The usefulness of computerized dynamic posturography for the study of equilibrium in patients with Meniere’s disease: correlation with clinical and audiologic data

Functional Level and Dynamic Posturography Results Two Years after Vestibular Neurectomy in Patients with Severe Meniere's Disease

Objectives: The aim of this study was to evaluate the functional outcomes and balance compensation in patients with severe Meniere's disease after vestibular neurectomy. Methods: Pre- and postoperative results were analyzed in twenty patients with unilateral Meniere's disease before and two years after vestibular neurectomy. Clinical evaluation was performed using a subjective grading scale proposed by the American Academy of Otolaryngology-Head and Neck Surgery and the Dizziness Handicap Inventory. Sensory organization test results were analyzed to assess the balance system before and after the surgery. Results: All patients reported a complete resolution of vertigo attacks after the vestibular neurectomy; 95% of patients reported functional level improvement according to a scale proposed by the American Academy of Otolaryngology-Head and Neck Surgery, and the average score decreased from 4.5 to 1.6. Clinical improvement, evaluated with the Dizziness Handicap Inventory, was present in all patients, with the average result decreasing from 81.7 to 16.4. Analyzing both grading systems, differences between pre- and postoperative results were statistically significant. No statistically significant differences were found between the sensory organization test results before and after vestibular neurectomy. Significant correlations were found between a patient's age and postoperative results of the Dizziness Handicap Inventory and posturography. Conclusions: Vestibular neurectomy is an effective vertigo treatment in patients with severe Meniere's disease with no clinical improvement despite conservative treatment. It results in subjective physical, functional, and emotional improvement, enabling patients to return to daily activities and work. An appropriate qualification of patients and comprehensive preoperative evaluation are essential to obtaining satisfactory clinical outcomes.

Does vestibular rehabilitation improve postural control of subjects with chronic subjective dizziness?

Postural control is the ability to maintain equilibrium and orientation in a gravitational environment. Patients with chronic subjective dizziness have some troubles with their postural stability. The present study aimed to assess the benefit of home-based vestibular rehabilitation in patients with chronic subjective dizziness using computerized dynamic posturography. Therefore, 100 subjects, between 19 to 86 years, diagnosed with dizziness were included in the study. Computerized dynamic posturography was performed to assess postural stability. Vestibular rehabilitation programs included exercises tailored to the particular needs of each patient. After vestibular rehabilitation, patients were re-examined using the same tests. Posturographic data were analyzed and compared for before and after vestibular rehabilitation findings. The mean composite scores before the intervention (58,92 ±11,64) was significantly (p<0.01) lower than the mean composite scores after vestibular rehabilitation (73,83 ± 8,26). This result is found to be statistically significant. In conclusion it could be suggested that the effectiveness of vestibular rehabilitation could be verified by means of computerized dynamic posturography as a concrete method.

Menière's disease patients improve specific posturographic parameters following diagnostic intratympanic injection

PURPOSE

Evaluation of specific computerized posturographic parameters in patients with Menière's disease (MD) following the intratympanic injection of gadolinium, a contrast agent, used in radiological diagnosing.

MATERIALS AND METHODS

We have observed 12 adult patients with unilateral Menière's Disease subjected to inner ear magnetic resonance imaging (MRI) examination after intratympanic gadolinium injection (ITG). The diagnoses have been performed according to the guidelines of the American Academy of otolaryngology. Before and after 24 h the ITG, all patients were subjected to the clinical evaluation and computerized posturography (CP), in 4 conditions depending on open/closed eyes and with/without foam cushion under feet.

RESULTS

After ITG, in the affected ear the MRI confirmed the endolymphatic hydrops revealing a thin or even disappeared perilymphatic space. The statokinesigram showed improvement of stability only with closed eyes on a foam cushion. The CP performed 24 h after the contrast intratympanic injection showed a significant reduction of Path Length and Confidence Ellipse Area, due to an improvement of vestibular function on static balance. This improvement could be directly dependent to intratympanic pressure modification mediated by volume of contrast liquid, by "columella effect".

