Vestibular Evoked Myogenic Potentials Show Altered Tuning in Patients with Ménière’s Disease

The Top 100 Cited Articles in Otology and Neurotology and Analysis of Female Authorship

INTRODUCTION

Despite the increasing number of female trainees in otology and neurotology, women remain underreported in academic medicine. This gender disparity persists in high-impact research, where women are less represented as first and corresponding authors.

METHODS

The top 100 most-cited articles from Otology & Neurotology (1980-2024) were identified using total citation counts. First and corresponding author gender was determined, and trends in female authorship were analyzed over time.

RESULTS

A total of 7,485 Otology & Neurotology articles published between 1980 and 2024 were reviewed and the top 100 cited studies (1.3%) were identified. Women accounted for 29% of first authors and 23% of corresponding authors, with a significant increase in female authorship over time. However, overall representation remains disproportionately low.

DISCUSSION

Our study highlights the persistent underrepresentation of women in otology and neurotology research, despite their growing presence in medicine. Additional efforts are needed to promote greater inclusivity in academic literature of otology and neurotology.

The Impact of Age and Gender on Cervical Vestibular-Evoked Myogenic Potentials Using 500 Hz Tone Bursts Stimuli: A Cross-Sectional Study

Background and objective Cervical vestibular-evoked myogenic potential (cVEMP) tests have attracted significant interest as clinical measures of vestibular function recently. A detailed knowledge of the potential individual factors influencing the cVEMP response is, however, essential for the reliability of the test. Hence, we aimed to analyze the trends of different cVEMP parameters with regard to changes in age and gender, under standard recording conditions. Methods cVEMP was conducted on 60 participants aged 18-60 years during the period from April 2023 to March 2024. cVEMP parameters, including response rates, amplitude, interaural amplitude asymmetry, threshold, threshold asymmetry, and latencies, were investigated for the impact of aging and gender differences. One-way ANOVA and Kruskal-Wallis tests were performed for the comparison between the age groups, while unpaired t-test and Kruskal-Wallis test were employed to find the gender differences in cVEMP parameters. Pearson correlation analysis was performed to assess the relationship between age and cVEMP parameters. Statistical significance was set at a p-value of 0.05. Results cVEMP response rate was 100 % in all the age groups. Significant differences were found in terms of p13-n23 amplitude and threshold (both right and left ear) between the age groups (p<0.001) (Kruskal-Wallis test). A significant negative correlation was found between age and both uncorrected and corrected amplitude in both the right ear (r = -0.73, p<0.001) and the left ear (r = -0.75, p<0.001). A significant positive correlation was observed between age and thresholds in both the right ear (r = 0.66, p<0.001) and the left ear (r = 0.75, p<0.001). There were no significant variations regarding p13 and n23 latencies, interaural amplitude asymmetry, and threshold asymmetry among the age groups (p>0.05) (one-way ANOVA) (Kruskal-Wallis test). Gender did not demonstrate variations in the cVEMP parameters tested (p>0.05) (unpaired t test and Kruskal-Wallis test). Conclusions cVEMP had an absolute detection rate in the age groups studied. However, a remarkable age-related decline in p13-n23 amplitude (corrected and uncorrected) and the threshold values highlights the importance of effective consideration of changes in age for optimizing the clinical evaluation. p13 and n23 latencies, and amplitude asymmetry were relatively stable with increasing age. The findings related to cVEMP evoked with 500 Hz short tone burst stimuli in adults (aged 18-60 years) can be utilized in the regional clinical settings.

Effects of Age on the Bone-Conduction Amplitude-Modulated cVEMP Temporal Modulation Transfer Function

OBJECTIVES

Cervical vestibular evoked myogenic potentials (cVEMPs) reflect saccular stimulation that results in an inhibitory muscle reflex recorded over the sternocleidomastoid muscle. These responses are utilized to study basic vestibular functions and are also applied clinically. Traditionally, cVEMPs have utilized transient stimuli such as clicks and tonebursts to evoke onset responses. Recently, amplitude-modulated tones have been used to elicit cVEMPs (AMcVEMPs). These AMcVEMP responses can provide information about the magnitude, phase synchrony, and nonlinearities from the vestibulo-collic reflexes that cannot be captured using other existing testing techniques. Although temporal modulation transfer functions (TMTFs) of AMcVEMPs for young, healthy adults have been established using different analysis techniques, there is currently no information regarding the effects of age on these responses. Thus, the current study aimed to examine the effects of age on AMcVEMPs across a broad range of modulation frequencies (MFs) using various AMcVEMP metrics including amplitude, signal to noise ratio (SNR), and phase coherence (PC).

DESIGN

The study included 16 (aged 20 to 39 years) young, 17 (aged 40 to 59 years) mid-age, and 16 (60 to 75 years) older adults with no history of neurological, vestibular, or middle-ear complaints. The stimuli consisted of amplitude-modulated tones with a carrier frequency of 500 Hz and 10 MFs ranging from 11 to 397 Hz. These stimuli were presented using a B81 transducer at 123 dB FL. AMcVEMPs were recorded from the sternocleidomastoid muscle (ipsilateral to the stimulating mastoid) using surface electrodes. Response analysis was performed using an FFT-based approach with analyses including amplitude, SNR, and PC.

RESULTS

AMcVEMP waveforms exhibited periodicity corresponding to the stimulus MF, consistent with previous observations. Furthermore, significant age-related degradation in AMcVEMP amplitude, SNR, and PC measures were observed across a broad range of MFs. While AMcVEMPs were elicited across a wide range of MFs (11 to 263 Hz) for young adults, in mid-age and older adults, these metrics were robust only across a narrower range of MFs, resulting in a reduced TMTF. In addition, the MF eliciting the most robust AMcVEMP varied across different AMcVEMP analysis metrics and age groups.

CONCLUSIONS

A significant decline in the AMcVEMP response is seen as an effect of aging; however, the effect of aging is not uniform across measures or across MFs. The TMTF of AMcVEMP gets flatter, and the overall range is reduced as an effect of aging. Results from this study enhance our understanding of age-related changes in the vestibular system. Expansion of AMcVEMP to clinical populations may lead to a deeper understanding of the pathophysiology of vestibular disorders.

Multidimensional Feature Analysis of Meniere's Disease and Vestibular Migraine: Insights from Machine Learning and Vestibular Testing

OBJECTIVE

Differentiating between Meniere's disease (MD) and vestibular migraine (VM) is challenging due to overlapping symptoms and limited diagnostic tools. Traditional statistical methods often rely on physician judgment and struggle with complex, high-dimensional data. This study applies the random forest (RF) machine learning algorithm to enhance the clinical differentiation between MD and VM.

