Semicircular canal versus otolithic involvement in idiopathic sudden hearing loss

The impact of vestibular symptoms and electronystagmography results on recovery from sudden sensorineural hearing loss

OBJECTIVES

Idiopathic sudden sensorineural hearing loss (SSNHL) represents a frequently encountered otological entity, of various types and severity, with an array of associated symptoms including vertigo. This is a devastating life-changing condition with a blurry prognosis. The objective of this study was to determine the clinical association of vestibular impairment by electronystagmography (ENG) and caloric tests, and their ability to predict prognosis.

METHODS

An observational, crossectional study was carried out amongst patients admitted with SSNHL. Each consenting patient had an audiometry test performed on admission as well as ENG and caloric tests. Treatment included oral steroids and carbogen with intratympanic steroids used only as salvage treatment. Follow-up was completed after 6 months when hearing gains were evaluated. Finally, an association was sought between the rate of recovery and ENG and caloric test results.

RESULTS

Of 35 patients included, marked recovery was seen in patients without vertigo when compared to those with vertigo (p=0.003). A statistically significant association was found between the presence of vertigo and hearing deterioration (p=0.008). More so, normal electronystagmography results were associated with marked recovery (p=0.04).

CONCLUSIONS

The vestibular end organs are both subjectively and objectively affected in SSNHL as demonstrated by the abnormal ENG and caloric tests in our study despite the small sample size. Concomitant vestibular involvement carries poorer prognosis and routine identification may help foresee the recovery of patients with SSNHL and as such, aid in patient counseling. ENG and caloric tests are easily available and may be recommended for all patients with SSNHL.

Vestibular assessment in sudden sensorineural hearing loss: Role in the prediction of hearing outcome and in the early detection of vascular and hydropic pathomechanisms

Introduction

Predicting hearing outcome in sudden sensorineural hearing loss (SSNHL) is challenging, as well as detecting the underlying pathomechanisms. SSNHL could be associated with vestibular damage since cochleo-vestibular structures share the same vascularization, along with being in close anatomical proximity. Whereas viral inflammations and autoimmune/vascular disorders most likely represent the involved aetiologies, early-stage Menière's disease (MD) can also present with SSNHL. Since an early treatment could beneficially influence hearing outcome, understanding the possible etiology plays a pivotal role in orienting the most appropriate treatment. We aimed to evaluate the extent of vestibular damage in patients presenting with SSNHL with or without vertigo, investigate the prognostic role of vestibular dysfunctions on hearing recovery and detect specific lesion patterns related to the underlying pathomechanisms.

Methods

We prospectively evaluated 86 patients with SSNHL. Audio-vestibular investigation included pure-tone/speech/impedance audiometry, cervical/ocular-VEMPs, vHIT and video-Frenzel examination. White matter lesions (WML) were evaluated on brain-MRI. Patients were followed-up and divided into "SSNHL-no-vertigo," "SSNHL+vertigo" and "MD" subgroups.

Results

Hearing was more impaired in "SSNHL+vertigo" patients who exhibited either down-sloping or flat-type audiograms, and was less impaired in "MD" where low frequencies were mostly impaired (p < 0.001). Otolith receptors were more frequently involved than semicircular canals (SCs). Although the "SSNHL-no-vertigo" subgroup exhibited the lowest vestibular impairment (p < 0.001), 52% of patients developed otolith dysfunctions and 72% developed nystagmus. Only "MD" subjects showed anterior SC impairment and upbeating spontaneous/positional nystagmus. They more frequently exhibited cervical-VEMPs frequency tuning (p = 0.036) and ipsilesional spontaneous nystagmus (p < 0.001). "SSNHL+vertigo" subjects presented with more frequently impaired cervical-VEMPs and posterior SC and with higher number of impaired receptors (p < 0.001). They mainly exhibited contralesional spontaneous and vibration-induced nystagmus (p < 0.05) and only they showed the highest WML score and "vascular" lesion patterns (p < 0.001). Concerning the outcomes, hearing was better in "MD" and worse in "SSNHL+vertigo" (p < 0.001). Hearing recovery was mostly affected by cervical-VEMPs impairment and the number of involved receptors (p < 0.05). Patients with "vascular" lesion patterns presented with the highest HL degree and WML score (p ≤ 0.001), while none of them exhibited a complete hearing recovery (p = 0.026).

Conclusions

Our data suggest that vestibular evaluation in SSNHL can provide useful information on hearing recovery and underlying aetiologies.

Vestibular function of pediatric patients with sudden sensorineural hearing loss: based on vertigo symptom and vestibular function testing

BACKGROUND

This study aimed to evaluate the relationship between vestibular and auditory functions in pediatric patients with sudden sensorineural hearing loss (SSHL).

METHODS

A total of 30 pediatric patients experiencing unilateral SSHL between 5.9 and 13.0 years of age were enrolled in this study. Pure tone audiometry was evaluated prior to treatment initiation and again after one month of treatment. Prior to treatment initiation, vertigo symptoms were noted; then several vestibular function tests were conducted including caloric testing, ocular vestibular evoked myogenic potentials (o-VEMPs) and cervical vestibular evoked myogenic potentials (c-VEMPs). Associations between pre and post-treatment vestibular function and hearing threshold levels were analyzed.