CONCLUSIONS

This study demonstrates the absence of vestibular damage in patients undergoing intratympanic gadolinium infiltration and confirms the relationship between intratympanic pressure and vestibular stability modifications providing positive evidences for an applicative use of CP as a functional assessment to better address diagnosis and follow-up in MD patients treated with intratympanic injections.

Disorders of the inner-ear balance organs and their pathways

Disorders of the inner-ear balance organs can be grouped by their manner of presentation into acute, episodic, or chronic vestibular syndromes. A sudden unilateral vestibular injury produces severe vertigo, nausea, and imbalance lasting days, known as the acute vestibular syndrome (AVS). A bedside head impulse and oculomotor examination helps separate vestibular neuritis, the more common and innocuous cause of AVS, from stroke. Benign positional vertigo, a common cause of episodic positional vertigo, occurs when otoconia overlying the otolith membrane falls into the semicircular canals, producing brief spells of spinning vertigo triggered by head movement. Benign positional vertigo is diagnosed by a positional test, which triggers paroxysmal positional nystagmus in the plane of the affected semicircular canal. Episodic spontaneous vertigo caused by vestibular migraine and Ménière's disease can sometimes prove hard to separate. Typically, Ménière's disease is associated with spinning vertigo lasting hours, aural fullness, tinnitus, and fluctuating hearing loss while VM can produce spinning, rocking, or tilting sensations and light-headedness lasting minutes to days, sometimes but not always associated with migraine headaches or photophobia. Injury to both vestibular end-organs results in ataxia and oscillopsia rather than vertigo. Head impulse testing, dynamic visual acuity, and matted Romberg tests are abnormal while conventional neurologic assessments are normal. A defect in the bony roof overlying the superior semicircular canal produces vertigo and oscillopsia provoked by loud sound and pressure (when coughing or sneezing). Three-dimensional temporal bone computed tomography scan and vestibular evoked myogenic potential testing help confirm the diagnosis of superior canal dehiscence. Collectively, these clinical syndromes account for a large proportion of dizzy and unbalanced patients.

Sensory organization test principally reflects utricular function

CONCLUSION

Our study showed that sensory organization test (SOT) could principally reflect utricular function, and our cut-score of VEST ratio (the indicator of inputs from the vestibular system in balance performance) in SOT could help to screen patients with unilateral peripheral vestibular dysfunction in non-fallers.

OBJECTIVES

We aimed to know SOT reflects the function of which vestibular end organs and to assess the possibility of screening patients with peripheral vestibular dysfunction in non-fall population by means of SOT.

METHODS

A total of 75 patients with unilateral peripheral vestibular dysfunction underwent SOT, ocular vestibular-evoked myogenic potential (oVEMP), cervical vestibular-evoked myogenic potential (cVEMP) and caloric tests.

RESULTS

Regression model indicated that oVEMP, as an independent variable, exerted the greatest influence on VEST ratio, followed by age and cVEMP. There were no significant differences in VEST ratio among groups with different extents of peripheral vestibular involvement (p > .05). VEST ratio in the vestibular impairment groups was significantly lower than in the control group and significantly higher than in fall group (p < .01). VEST ratio in group with normal oVEMP was significantly higher than in group with abnormal oVEMP (p = .013). The cut-score between populations with functional and dysfunctional vestibule was 0.649.

Dynamic posturography for staging of patients with Ménière's disease

Objective:

In recent years, techniques such as computerised dynamic posturography have facilitated objective evaluation of patients with balance disorders. In this study, we used computerised dynamic posturography for clinical staging of Ménière's disease.

Material and methods:

We applied a computerised dynamic posturography sensory organisation test to 53 patients with American Academy of Otolaryngology criteria of Ménière's disease. The following parameters were considered in data analysis: computerised dynamic posturography scores for testing the patient's centre of gravity with a mobile surface, immobile visual surroundings and eyes closed, scores for testing with a mobile surface, mobile visual surroundings and eyes open, and vestibular ratio. We used four hearing threshold stages (although we had no patients at stage four).