METHODS

We retrospectively analyzed data from 36 VM (26 female) and 100 unilateral MD patients (51 female). The data were anonymized and labeled. Symptomatic and examination parameters were selected as features, and exploratory data analysis identified key parameters for diagnosis. An RF model was used to rank these features.

RESULTS

MD patients more commonly experienced ear-related symptoms, while VM patients reported more headaches and dizziness. Examination findings showed greater asymmetry in vHIT saccade latency in MD patients, particularly on the affected side. A total of 40 key parameters were identified. Heatmap and clustering analysis revealed that time constant (Tc) in velocity step test (VST) correlated more strongly with headache and other symptoms, while saccade latencies and velocities correlated with pure tone averages. The RF model selected 27 parameters for prediction, achieving 91.86% accuracy (95% confidence interval [85.37%, 95.18%]). Tc and saccade velocity were among the top 10 contributing features. Additionally, MD patients had earlier saccades and shorter Tc values on the affected side compared to both healthy controls and VM patients.

CONCLUSIONS

Machine learning successfully classified MD and VM patients, with Tc and saccade velocity identified as key diagnostic indicators alongside symptoms.

Assessing otolith dysfunction in Meniere's disease: insights from multi-frequency vestibular evoked myogenic potential testing

OBJECTIVE

To investigate the impact of Meniere's Disease (MD) on balance and proprioception by utilising multi-frequency Vestibular Evoked Myogenic Potentials (VEMP) to evaluate otolith function.

DESIGN

Observational study employing the Otolith Tuning Index (OTI) to quantify vestibular function through analysis of VEMP response rates and tuning ratios.

STUDY SAMPLE

A total of 123 participants were included, comprising 94 patients diagnosed with MD and 29 healthy controls. VEMP testing was conducted at frequencies of 500 Hz, 750 Hz, and 1 kHz.

RESULTS

Among MD patients, 69% reported imbalance, with severe cases predominating in advanced stages. The non-response rate for oVEMP at 500 Hz was 73.3% on the affected side, associated with unpredictable falls. Significant correlations were observed between cVEMP non-responses and both disease severity (p = 0.012) and walking imbalance (p = 0.037). oVEMP responses were lowest at 500 Hz, improving at 1 kHz, whereas cVEMP amplitudes peaked at 500 Hz bilaterally. OTI values indicated significant otolith dysfunction on affected sides compared to contralateral sides and controls (p = 0.026, p = 0.032, p < 0.001), with dysfunction worsening with disease progression and age.

CONCLUSIONS

The Otolith Tuning Index (OTI) effectively measures otolith dysfunction in MD patients, offering valuable insights to enhance diagnostics, patient management, and treatment planning.

Cervical Vestibular-evoked Myogenic Potential in Healthy Adults: A Cross-sectional Study Investigating the Impact of Various Stimuli and Recording Conditions

Background

Cervical vestibular-evoked myogenic potentials (c-VEMPs) is a noninvasive procedure that captures the electrical activity of sternocleidomastoid (SCM) muscles in response to auditory stimuli. The clinical value of VEMP, however, is affected by the use of appropriate stimuli and correct testing techniques. This study investigates the effects of different stimuli and recording conditions on c-VEMP recordings.

Materials and Methods

Sixty healthy participants, aged 18-60 years, underwent c-VEMP recordings. Air-conducted sound stimuli (tone bursts and clicks) in sitting, supine neck torsion, and supine head lift and neck torsion positions along with the variation in the active electrode positions were employed to obtain the c-VEMP records. The c-VEMP parameters were compared by paired t-test, Wilcoxon signed-rank test and one-way ANOVA. P < 0.05 was considered statistically significant.

Results

Tone burst and click-evoked c-VEMP varied with statistically significant differences in terms of amplitudes, corrected amplitudes, and thresholds (P = 0.0000). Tone burst stimuli produced larger amplitudes and lower thresholds in both ears. No significant difference was found in c-VEMP parameters tested for differences in active electrode placement except for threshold asymmetry (P = 0.0123) (Wilcoxon signed-rank test). c-VEMP recordings in the sitting position produced significantly larger corrected amplitudes compared to the supine head lift and neck torsion positions, for both sides (one-way ANOVA).

Conclusion

The results of the current study revealed a greater response rates and larger amplitudes for tone burst-evoked c-VEMP responses as compared to those with click stimuli. A seated, head-turned position with the active electrode placed in the middle of the SCM muscle yielded larger tone burst-evoked c-VEMP responses. The variation in the VEMP data obtained owing to different stimuli and recording conditions should be considered when evaluating patients in clinical practice to optimize the clinical applicability of the VEMP examination.

Assessment of the Inter-Frequency Amplitude Ratio (1000/500 Hz) in cVEMP and oVEMP for the Diagnosis of Ménière's Disease

Objectives: to retrospectively evaluate the clinical relevance of the 1000/500 Hz inter-frequency amplitude ratio (IFAR) in cervical and ocular vestibular evoked myogenic potentials (cVEMPs and oVEMPs) in patients with unilateral definite Ménière's disease (MD) to identify the pathological ear. Method: cVEMPs and oVEMPs results obtained at 500 Hz and 1000 Hz were retrospectively analyzed in 28 patients with unilateral definite MD. 1000/500 Hz IFAR were calculated and compared for each ear. Spearman correlation tests between patient age and 1000/500 Hz IFAR were also performed. Results: No significant difference was observed between the 1000/500 Hz IFAR calculated in both pathological and healthy ears when the cVEMPs were performed (p = 0.74; Wilcoxon signed-rank test). 1000/500 Hz IFAR results obtained in healthy and pathological ears were also not different for oVEMPs (p = 0.73; Wilcoxon signed-rank test). Analysis of modified 1000/500 Hz IFARs for healthy and pathological ears showed no difference in both cVEMPs and oVEMPs (p = 0.44; p = 0.95, respectively; Wilcoxon signed-rank test). There was a significant positive correlation between IFARs, modified IFARs, and patient age for cVEMPs (p = 0.017; p = 0.012, respectively, Spearman's correlation test). A significant positive correlation was also found between modified IFARs and the subject age in oVEMPs (p = 0.019, Spearman's correlation test). Conclusions: We did not observe any significant increase of 1000/500 Hz IFARs and 1000/500 Hz modified IFARs in ears affected by definite MD compared to healthy ears. Moreover, our research suggests that the age of the participants may influence IFAR results, which may lead to misdiagnosis in the elderly. It is, therefore, essential to conduct further prospective studies in larger cohorts, stratifying results by participant age, to better understand the role of 1000/500 Hz IFAR values in the diagnosis of MD.

