sample size prevented a comprehensive assessment of the differences in vestibular function between patients with Meniere's disease and acute hypotonic sensorineural hearing loss, and a larger sample size will be investigated in the future to provide useful insight into the diagnosis, treatment and differentiation of Meniere's disease, and acute hypotonic sensorineural hearing loss.

Does the video head impulse test replace caloric testing in the assessment of patients with chronic dizziness? A systematic review and meta-analysis

Introduction

Caloric testing is the most frequently used test to assess peripheral vestibular function since the beginning of the 20th century. However, the video head impulse test, vHIT, has gained prominence in the field of neurotology, as it is a faster examination, easier to perform and less uncomfortable for the patient.

Objective

To compare, through systematic review and meta-analysis, the proportion of altered cases between vHIT tests and caloric testing in patients with chronic dizziness, in addition to assessing the sensitivity and specificity of vHIT, with caloric testing as the gold standard.

Methods

The literature search was carried out in the PubMed, Scopus, BVS-Bireme, Web of Science, Embase, Cochrane and ProQuest indexed databases, with no restrictions regarding the publication period. All articles that contained the results of the two tests were included in the evaluation of patients with dizziness. Two researchers independently conducted data selection and extraction from the studies, strictly following the inclusion and exclusion criteria defined in the research protocol. In case of disagreement during the selection, a discussion was carried out with a third evaluator.

Results

Eleven of the 1293 initial articles met the eligibility criteria and were analyzed. 2670 patients were evaluated, of which 1112 (41.6%) were males and 1558 (58.4%) females, with a mean age of 51.6 years. The proportion of altered results in the vHIT was 21% (95%CI 9% –33%), and 55% in the caloric testing (95%CI 43% –67%).

Conclusion

The vHIT does not substitute for caloric testing. The tests are complementary in assessing the patient with dizziness, as they describe the tonotopy of the ampullary crest at different frequency ranges of stimulation. In chronic cases, the vHIT has a low sensitivity and high diagnostic specificity in comparison to caloric testing.

Usefulness of Video Head Impulse Test Results in the Identification of Meniere's Disease

Meniere's disease (MD) is an inner ear disorder inducing tinnitus, aural fullness, sensorineural hearing loss, and vertigo episodes. In the past few years, efforts have been made to develop objective measures able to distinguish MD from other pathologies. Indeed, some authors investigated electrophysiological measures, such as electrocochleography and vestibular evoked myogenic potentials or imaging techniques. More recently, the video head impulse test (vHIT) was developed to assess the vestibulo-ocular reflex (VOR). In the last few years, authors aimed at identifying how vHIT may help to identify MD. The objective of this manuscript is to review the different vHIT results in MD patients. We will discuss the usefulness of these findings in the identification of MD, how these results may be explained by pathophysiological mechanisms associated with MD, and finally provide directions for future studies.