Results and discussion:

This study did not observe a statistically significant correlation between audiometric hearing thresholds and computerised dynamic posturography scores. Computerised dynamic posturography scores showed statistically significant variation with time elapsed since the last vertigo attack. Although our results showed an increasing trend in computerised dynamic posturography scores as Ménière's disease activity level decreased from recent post-attack (i.e. less than one week since last attack) through late post-attack (i.e. one week to 60 days since last attack) to inactive (i.e. more than 60 days since last attack), these differences were not statistically significant.

Disability perception in Menière's disease: when, how much and why?

The purpose of the study was to evaluate self-perceived handicap in patients with definite Menière's disease (MD). A cross-sectional study was conducted. To examine the self-perception of disability, participants completed a DHI (Dizziness Handicap Inventory). Parameters compared with DHI scores: sex, age, unilateral/bilateral affectation, time elapsed since the onset of symptoms, pure-tone average (PTA), stages of MD, audiometric change (last 6 months), PTA in low frequencies (PTAl) and audiometric change in PTAl, subjective perception of fluctuating hearing threshold, tinnitus between attacks, number of vertiginous episodes (last 6 months), time elapsed since last attack, subjective perception of instability intercrises and Tumarkin attacks. 90 patients were included; they completed a total of 104 questionnaires. DHI scores ranged from 2 to 100 (average: 47.08, SD 24.45). In 29 cases (27.9 %) the disability perception was mild, in 43 (41.3 %) moderate, and in 32 (30.8 %) severe. Correlation between disability perception and some vestibular symptoms was found: number of typical attacks (last 6 months), time elapsed since last attack, instability intercrises and Tumarkin attacks. No relationship was found with the rest of variables. Disability perception in patients with MD depends primarily on vestibular symptoms (particularly, instability and frequency of attacks). So, we suggest to design a new staging system of MD taking into account both auditory criteria and also vestibular symptoms.

Clinical efficacy of the Romberg test using a foam pad to identify balance problems: a comparative study with the sensory organization test

The modified Romberg test using a foam pad ("MRuFP") as a bedside examination has been used to assess the function of the complex sensory input needed for upright stance. The objective of this study was to assess its clinical value detecting vestibular falls in comparison with the sensory organization test (SOT), the gold standard. In total, 80 patients who had undergone the MRuFP, SOT, and bithermal caloric tests were included in this study. The MRuFPs were performed on two (height 12 cm, MRu2FP) or three (18 cm, MRu3FP) layers of foam pads. The odds ratios of falling on SOT were calculated. Iterative algorithms were used for linear curve fitting between the balance time on the MRuFP and SOT equilibrium score (ES). The diagnostic performance of MRuFP under different conditions was poor, with low sensitivity (0.07-0.63), when the results of SOT were used as the gold standard. However, the odds ratios of failing SOT condition 5 were 6.78 (95% CI = 1.26-36.50) for patients with abnormal findings on eyes closed (EC)-MRu2FP and 10.91 (95% CI = 2.58-46.11) for those on the EC-MRu3FP in patients without caloric weakness. In patients with caloric weakness, the odds ratio of failing SOT condition 5 for patients with abnormal findings on EC-MRu2FP was 7.0 (95% CI = 0.69-70.74, p > 0.05), and 32.0 for those on EC-MRu3FP (95% CI = 2.81-364.7). A linear equation was presented as the model fit (adjusted R(2) = 0.355) predicting the SOT condition 5 ES according to the balance time on EC-MRu3FP. In conclusion, the EC-MRu3FP, as a bedside examination, correlated well with SOT condition 5 as an objective measure.

Factors Affecting Postural Instability in Ménière’s Disease

Objective

To assess the influence of factors that can affect the postural instability of Ménière’s disease (MD) patients.

Study Design

Case-control study.

Setting

Outpatient clinic in a university hospital.

Subjects and Methods

Fifty-four definite MD patients and 66 controls were included. Two-legged stance tasks were performed in 4 conditions: eyes open with and without foam rubber and eyes closed with and without foam rubber. We examined 6 variables: the velocity of movement of the center of pressure (COP), the envelopment area traced by the movement of the COP, Romberg’s ratio of velocity and area, and the foam ratios of velocity and area. For patients, stepwise multiple regression analyses were performed to explore the relationship between the 6 variables and the following independent variables: gender, age, the presence of abnormal caloric and/or cervical vestibular evoked myogenic potential (cVEMP) responses, the time elapsed since the last vertigo attack, and the disease duration.