Effects of Age on the Frequency Amplitude Ratio of Cervical and Ocular Vestibular Evoked Myogenic Potentials

PURPOSE

An increase in the 1000/500 Hz frequency amplitude ratio (FAR) of the cervical and ocular vestibular evoked myogenic potentials (cVEMP and oVEMP, respectively) may serve as a potential biomarker for diagnosing Meniere's disease (MD). However, the aging process can also result in an increased FAR for VEMPs. In older patients, distinguishing whether changes in VEMP FAR are due to MD or aging processes becomes difficult. We aimed to investigate the effects of age on VEMP FARs and establish a FAR-normative range for different age groups.

METHOD

cVEMP and oVEMP were recorded from a total of 106 participants grouped as young, middle-aged, and older adults using air-conducted tone bursts at 500, 750, and 1000 Hz at 125 dB pSPL. The FAR was calculated for the cVEMP and oVEMP for the following frequencies: FAR1 = 1000/500, FAR2 = 1000/750, and FAR3 = 750/500.

RESULTS

A significant age-related effect was observed on the cVEMP FAR. Although the oVEMP FAR showed an increasing trend with age, it was not statistically significant. Age-based normative FAR values are provided.

CONCLUSIONS

Drawing from the normative FAR from this study, there is evidence that the existing MD diagnostic criteria would misidentify a considerable number of older adults. Therefore, to reduce false positives, we recommend a more stringent cVEMP and oVEMP FAR criterion in older adults.

Machine learning models help differentiate between causes of recurrent spontaneous vertigo

BACKGROUND

Vestibular migraine (VM) and Menière's disease (MD) are two common causes of recurrent spontaneous vertigo. Using history, video-nystagmography and audiovestibular tests, we developed machine learning models to separate these two disorders.

METHODS

We recruited patients with VM or MD from a neurology outpatient facility. One hundred features from six "feature subsets": history, acute video-nystagmography and four laboratory tests (video head impulse test, vestibular-evoked myogenic potentials, caloric testing and audiogram) were used. We applied ten machine learning algorithms to develop classification models. Modelling was performed using three "tiers" of data availability to simulate three clinical settings. "Tier 1" used all available data to simulate the neuro-otology clinic, "Tier 2" used only history, audiogram and caloric test data, representing the general neurology clinic, and "Tier 3" used history alone as occurs in primary care. Model performance was evaluated using tenfold cross-validation.

RESULTS

Data from 160 patients with VM and 114 with MD were used for model development. All models effectively separated the two disorders for all three tiers, with accuracies of 85.77-97.81%. The best performing algorithms (AdaBoost and Random Forest) yielded accuracies of 97.81% (95% CI 95.24-99.60), 94.53% (91.09-99.52%) and 92.34% (92.28-96.76%) for tiers 1, 2 and 3. The best feature subset combination was history, acute video-nystagmography, video head impulse test and caloric testing, and the best single feature subset was history.

CONCLUSIONS

Machine learning models can accurately differentiate between VM and MD and are promising tools to assist diagnosis by medical practitioners with diverse levels of expertise and resources.

Multi-frequency VEMPs improve detection of present otolith responses in bilateral vestibulopathy

Objective

To investigate whether multi-frequency Vestibular Evoked Myogenic Potential (VEMP) testing at 500, 750, 1,000, and 2,000 Hz, would improve the detection of present dynamic otolith responses in patients with bilateral vestibulopathy (BV).

Methods

Prospective study in a tertiary referral center. BV patients underwent multi-frequency VEMP testing. Cervical VEMPs and ocular VEMPs were recorded with the Neuro-Audio system (v2010, Neurosoft, Ivanovo, Russia). The stimuli included air-conducted tone bursts of 500, 750, 1,000, and 2,000 Hz, at a stimulation rate of 13 Hz. Outcome measures included the percentage of present and absent VEMP responses, and VEMP thresholds. Outcomes were compared between frequencies and type of VEMPs (cVEMPs, oVEMPs). VEMP outcomes obtained with the 500 Hz stimulus, were also compared to normative values obtained in healthy subjects.

Results

Forty-nine BV patients completed VEMP testing: 47 patients completed cVEMP testing and 48 patients completed oVEMP testing. Six to 15 % more present VEMP responses were obtained with multifrequency testing, compared to only testing at 500 Hz. The 2,000 Hz stimulus elicited significantly fewer present cVEMP responses (right and left ears) and oVEMP responses (right ears) compared to the other frequencies (p ≤ 0.044). Using multi-frequency testing, 78% of BV patients demonstrated at least one present VEMP response in at least one ear. In 46% a present VEMP response was found bilaterally. BV patients demonstrated a significantly higher percentage of absent VEMP responses and significantly higher VEMP thresholds than healthy subjects, when corrected for age (p ≤ 0.002). Based on these results, a pragmatic VEMP testing paradigm is proposed, taking into account multi-frequency VEMP testing.

Conclusion

Multi-frequency VEMP testing improves the detection rate of present otolith responses in BV patients. Therefore, multi-frequency VEMPs should be considered when evaluation of (residual) otolith function is indicated.

Vestibular evoked myogenic potential (VEMP) test-retest reliability in adults

BACKGROUND

The technique of measuring ocular vestibular evoked myogenic potentials (oVEMP) in response to Mini-shaker vibration is relatively new, there is a limited normative data to define the presence or absence of a response in the literature.

OBJECTIVE

To determine the test-retest reliability of cervical and ocular VEMPs (cVEMP and oVEMP, respectively) to air-conducted sound (ACS) and bone-conducted vibration (BCV) stimulation and to determine normative ranges for the responses.

METHODS

Twenty normal-hearing individuals (40 ears) and 20 hearing impaired volunteers with normal balance function (40 ears) were examined in this study. ACS cVEMP and BCV oVEMP (using a Mini-shaker) were recorded from both groups to assess the test-retest reliability and to collect normative VEMP data for P1/N1 latencies and amplitudes from 20 normal hearing individuals. To test reliability, VEMP recordings were repeated within the same session.

RESULTS

The test-retest reliability for all the cVEMP parameters showed excellent reliability whereas oVEMP parameters showed between fair and excellent reliability depending on the parameter tested. Normative data for VEMP P1/N1 latencies and amplitudes were established.

CONCLUSIONS

Normative data and test-retest reliability for BCV oVEMP using the Mini-shaker at 100 Hz were established in our study for the first time in the literature. Responses appear reliable.

Multifrequency Analysis of Masseter Vestibular Evoked Myogenic Potentials in Young Adults

PURPOSE

The purpose of this study was to explore the dynamics of multifrequency tone bursts on the masseter vestibular evoked myogenic potential (mVEMP) parameters. Furthermore, it sought to determine the optimal frequency tuning of mVEMP responses.