RESULTS

Initial hearing thresholds of children with vertigo were higher than thresholds of children without vertigo (92 dB vs 79 dB, P = 0.033), while initial hearing thresholds of children with abnormal caloric test findings were higher than thresholds of children with normal caloric test findings (93 dB vs 67 dB, P = 0.014). Cutoff values of hearing thresholds for those with vertigo symptoms and abnormal vestibular test results were 86.000- and 89.583-dB HL, respectively. Regarding prognosis, children with vertigo exhibited lower recovery rates than children without vertigo (33% vs 75%, P = 0.025); recovery rates of children with abnormal caloric test results were lower than the overall recovery rate (25% vs 73%, respectively, P = 0.039).

CONCLUSION

Assessments of vertigo symptoms and vestibular function are useful tools in predicting pediatric SSHL patient disease severity and prognosis.

Vestibular evoked myogenic potentials in the prognosis of sudden hearing loss ‒ a systematic review

INTRODUCTION

Sudden hearing loss is an otorhinolaryngological emergency that often leads to severe damage to the auditory and vestibular function. The vestibular evoked myogenic potential is a test that allows a noninvasive evaluation of the otolithic system function and vestibulospinal and vestibulo-ocular pathways.

OBJECTIVE

To evaluate the importance of vestibular evoked myogenic potential in determining the prognosis of patients with sudden hearing loss.

METHODS

A search for articles published up to December 2018 was performed in the PubMed, Cochrane, VHL and LILACS databases using MeSH descriptors. Retrospective and prospective articles were included containing cervical or ocular vestibular evoked myogenic potential in sudden hearing loss patients and information on associated vertigo and/or dizziness.

RESULTS

Sixteen of 62 initially selected articles met the inclusion criteria and were analyzed. Regarding the methodology of the evaluated studies, 8 studies were prospective, six were retrospective, one contained part of the data from a retrospective analysis and another part from a prospective analysis, and one study was cross-sectional. A total of 872 patients were evaluated (50.22% males and 49.77% females) with a mean age of 51.26 years. Four hundred and twenty-six patients (50.35%) had vertigo and/or dizziness associated with sudden hearing loss. The cervical vestibular evoked myogenic potential was performed in all studies, but only seven assessed the ocular vestibular evoked myogenic potential. The cervical vestibular evoked myogenic potential showed alterations in 38.65% of 846 evaluated ears, whereas ocular vestibular evoked myogenic potential showed alterations in 47.88% of 368 evaluated ears. The hearing recovery rate was analyzed by 8 articles, with 63.4% of 410 evaluated ears showing hearing recovery.

CONCLUSIONS

The studies suggest that the assessment of the vestibular system using vestibular evoked myogenic potential seems to be important in the prognosis of sudden hearing loss. For better follow-up of patients with sudden hearing loss, the emphasis should not be limited to the cochlea, but also include the diagnosis and treatment of vestibular abnormalities, regardless of the presence of vertigo.

Ocular and cervical vestibular-evoked myogenic potentials in idiopathic sudden sensorineural hearing loss (ISSHL) without vertigo: VEMPs in ISSHL

PURPOSE

Idiopathic sudden sensorineural hearing loss (ISSHL) is a hearing impairment greater than 30 dB at three consecutive frequencies developing in less than 3 days. The aim of this study was to evaluate VEMPs and caloric testing in patients affected by ISSHL without vertigo.

METHODS

We retrospectively evaluated 35 subjects affected by ISSHL. The audio-vestibular investigation consisted of pure-tone and speech audiometry, impedance, bithermal caloric testing, oVEMPs and cVEMPs.

RESULTS

VEMPS were abnormal in 21 patients (60%): cVEMPs in 12 (34.2%) and oVEMPs in 19 (54.2%). 10 patients (28.5%) presented with both c-and oVEMPs altered. Subjects without vestibular involvement showed a significant lower PTA in the affected ear both at admission and at discharge. Recovery rate was significantly higher in group without vestibular involvement.

CONCLUSION

The evaluation of the vestibular system can be useful for predicting the auditory recovery in patients without vertigo also.

Vestibular Dysfunctions in Sudden Sensorineural Hearing Loss: A Systematic Review and Meta-analysis

Background

Sudden sensorineural hearing loss (SSHL) not only involves cochlear function but might also be accompanied by vestibular disturbances. The assessment of vestibular function could be of great relevance in SSHL.

Objective

To investigate the prevalence of vestibulocochlear lesions in SSHL and the correlation of specific vestibular organs with hearing prognosis.

Data sources

A complete literature search of eligible studies in the PubMed and EMBASE databases was performed.

Study selection

For our aim, studies that focused on vestibular examination in the case of SSHL were retrieved, including caloric tests, cervical vestibular-evoked myogenic potential (cVEMP) tests, or ocular vestibular-evoked myogenic potential (oVEMP) tests.