Results

The presence of MD had a significantly positive relationship with all 6 of the variables ( P < .05). The presence of abnormal caloric and/or cVEMP responses had a significantly positive relationship with Romberg’s ratio of velocity ( P < .05) and area ( P < .01). The shorter time interval from last vertigo attack to measurement had a significantly positive relationship with the foam ratio of area ( P < .01).

Conclusion

MD patients show poor postural performance, which is affected by the existence of their peripheral vestibular function and the shorter time interval from last vertigo attack to measurement.

Bedside vestibular examination in patients with unilateral definite Ménière's disease

CONCLUSION

Although vestibular clinical examinations are quite variable in Ménière's disease (MD), when used in a grouped fashion they attach valuable information to the understanding of MD.

OBJECTIVE

Evaluation of unilateral MD vestibular bedside examination.

METHODS

This was a retrospective study of patients with definite unilateral MD at a tertiary care facility. Assessment of spontaneous nystagmus (SN), head-shaking nystagmus (HSN), head impulse test (HIT) and vibration-induced nystagmus (VIN) was carried out. Clinical manifestations and auditory and vestibular function were studied.

RESULTS

The study included 97 patients: 47 presented SN, 75 a positive HSN (biphasic in 14) and in 73 a VIN was observed. After excluding patients with biphasic HSN, a homogeneous response was observed in 43.4%: no nystagmus in 15.7%; nystagmus of similar direction in 27.8% (paretic, 14.5%; irritative, 13.3%). There were no significant differences in duration of the disease, functional level and vertigo index, although a trend towards a shorter time since last crisis was observed in patients with an irritative nystagmus. In 36.1% nystagmus was revealed with a consistent direction in at least one of the tests and in 20.5% it was non-coherent, something more frequently observed closer to the crisis. Independently only in VIN an irritative response was associated with a higher functional level and a shorter time from last attack.

Posturography with virtual reality stimulations in normal young adults with no balance complaints

PURPOSE

To analyze the findings of posturography with virtual reality stimuli carried out in young healthy adults with no otoneurological complaints, based on the parameters center of pressure, limit of stability and sway speed for different visual stimuli, and regarding differences between female and male genders.

METHODS

Participants were 50 healthy individuals of both genders (50% female and 50% male) with ages ranging from 18 to 25 years (mean age 21.30 years), with no complaints regarding body balance, and with vestibular outcomes assessed through digital vectonistagmography within normal limits. Posturography was composed of 11 visual stimuli and determined the limit of stability area (LOS), the ellipse area, and the sway speed in ten sensorial conditions. Results were calculated for the studied age range and analyzed according to the values for each stimulus, with the aim to obtain normality parameters.

RESULTS

The average values obtained in posturography regarding limit of stability, ellipse area and sway speed for stimuli with viso-vestibular interaction presented significant differences between genders, and, in all cases, women obtained lower values than men.

CONCLUSION

The findings of posturography with virtual reality stimuli in healthy young adults evidence that the parameters center of pressure, limit of stability and sway speed present differences between genders and, therefore, must be considered separately.

Cluster analysis of auditory and vestibular test results in definite Menière's disease

OBJECTIVES/HYPOTHESIS

To determine whether patients with Menière's disease can be grouped into distinct subtypes based on a cluster analysis of distinct disease parameters.

STUDY DESIGN

Prospective study at a tertiary center associated with a university hospital.

METHODS

The study included 153 patients diagnosed with unilateral definite Menière's disease. The main variables employed were taken from auditory, vestibular, posturographic, and disability assessments.