METHOD

Twenty young adults with normal hearing sensitivity participated in the study. Bilateral tone burst evoked mVEMPs were obtained using the zygomatic montage at 250-, 500-, 750-, 1000-, 1500-, and 2000-Hz stimulation frequencies. Self-monitoring biofeedback was given during the procedure to confirm the tension of the masseter muscle between 49.9 and 150.6 rms. Furthermore, the electromyography (EMG) scaling was done to avoid any muscle-related irregularities.

RESULTS

Tone burst evoked mVEMPs were found to be 100% present at the stimulation frequencies of 250, 500, 750, and 1000 Hz. There were no ear and gender effects seen for any of the frequencies. Significant shortening of the P1 and N1 latencies with increasing stimulation frequencies was observed. The peak-to-peak amplitude was the highest at 500 Hz and lowest at 2000 Hz tone bursts under both EMG scaled and unscaled conditions.

CONCLUSION

The present revealed higher response rates and larger amplitudes study of mVEMP at lower frequencies, and, therefore, the frequency tuning was seen for the stimulation frequency at 500 Hz.

Peripheral vestibular loss in noise-exposed firefighters

Introduction

Occupational workers are increasingly aware of the risk of noise overexposure to the auditory system but lack awareness about potential risks to the vestibular system. The purpose of this study was to investigate changes in vestibular end organ function in a known at-risk noise-exposed population, firefighters compared to age- and sex-matched controls using electrophysiologic measures of cervical vestibular evoked myogenic potentials (cVEMP).

Methods

A cross-sectional observational study compared cVEMP response characteristics in 38 noise-exposed firefighters. Firefighters were grouped by years of exposure in the fire service. The cVEMP responses were compared within firefighter groups and between firefighters and age- and sex-matched controls. Dependent variables included the response characteristics of amplitude, latency and threshold.

Results

cVEMP response amplitudes were significantly decreased in firefighters compared to their age- and sex-matched controls. Threshold of the cVEMP responses were significantly higher in firefighters compared to controls and firefighters had a higher incidence of absent cVEMP responses compared to controls. Response amplitudes decreased with increasing years in the fire-service at an increased rate compared to their age- and sex-matched controls. Latency of the cVEMP response was not significantly different in firefighters compared to controls. These findings are consistent with both animal and human studies suggesting noise-induced changes in the sacculocollic pathway.

Discussion

In the absence of any reported vestibular symptoms or auditory indicators of noise-induced hearing loss, these early effects on the vestibular system point to a potential hidden vestibular loss.

Exploring the Relationship between Masseter and Cervical Vestibular-Evoked Myogenic Potentials in Young Adults with Hearing Thresholds Less Than or Equal to 15 dB HL

BACKGROUND

 Cervical vestibular-evoked myogenic potentials (cVEMPs) and masseter vestibular-evoked myogenic potentials (mVEMPs) are considered to have a common saccular origin. While a few studies have examined both vestibular-evoked myogenic potentials (VEMPs) in individuals with brainstem disorders as part of a test battery, the relation between these two potentials has rarely been the subject of discussion.

PURPOSE

 The present study explored the relation between mVEMPs and cVEMPs using electromyography (EMG)-scaled parameters in normal-hearing young adults.

RESEARCH DESIGN

 Within-subject study design.

STUDY SAMPLE

 Twenty young adults between 18 and 39 years of age (11 males, 9 females) participated in the study.

DATA COLLECTION AND ANALYSIS

 cVEMP and mVEMP were performed on all the participants at 95 dBnHL with 500 Hz tone burst stimuli. Various VEMP parameters were evaluated including P13 and N23 peak latencies, the amplitude of the P13-N23 complex, and the Interaural Amplitude Asymmetry Ratio in EMG-scaled and unscaled conditions.

RESULTS

 All participants exhibited a 100% response rate for cVEMP and mVEMP responses. There were no significant ears and gender effect for both cVEMP and mVEMP. No correlation was found between cVEMP and mVEMP. There was no significant difference found between P1 and N1 latency values of cVEMP and mVEMP; however, a significant variation was observed for peak-to-peak amplitude both in EMG-scaled and unscaled conditions between cVEMP and mVEMP.

CONCLUSIONS

 Minimal to no association between any parameters of cVEMPs and mVEMPs suggests no significant relationship between these two VEMPs.

Utility of Inter-Frequency Amplitude Ratio of Vestibular-Evoked Myogenic Potentials in Identifying Meniere's Disease: A Systematic Review and Meta-Analysis

OBJECTIVES

A recently devised parameter of vestibular-evoked myogenic potential (VEMP) based on the principles of frequency tuning is the inter-frequency amplitude ratio (IFAR). It refers to the ratio of the amplitude of 1000 Hz tone burst evoked VEMP to 500 Hz evoked tone burst. A pathology like Meniere's disease changes the frequency response and alters the frequency tuning of the otolith organs. Because IFAR is based on the principle of frequency tuning of VEMP, it is likely to help identify Meniere's disease. Few studies in the last decade have investigated the utility of IFAR in identifying Meniere's disease. However, a systematic review and a meta-analysis on IFAR in Meniere's disease are lacking. The present study investigates whether the IFAR of VEMP helps identify Meniere's disease and differentiates it from healthy ears and other vestibular pathologies.

DESIGN

The present study is a systematic review and a meta-analysis. The studies investigating the IFAR of cervical and ocular VEMPs in Meniere's disease, healthy controls, and other vestibular pathologies were searched across research databases such as PubMed, Science Direct, and Scopus. The search strategy was developed using the PICO (population, intervention, comparison, and outcomes) format, and Medical Subject Headings (MeSH) terms and Boolean operators were employed. The systematic review was performed using the Rayyan software, whereas the Review Manager software was used to carry out the meta-analysis. A total of 16,605 articles were retrieved from the databases. After the duplicate removal, 2472 articles remained. These were eliminated using title screening, abstract screening, and full-length inspections. A total of nine articles were found eligible for quality assessment and meta-analysis, and the New Castle-Ottawa Scale was used for quality assessment. After the data extraction, 24 six articles were found to have the desired data format for the meta-analysis.

RESULTS

The results showed significantly higher IFAR in the affected ears of individuals in the Meniere's disease group than in the control group's unaffected ears. There was no significant difference between the unaffected ears of individuals in the Meniere's disease group and the ears of the control group. The only study on Meniere's disease and benign paroxysmal positional vertigo found significantly larger ocular VEMP IFAR in ears with Meniere's disease than in benign paroxysmal positional vertigo.

CONCLUSIONS

This systematic review and meta-analysis found IFAR efficient in differentiating Meniere's disease from healthy controls. We also found an enhanced IFAR as a potential marker for Meniere's disease. However, more investigations are needed to confirm the utility of an enhanced IFAR value in the exclusive identification of Meniere's disease.