Results

Of the 18 studies included, a caloric test was performed in 16 studies, cVEMP in 13 studies, and oVEMP in 5 studies, and together the studies included a total population of 1,468 subjects. The scores on the Agency for Healthcare Research and Quality (AHRQ) questionnaire ranged from 6 to 11. These results indicated that the most commonly damaged vestibular organ in SSHL was the utricle and superior vestibular pathway (U + S) followed by the lateral semicircular canal and superior vestibular pathway (LSC + S), the saccule and inferior vestibular pathway (S + I), and the cochlea only (C only). The meta-analysis indicated that SSHL patients with vertigo have a statistically increased risk of vestibular organ lesions compared with those without vertigo, including the LSC + S subgroup (OR = 4.89, 95% CI = 1.20-19.93, I² = 80%, p = 0.03) and the S + I subgroup (OR = 3.58, 95% CI = 1.61-7.95, I² = 0%, p = 0.002). The pooled possibility of hearing recovery within the LSC + S lesion group was less than half that of the non-LSC + S lesion group (OR = 0.24, 95% CI = 0.11-0.52, I² = 68%, p = 0.0003).

Conclusion

This study shows the relevance of vestibular damage concomitant with SSHL and that SSHL patients with vertigo are at an increased risk of vestibular organ lesions compared with patients without vertigo. LSC + S lesions thus appear to be a critical variable that influence the possibility of hearing improvement in SSHL.

Association between Vestibular Function and Hearing Outcome in Idiopathic Sudden Sensorineural Hearing Loss

BACKGROUND AND OBJECTIVES

To investigate whether different vestibular function tests such as cervical vestibular evoked myogenic potential (cVEMP) and caloric test were correlated with severity, pattern and prognosis in idiopathic sudden sensorineural hearing loss (ISSNHL).

SUBJECTS AND METHODS

Ninety-two patients with unilateral ISSNHL were subjected to complete audiovestibular evaluation. cVEMP and caloric test results were compared with patients' initial and final audiogram. We classified patients in 4 groups as cochlear nerve (C) type, cochlear and superior vestibular nerve (C+S) type, cochlear and inferior vestibular nerve (C+I) type and cochlear, superior vestibular nerve, inferior vestibular nerve (C+S+I) type, for evaluation of the results. cVEMP and caloric tests were compared among the groups.

RESULTS

Abnormal caloric test results and abnormal cVEMP results were found in 50% and 31.6% patients, respectively. Multivariate analysis showed that abnormal caloric result (canal paresis) is a significant negative prognostic factor.

CONCLUSIONS

Initial vestibular function test can be valuable in predicting the final outcome in patients with ISSNHL.

Contribution of Vestibular-Evoked Myogenic Potential (VEMP) testing in the assessment and the differential diagnosis of otosclerosis

Background

The aim of this prospective clinical study was to evaluate the clinical importance of Vestibular-Evoked Myogenic Potentials (VEMPs) in the assessment and differential diagnosis of otosclerosis and otologic diseases characterized by “pseudo-conductive” components. We also investigated the clinical appearance of balance disorders in patients with otosclerosis by correlating VEMP results with the findings of caloric testing and pure tone audiometry(PTA).

Material/Methods

Air-conducted(AC) 4-PTA, bone-conducted(BC) 4-PTA, air-bone Gap(ABG), AC, BC tone burst evoked VEMP, and calorics were measured preoperatively in 126 otosclerotic ears.

Results

The response rate of the AC-VEMPs and BC-VEMPs was 29.36% and 44.03%, respectively. Statistical differences were found between the means of ABG, AC 4-PTA, and BC 4-PTA in the otosclerotic ears in relation to AC-VEMP elicitability. About one-third of patients presented with disequilibrium. A statistically significant interaction was found between calorics and dizziness in relation to PTA thresholds. No relationship was found between calorics and dizziness with VEMPs responses.

Conclusions

AC and BC VEMPs can be elicited in ears with otosclerosis. AC-VEMP is more vulnerable to conductive hearing loss. Evaluation of AC-VEMP thresholds can be added in the diagnostic work-up of otosclerosis in case of doubt, enhancing differential diagnosis in patients with air-bone gaps. Otosclerosis is not a cause of canal paresis or vertigo.

Prognosis of patients with idiopathic sudden hearing loss: role of vestibular assessment

Objective:

To evaluate the correlation between caloric and vestibular evoked myogenic potential test results, initial audiogram data, and early hearing recovery, in patients with idiopathic sudden hearing loss.

Materials and methods:

One hundred and four patients with unilateral idiopathic sudden hearing loss underwent complete neurotological evaluation. Results for vestibular evoked myogenic potential and caloric testing were compared with patients' initial and final audiograms.

Results:

Overall, abnormal vestibular evoked myogenic potential responses occurred in 28.8 per cent of patients, whereas abnormal caloric test results occurred in 50 per cent. A statistically significant relationship was found between the type of inner ear lesion and the incidence of profound hearing loss. Moreover, a negative correlation was found between the extent of the inner ear lesion and the likelihood of early recovery.

Conclusion:

In patients with idiopathic sudden hearing loss, the extent of the inner ear lesion tends to correlate with the severity of cochlear damage. Vestibular assessment may be valuable in predicting the final outcome.