RESULTS

A four-cluster solution best fitted the data. Each cluster represented a distinct patient profile. Cluster 1 patients (13.1%) were the eldest, with the worst hearing bilaterally and good vestibular function but with a significant postural impact and a low level of disability. Cluster 2 patients (41.2%) were the least affected in all the parameters that were close to normal. Cluster 3 patients (34.6%) were the most affected, experiencing frequent and intense vertigo attacks, and they were visually dependent. Cluster 4 patients (11.1%) had strong asymmetric hearing between both ears and the most uncompensated vestibular deficit; they were moderately disabled.

CONCLUSIONS

We have identified four distinct profiles of patients with definite Menière's disease that we consider as "mildly active elderly," "mildly active young," "active compensated," and "active uncompensated." We have demonstrated that only in a restricted population of patients can the American Academy of Otolaryngology-Head and Neck Surgery staging system provide analysis of subtypes of the disease.

Audiovestibular testing in patients with Meniere's disease

In this article, the present state of the art with respect to audiovestibular testing for Meniere's disease (MD) is reviewed. There is no gold standard for MD diagnosis, and the classic dictum is that even the "best" tests yield positive results in only two-thirds of patients with MD. Still, we advocate the use and further investigation of advanced audiovestibular testing in patients with MD in an attempt to answer the questions that confront any clinician who cares for patients with audiovestibular symptoms.

Normal and vestibular patterns in dynamic posturography in patients with Meniere's disease

INTRODUCTION

The Sensory Organization Test of dynamic posturography allows a reliable assessment of the ability of any given patient to maintain a correct stability when conditions in the visual surrounding and/or support surface are deliberately modified. The results of this test can be analyzed according to the norms of the manufacturer of the device or through the application of specific formulae such as those by Cevette.

OBJECTIVES

To evaluate if the Cevette formulae distinguish correctly between the normal and vestibular patterns, as well as observing the differences between these two groups of patients (normal and vestibular), obtained either through standardized calculation or by the Cevette formulae. The work has been restricted to patients diagnosed with unilateral Menière's disease who presented an active form of the disease and who had not suffered a recent crisis.

MATERIAL AND METHODS

63 patients were studied who fulfilled the inclusion criteria for this study. A clinical and instrumental audio-vestibular study was carried out. The results of the sensory organization test were analyzed according to the pattern offered by the device and through the application of the Cevette formulae.

RESULTS

In 63 patients the pattern obtained was normal or vestibular. In 41 the pattern obtained through one system of analysis or the other coincided but in 22 they did not. The analysis of patients using the Cevette formulae offers a higher capacity for clinical discrimination but is not sensitive to the bias introduced by age; however, combined with the classification offered by the device, it manages to differentiate two populations (normal and vestibular) with a very good audio-vestibular correlation.

CONCLUSION

The combined assessment of the results of the sensory organization test using both the equipment analysis and the Cevette formulae provides much better and real information of clinical differences amongst patients with Menière's disease when the result is normal or of vestibular deficiency.

The limits of stability in patients with Ménière's disease

OBJECTIVE

To determine the ability of patients with unilateral Ménière's disease (MD) to reach the corresponding limits of stability and to define the existence of directional constraints.

PATIENTS

112 patients with unilateral MD and 30 normal age-matched subjects with no history of equilibrium problems.

METHODS

A computerized dynamic posturography system was used to test the ability of subjects to displace their centre of pressure (COP) to the corresponding limits of stability. The eight targets used were separated by 45 degrees to form a circle around the subject who had to displace their COP to the target. Reaction time, velocity, accuracy and an overall evaluation of the intended movement towards and away from the target were analysed. Other characteristics of the patients were also assessed.

RESULTS

A small but significant correlation was found between auditory and vestibular deficit and the different variables studied in the limits of stability test. Three factors were derived from variables obtained with short displacements, and the results are significantly different between patients and controls and are correlated with the period since the last vertigo spell, the level of disability, hearing loss and vestibular deficit.

CONCLUSIONS

Dynamic balance is moderately impaired in patients with Ménière's disease.

Comparison of electronystagmography results with dynamic posturography findings in patients with vestibular schwannoma

CONCLUSION

Condition-5-score (C5S) and condition-6-score (C6S) of computerized dynamic platform posturography (CDPP) can detect the presence of a functional deficit of the lateral semicircular canal (and the superior vestibular nerve), irrespective of the central vestibular compensatory status, in vestibular schwannoma (VS) patients.