Effect of Real-Ear Adjusted Stimuli on Vestibular Evoked Myogenic Potential Variability in Children and Young Adults

OBJECTIVES

There is large variability in cervical and ocular vestibular evoked myogenic potential (c- and oVEMP) amplitudes. One potential source of variability is differences in ear canal shape and size. Real ear-to-coupler difference (RECD) values are used to measure the acoustic environment of an individual's ear canal. RECD may be a useful measure to calibrate air conducted VEMP stimuli, which are elicited at high intensities and may put patients at risk of unsafe sound exposure. A recommendation for avoiding unsafe exposure is to use a 125 dB SPL stimulus for individuals with an equivalent ear canal volume (ECV) ≥ 0.9 mL and a 120 dB SPL stimulus for individuals with a smaller ECV. The purpose of this project was to determine if using a stimulus calibrated in the ear using RECD values significantly reduces intra-subject and inter-subject VEMP amplitude variability. We hypothesized that using a RECD-calibrated stimulus would significantly reduce inter-subject amplitude variability but not significantly reduce intra-subject variability. We further hypothesized that an RECD-adjusted VEMP stimulus would better protect against delivering unsafe sound exposure compared to the method of using ECV alone.

DESIGN

Eleven children (4 to 9 years), 10 adolescents (10 to 18 years), and 10 young adults (20 to 40 years) with normal hearing, tympanometry, vestibular and neurological function participated. On all subjects, RECD was measured twice per ear to account for test-retest reliability. cVEMP and oVEMP were then recorded bilaterally with a 500 Hz tone burst at a traditional and an adjusted VEMP intensity level. The traditional intensity level was 125 dB SPL for individuals with ≥ 0.9 mL ECV and 120 dB SPL for individuals with ≤ 0.8 mL ECV. The adjusted intensity level was calculated by subtracting the average 500 Hz RECD measured values from the 500 Hz normative RECD value. This value was applied as a correction factor to a 125 dB SPL stimulus. Peak to peak amplitudes were recorded and used to calculate asymmetry ratios.

RESULTS

Young children had significantly smaller ECVs compared to adolescents and young adults. Young children had larger RECDs; however, this was not significant in post hoc analyses. The method of calibration had no significant effect on intra-subject variability for cVEMP [ F (1, 27)= 0.996, p = 0.327] or oVEMP [ F (1, 25)= 1.679, p = 0.206]. The method of calibration also had no significant effect on inter-subject amplitude variability for cVEMP [ F (1, 120)= 0.721, p = 0.397] or oVEMP [ F (1, 120)= 0.447, p = 0.505]. Both methods of calibration adequately protected against unsafe exposure levels. However, there were subjects with ECVs ≥ 0.9 mL who approached unsafe exposure levels from the ECV-calibrated stimulus, suggesting there may be rare cases in which a 125 dB SPL stimulus is unsafe, even for patients with larger ECVs.

CONCLUSIONS

The calibration method made no significant difference in intra- or inter-subject variability, indicating that the acoustic environment of the outer ear is not significantly contributing to VEMP amplitude variability. The RECD-adjusted stimulus is effective in protecting against unsafe exposure levels for two trials of both c- and oVEMPs. There may be instances where more than two trials of each test are required, which increases the effective stimulation level. Clinicians should be cautious when delivering VEMPs and not unnecessarily expose patients to unsafe levels of sound.

Vestibular migraine or Meniere's disease: a diagnostic dilemma

Meniere's disease (MD) represents one of the vertigo disorders characterized by triad symptoms (recurrent vertigo, fluctuating hearing loss, tinnitus or ear fullness). The diagnosis of MD relies on the accurate and detailed taking of medical history, and the differentiation between MD and vestibular migraine (VM) is of critical importance from the perspective of the treatment efficacy. VM is a highly prevalent vertigo condition and its typical symptoms (headache, vestibular symptoms, cochlear symptoms) mimic those of MD. Furthermore, the misdiagnosis in MD and VM could lead to VM patients mistakenly receiving the traumatic treatment protocol designed for MD, and sustaining unnecessary damage to the inner ear. Fortunately, thanks to the advances in examination technologies, the barriers to their differentiation are being gradually removed. These advances enhance the diagnostic accuracy of vertigo diseases, especially VM and MD. This review focused on the differentiation of VM and MD, with an attempt to synthesize existing data on the relevant battery of differentiation diagnosis (covering core symptoms, auxiliary tests [audiometry, vestibular tests, endolymphatic hydrops tests]) and longitudinal follow-up. Since the two illnesses are overlapped in all aspects, no single test is sufficiently specific on its own, however, patterns containing all or at least some features boost specificity.

[Method of registration of vestibular myogenic evoked potentials in the diagnosis of diseases of the inner ear]

The literature review is devoted to the practical application of the method of recording vestibular evoked myogenic potentials (VEMPs) in the diagnosis of the inner ear diseases: superior semicircular canal dehiscence syndrome, Meniere's disease, benign paroxysmal positional vertigo (BPPV), vestibular neuritis. Registration of VMEP is an electrophysiological research method that allows to assess objectively the functional state of the otolith receptors (sacculus and utriculus) and their pathways, which expands the diagnostic capabilities in diagnosis of the inner ear diseases.

Normative and Pathological Ranges of Cervical Vestibular Evoked Myogenic Potentials in Normal Subjects and Patients with Complete Compensated Unilateral Vestibular Loss: A Cross Sectional Study

To know the normative ranges of VEMP response metrics in healthy young adults. To know the pathological cutoff of VEMP metrics in unilateral vestibular loss patients. To compare our VEMP metrics with the normative values of other studies from the western world. Prospective cross-sectional study. Tertiary care audiovestibular laboratory. 30 healthy subjects and 15 cases with a unilateral complete compensated loss. Various VEMP parameters-p1 latency, n1 latency, p1-n1 amplitude and Interaural asymmetry ratio (IAR) were entered into databases and analyzed. We compared our parameters with the most cited scientific data on VEMP available in the PubMed database, and we analyzed the results. 90% of controls and 80% of cases got VEMP responses at 95 dB HL threshold, 500 Hz with subject/patient placed in sitting upright with head turned to opposite side position. The normative data of VEMP response metrics in young adults for p1, n1 latencies, p1-n1 amplitude, and IAR are 13 ± 2 ms, 21 ± 2 ms, 91 ± 33 uV, and 9.25 ± 7.3, respectively. As the VEMP test has 100% sensitivity and 100% (95% CI 87-100%) negative predictive value in detecting the saccular dysfunction, we recommend the VEMP test as a mandatory tool in the vestibular test battery. There is no statistically significant difference in various VEMP parameters between the control and normal sides of the case group.

Multifrequency Narrowband Chirp Evoked Cervical Vestibular Myogenic Potentials: Evaluation of Responses in Normal-Hearing Young Adults

Purpose:

The study aimed to explore the various parameters of multifrequency narrowband Claus Elberling chirp (NB CE-chirp) evoked cervical vestibular evoked myogenic potentials (cVEMPs) in normal-hearing healthy young adults. The study also attempted to define the optimal frequency tuning characteristic of NB CE-chirp evoked cVEMPs.

Method:

cVEMP was performed on 26 young healthy adults using four different NB CE-chirps centered at 500, 1000, 2000, and 4000 Hz. The neck torsion method was applied for electrode placement. To have the acute recording, visual feedback of sternocleidomastoid muscle contraction was provided, and electromyography (EMG) scaling was done.

Results:

cVEMPs were present for 100% across all frequencies except at 4000 Hz. Amplitudes between each pair of frequencies were significantly different for EMG scaled and unscaled conditions. Frequency tuning was observed at 500 Hz regardless of scaling done. Positive peak 1 of cVEMP (P1) latencies showed no differences between frequencies while both negative peak 1 of cVEMP and the complex of positive peak 1 and negative peak 1 of cVEMP (P1N1) interpeak latency values decreased with increasing frequency. Interaural amplitude asymmetry ratio showed no difference between scaled and unscaled amplitudes. Intraclass correlation revealed a range of test–retest reliability across frequencies. EMG unscaled amplitude were having relatively lower test–retest reliability consistently across frequencies

Conclusions:

Differences in amplitudes between frequencies with a maximum at 500 Hz can be attributed to the low frequency centered saccular response. No differences in P1 were observed. Yet, N1 latency and P1N1 interpeak latency difference gradually shortened with the decrement in the stimulus duration as the stimulation frequency increased. The lower reliability of EMG unscaled amplitude across frequencies supports the need to use EMG scaling to avoid confounding variables related to muscle contraction.

Comparison of Glycerol Test, ECochG and VEMP Findings in Patients with Meniere’s Disease

Present study aimed to find if multiple audio-vestibular tests can be used to improve in diagnosing Meniere's disease. The study compares the results of four test procedures of glycerol test, Electrocochleography (ECochG), cervical Vestibular Evoked Myogenic Potential (c-VEMP) and ocular Vestibular Evoked Myogenic Potential (o-VEMP) individually and also together to see whether the diagnosis of Meniere's disease can be improved. Experimental group consist of 16 participants (32 ears) diagnosed with Meniere's disease as per American Academy of Otolaryngology (AAO) -Head and Neck Foundation (2020) guidelines. Control group consist of 16 participants with compliant of only vertigo participated in the study. Participants in both group underwent glycerol test, Electrocochleography (ECochG), cervical Vestibular Evoked Myogenic Potential (c-VEMP) and ocular Vestibular Evoked Myogenic Potential (o-VEMP). Glycerol test showed a 38% positive rate for the presence of Meniere's disease. ECochG indicated the presence of endolymphatic hydrops in 62% of the participants. Abnormal finding in c-VEMP and o-VEMP was seen in 31% and 56% of the participants respectively. The combination of two tests such as ECochG and o-VEMP has increased the positive rate upto 87%. Adding one more test of c-VEMP or combining all four audiovestibular tests had a positive rate of 94% only. The present study indicated ECochG is a more sensitive tool in the diagnosis of Meniere disease followed by o-VEMP. Thus, the present study indicated that combination ECochG and o-VEMP could be used to find the presence of Meniere's disease successfully.

Effects of Age and Middle Ear on the Frequency Tuning of the cVEMP and oVEMP

BACKGROUND

Upward shift in the air conducted (AC) frequency tuning of vestibular evoked myogenic potentials (VEMPs) as an effect of aging is hypothesized to be due to the microstructural stiffening changes in the inner ear. However, with an AC stimulus, it may be possible that the shift in the frequency tuning of VEMPs as an effect of aging may also be due to contributions from the middle ear.

PURPOSE

The main aim of this study was to examine the effects of age on the frequency tuning of the cervical VEMP (cVEMP) and ocular VEMP (oVEMP) and determine the role of middle ear transmission characteristics in shaping these effects.

RESEARCH DESIGN

Standard group comparison.

STUDY SAMPLE

One-hundred seven participants divided in three groups: young adult, middle-age, and older adults with "normal" middle ear and negative history of neurological or vestibular complaints.

DATA COLLECTION AND ANALYSES

Middle ear measures included static admittance and middle ear resonant frequency. cVEMP and oVEMPs were elicited with AC tone bursts at 500, 750, and 1,000 Hz.

RESULTS

No significant effect of age was observed on any of the middle ear measures. There was a significant effect of age on the amplitude of the cVEMP, but this effect was frequency specific. The age-related reduction in cVEMP corrected amplitude was only observed when the eliciting stimulus was 500 or 750 Hz, with no significant effect observed with a 1,000 Hz stimulus. For the oVEMP, the effects of age were apparent at all stimulus frequencies. We also observed a general upward shift in the frequency tuning of both the cVEMP and oVEMP for middle-age and older adults, with 750 and 1,000 Hz yielding higher response rates and larger amplitudes among middle-aged and older adults. Measurements of middle ear did not significantly contribute to the observed findings.

CONCLUSIONS

The upward shift in frequency tuning of VEMPs among middle age and older adults could be due to the changes in the vestibular system and not from the middle ear. These results support the use of different frequency stimuli (i.e., 750 or 1,000 Hz) to elicit a VEMP if a response is absent using a 500 Hz stimulus, especially in patients over the age of 40.

Non-contrast MRI of Inner Ear Detected Differences of Endolymphatic Drainage System Between Vestibular Migraine and Unilateral Ménière's Disease

Objective

We aimed to evaluate the diagnostic performance of some anatomical variables with regard to endolymphatic sac (ES) and duct (ED), measured by non-contrast three-dimensional sampling perfection with application-optimized contrasts using different flip angle evolutions (3D-SPACE) magnetic resonance imaging (MRI), in differentiating vestibular migraine (VM) from unilateral Ménière's disease (MD).

Methods

In this study, 81 patients with VM, 97 patients with unilateral MD, and 50 control subjects were enrolled. The MRI-visualized parameters, such as the distance between the vertical part of the posterior semicircular canal and the posterior fossa (MRI-PP distance) and visibility of vestibular aqueduct (MRI-VA), were measured bilaterally. The diagnostic value of the MRI-PP distance and MRI-VA visibility for differentiating VM from unilateral MD was examined.