OBJECTIVES

To test whether CDPP findings differ between VS patients with and without asymmetry on caloric and/or rotational ENG studies.

PATIENTS AND METHODS

This was a retrospective review of 216 consecutive patients with VS. C5S and C6S of CDPP (Equitest) were compared among patients with normal caloric and rotational studies, patients with asymmetry on caloric studies and normal rotational studies, and patients with asymmetric caloric and rotational studies using the Wilcoxon-Mann-Whitney test.

RESULTS

C5S and C6S of VS patients with normal caloric and rotational studies were significantly higher than in VS patients with either asymmetry on both rotational and caloric test results (p<0.001 for both C5S and C6S) or normal rotational studies and asymmetry on caloric testing (p<0.001 for both C5S and C6S). Neither C5S nor C6S were significantly different between patients with asymmetry on caloric testing and normal rotational studies and patients with asymmetry on both rotational and caloric testing.

Dynamic Posturography Findings Predict Balance Status in Vestibular Schwannoma Patients

OBJECTIVE

To test whether condition 5 score (C5S) and condition 6 score (C6S) of the sensory organization test of computerized dynamic platform posturography (CDPP) differ between vestibular schwannoma (VS) patients with and without vestibular symptoms.

STUDY DESIGN

Retrospective review of prospectively collected data.

SETTING

Tertiary academic referral center.

PATIENTS

Two hundred and sixteen consecutive patients with a histological diagnosis of a VS (103 women; 113 men; age range, 18-78 years; median, 54 years) who had been preoperatively evaluated by CDPP. A hundred and twelve patients had a history of vertigo, dizziness, and/or imbalance, and 104 patients had neither present nor past vestibular symptoms at all.

INTERVENTION

Diagnostic. Preoperative CDPP in VS patients with and without vestibular symptoms.

MAIN OUTCOME MEASURES

Condition 5 score and C6S of the sensory organization test of CDPP of VS patients. To test whether C5S and C6S differ between VS patients with and without vestibular symptoms, the Wilcoxon-Mann-Whitney rank sum test was applied.

RESULTS

Both C5S (p = 0.001) and C6S (p < 0.0005) were significantly lower in VS patients with vestibular symptoms than in VS patients without vestibular symptoms.

CONCLUSION

There is a significant difference in the distribution of C5S and C6S between VS patients with and without vestibular symptoms. Thus, patients with symptoms tend to have lower C5S and C6S than patients without symptoms, although this trend is not sufficient for reliable discrimination for all patients.

Influence of nerve of origin and tumor size of vestibular schwannoma on dynamic posturography findings

CONCLUSION

Condition 5-score (C5S) and vestibular ratio (VER) correlate, but condition-6-score (C6S) and mean overall balance score (MOBS) do not, with the size of an inferior vestibular nerve (IVN) vestibular schwannoma (VS). In IVN VS patients the visual system plays a major role in the maintenance of postural stability.

OBJECTIVES

To test whether the size of a superior vestibular nerve (SVN) or IVN VS, as measured on MRI scans, correlates with computerized dynamic platform posturography (CDPP) findings and whether CDPP findings could preoperatively predict the nerve of origin of the VS.

PATIENTS AND METHODS

This was a retrospective study. Seventy-five consecutive VS patients were evaluated. C5S, C6S, VER, and MOBS were evaluated. Spearman's rank correlation coefficients were calculated between the tumor's larger dimension and each of the four parameters for SVN and IVN VS. The nerve of VS origin was identified intraoperatively. To test for differences between CDPP findings of the SVN and IVN groups of VS patients, the Wilcoxon-Mann-Whitney sum rank test was applied.

RESULTS

Larger dimension of VS was correlated with C5S and VER in IVN VS patients (r = - 0.358, p=0.008 and r = - 0.356, p=0.008, respectively). Neither C6S nor MOBS showed any significant correlation with the tumor's larger dimension. None of the four scores showed any significant difference between the SVN and IVN groups of VS patients.