Results

(1) Compared with the VM patients, patients with unilateral MD exhibited shorter MRI-PP distance and poorer MRI-VA visibility. No differences in the MRI-PP distance and MRI-VA visibility were detected between patients with VM and control subjects. (2) No significant interaural difference in the MRI-PP distance and MRI-VA visibility was observed in patients with VM and those with unilateral MD, respectively. (3) Area under the curve (AUC) showed a low diagnostic value for the MRI-PP distance and MRI-VA visibility, respectively, in differentiating between the VM and unilateral MD.

Conclusions

Based on non-enhanced MRI-visualized measurement, anatomical variables with regard to the endolymphatic drainage system differed significantly between the patients with VM and those with unilateral MD. Further investigations are needed to improve the diagnostic value of these indices in differentiating VM from unilateral MD.

Endolymphatic hydrops in the unaffected ear of patients with unilateral Ménière's disease

PURPOSE

Current studies show that frequency tuning modification is a good marker for the detection of endolymphatic hydrops (EH) employing magnetic resonance imaging (MRI) in patients with Ménière's disease (MD). The purpose of the present study is to analyze the auditory and vestibular function with audiometric and vestibular-evoked myogenic potentials (VEMP) responses, respectively, in both the affected and unaffected ears of patients with unilateral MD using MRI as diagnostic support for the degree of EH.

METHODS

We retrospectively reviewed the medical records of 76 consecutive patients with unilateral definite MD (age 55 (28-75); 39 women, 37 men). MRI was used through intravenous gadolinium administration, audiometry, and VEMPs. Functional tests were performed up to a week after the MRI. All were followed up one year after imaging utilizing clinical, auditory, and vestibular testing to rule out bilateral involvement.

RESULTS

In the unaffected ear, the mean pure-tone average is normal even in cases with hydrops and, for a similar severity of hydrops is significantly lower than in the affected ear. Significant differences for the amplitude of the response at 0.5 kHz, at 1 kHz between the affected and unaffected ears were found to be lower in the affected ears. The relative amplitude ratio (1 Kz-0.5 kHz) was significantly lower in the affected ear and in the case of the oVEMP response depends on the degree of EH. The response in the unaffected ear was not modified by the presence or the degree of hydrops.

CONCLUSION

In the unaffected ear, hydrops is not associated with hearing deterioration. For a similar degree of hydrops, hearing loss is significantly greater in the affected ear. The endolymphatic hydrops in the vestibule induces a frequency bias in the VEMP response only in the affected ear and not in the unaffected ear. Because of these findings we consider that hydrops does not represent an active disorder in the unaffected ear.

Skull Vibration-Induced Nystagmus Test (SVINT) in Vestibular Migraine and Menière's Disease

BACKGROUND

Vestibular migraine (VM) and Menière's disease (MD) are the two most frequent episodic vertigo apart from Benign Paroxysmal Positional Vertigo (BPPV) differential diagnosis for them may be troublesome in the early stages. SVINT is a newly proposed vestibular test, which demonstrated to be fast and reliable in diagnoses above all of peripheral vestibular deficits.

METHODS

We retrieved clinical data from two groups of subjects (200 VM and 605 MD), enrolled between 2010 and 2020. Among others, these subjects were included when performing a SVINT. The purpose of the study is to assess if SVINT can be useful to differentiate the two episodic disorders.

RESULTS

59.2% of MD subjects presented as positive with SVINT while only 6% did so with VM; among other tests, only video HIT demonstrated a different frequency in the two groups (13.1% and 0.5%, respectively), but the low sensitivity in these subjects makes the test unaffordable for diagnostic purposes.

CONCLUSIONS

Since SVINT demonstrated to be positive in a peripheral vestibular deficit in previous works, we think that our data are consistent with the hypothesis that, in the pathophysiology of VM attacks, the central vestibular pathways are mainly involved.

Validation of inner ear MRI in patients with Ménière's disease by comparing endolymphatic hydrops from histopathologic specimens

Intravenous gadolinium-enhanced inner-ear magnetic resonance imaging (IV-Gd inner-ear MRI) has been used to visualize endolymphatic hydrops (EH) in clinical diagnosis of Ménière's disease (MD). However, lack of histological validation has led to several concerns regarding how best to interpret the resulting images. Here, we compared hydropic changes in temporal bone specimens with the results of IV-Gd inner-ear MRI in patients with MD. Histopathologic images of temporal bones from 37 patients with MD and 10 healthy controls were collected from the National Temporal Bone Bank of the Massachusetts Eye and Ear Infirmary in the United States. The EH ratios in the vestibule and cochlea were calculated from temporal bones using the methods used for IV-Gd inner-ear MRI, and the degree to which the saccular and utricular hydrops contributed to vestibular hydrops was measured. The presence of hydropic change in each semicircular canal was assessed using temporal bone images and compared with IV-Gd inner-ear MRI scans of 74 patients with MD. Based on human temporal bone imagery, the EH ratios in the cochlea and the vestibule on the affected side were 0.314 and 0.757, respectively. In the healthy control group, the ratio was 0.064 for the cochlea and 0.289 for the vestibule; these values were significantly different from those for the affected side of MD patients. The values for the affected ear were similar to the ratios from the IV-Gd inner-ear MRI scans in MD patients. In the vestibule, saccular hydrops were more common than utricular hydrops. The average EH ratios in the saccule and utricle were 0.513 and 0.242, respectively. No significant hydropic change from each of three semicircular canals was evident in temporal bone histopathology. However, herniation of otolithic organs (saccule or utricle) into the lateral semicircular canal was found in 44.4% of the patients, with saccular herniation (24.8%) more common than utricular herniation (16.7%). Although IV-Gd inner-ear MRI might not reflect fully the results of actual histopathology due to the limited resolution of MRI and image-processing techniques, the measured EH ratios from temporal bone specimens and IV-Gd inner-ear MRI scans were similar. Hydropic change in the three semicircular canals was not significant at either the ampullated or nonampullated end. Canal invasion of vestibular hydrops seen on MRI also appeared in temporal bone histopathology, and saccular invasion was dominant.

Isolated Saccular Hydrops on High-resolution MRI Is Associated With Full Spectrum Menière's Disease

OBJECTIVE

To describe the clinical presentation of patients with isolated saccular endolymphathic hydrops (EH) detected.

STUDY DESIGN

Clinical case series.

SETTING

University-based tertiary referral center.

PATIENTS

All subjects presenting with vertigo or hearing loss who had isolated saccular EH detected.

INTERVENTION

High-resolution delayed-contrast magnetic resonance imaging (MRI) conducted between November 2015 and November 2016.

MAIN OUTCOME MEASURES

Audiovestibular testing results and analysis of clinical histories.

RESULTS

Isolated saccular EH was detected in 18 subjects. Sixteen met criteria for definite Menière's disease (MD, n = 12) or delayed endolymphatic hydrops (DEH, n = 4). One had a history of sudden sensorineural hearing loss (SSNHL) and 3 years after MRI developed recurrent vertigo characteristic of DEH. One patient had a history of atypical DEH (Tumarkin falls without vertigo following SSNHL). Four patients had Tumarkin falls. Most (83%) demonstrated mild-to-severe low-frequency fluctuating loss, and six (33.3%) had a history of ipsilateral sudden profound SNHL. Nine of the 17 (53%) patients tested had an ipsilateral caloric paresis ranging from 26 to 67%. Ipsilateral vestibular-evoked myogenic potentials showed reduced or absent responses in 5 of the 17 tested (29%).

CONCLUSIONS

The full spectrum of MD may be associated with saccular hydrops. We propose that MD and DEH often begin in the saccule, and MRI may provide clues to the pathophysiology of MD. Saccular hydrops was present in one patient with SSNHL who did not develop vertigo spells until 3 years after MRI, indicating that saccular hydrops may be the first manifestation of MD or DEH.

Altered mapping of sound frequency to cochlear place in ears with endolymphatic hydrops provide insight into the pitch anomaly of diplacusis

A fundamental property of mammalian hearing is the conversion of sound pressure into a frequency-specific place of maximum vibration along the cochlear length, thereby creating a tonotopic map. The tonotopic map makes possible systematic frequency tuning across auditory-nerve fibers, which enables the brain to use pitch to separate sounds from different environmental sources and process the speech and music that connects us to people and the world. Sometimes a tone has a different pitch in the left and right ears, a perceptual anomaly known as diplacusis. Diplacusis has been attributed to a change in the cochlear frequency-place map, but the hypothesized abnormal cochlear map has never been demonstrated. Here we assess cochlear frequency-place maps in guinea-pig ears with experimentally-induced endolymphatic hydrops, a hallmark of Ménière’s disease. Our findings are consistent with the hypothesis that diplacusis is due to an altered cochlear map. Map changes can lead to altered pitch, but the size of the pitch change is also affected by neural synchrony. Our data show that the cochlear frequency-place map is not fixed but can be altered by endolymphatic hydrops. Map changes should be considered in assessing hearing pathologies and treatments.

Recurrent vestibulopathy: are cVEMP, oVEMP and inner ear MRI useful to distinguish patients with Menière's disease and vestibular migraine?

PURPOSE

The aim of this study was to assess the rate of endolymphatic hydrops (EH) on MRI and the rate of otolithic dysfunction with cVEMP and oVEMP, in patients with recurrent vertigo such as Menière's disease (MD), vestibular migraine (VM) and vestibular Menière's disease (vMD).

METHODS

In this retrospective study, we performed 3D-FLAIR sequences with delayed acquisition in 20 MD, 20 VM and 20 vMD patients. Each subject was then assessed for the presence of EH on MRI. All patients underwent pure-tone audiometry, cVEMP and oVEMP.

RESULTS

In MD patients, EH was observed in 18 (90%) out of 20 patients while EH was observed in only 1 MV (5%) and 1 vMD (5%) patients. We found significant differences between groups for the presence of EH on MRI (p = 0.001). MD patients had significant higher PTA level (p < 0.001) and oVEMP impairment than MV and vMD (p = 0.08 and p = 0.06, respectively). However, no significant differences were observed for cVEMP impairment, either asymmetric ratio (p = 0.36) and 1000/500 ratio (p = 0.20).

CONCLUSIONS

Concerning cVEMP, we observed no significant differences between VM, vMD and MD. However, we observed higher oVEMP impairment, PTA level and EH on MRI in MD patients. We believe that MRI could be used to differentiate MD from VM patients with cochlear symptoms. However, in cases of migraine associated with recurrent vertigo and without cochlear symptoms, we believe that MRI is not a useful tool to differentiate between VM and vMD.

Cervical Vestibular Evoked Myogenic Potentials That Are Absent at 500 Hz But Present at 1000 Hz Are Characteristic of Endolymphatic Hydrops-Related Disease

OBJECTIVES

It remains unclear whether the dominance of 1000 Hz responses over responses at 500 Hz in cervical vestibular evoked myogenic potentials (cVEMPs) are characteristic of endolymphatic hydrops (EH), due to the presence of patients with absent responses at both frequencies. The purpose of the present study is to examine whether the dominant cVEMP responses at 1000 Hz over 500 Hz are characteristic findings of EH-related diseases among patients who show various cVEMP findings.

DESIGN

We retrospectively reviewed the medical records of 470 consecutive patients who underwent cVEMP testing with short-tone bursts at both 500 Hz and 1000 Hz. We categorized the cVEMP responses of these 470 patients into the following five groups: (group 1) present responses at both frequencies bilaterally, (group 2) present responses at 500 Hz but absent at 1000 Hz on at least one side, (group 3) absent responses at 500 Hz but present at 1000 Hz on at least one side, (group 4) absent responses at both frequencies on one side and present at both frequencies on the other side, and (group 5) absent responses at both frequencies bilaterally. We compared the proportion of EH-related diseases between each group and the other four groups and then investigated any increased or decreased disease incidence in each group.

RESULTS

In group 3, the proportion of EH-related disease was significantly higher (p < 0.01), and the incidence of an EH-related disease was greatly increased (standard residual value > 3).

CONCLUSIONS

cVEMPs that are absent at 500 Hz and present at 1000 Hz may be characteristic of EH-related disease.

Air and bone-conducted vestibular evoked myogenic potentials in children with large vestibular aqueduct syndrome

BACKGROUND

There are few studies focused on vestibular symptoms and function of the children with LVAS.

OBJECTIVES

This study aimed to find the characteristics of air and bone-conducted VEMPs among children with LVAS, and to investigate the relationship between VEMPs and vestibular symptoms.

MATERIAL AND METHODS

A total of 44 children with LVAS and 10 healthy children were recruited as the case group and control group. Air and bone-conducted VEMP were performed to the participants.

RESULTS

For air-conducted measurement, there was elevated amplitude of cVEMP in case group than control group. There was no significant difference at oVEMP parameters between the case group and control group. For bone-conducted measurement, significantly longer P1 latency and shorter P1-N1 latency of cVEMP were observed among the case group; there were a series of changes in oVEMP parameters among the case group. Logistic regression model revealed that air-conducted oVEMP asymmetric ratio was valuable to predict vestibular symptoms' development among the kids with LVAS.

CONCLUSION

Asymmetric ratio of oVEMP could be used as one predictor of developing vestibular symptoms of the children with LVAS. Applying bone-conducted VEMP as one alternative parameter of vestibular syndrome is novel and will certainly remain an area of continued investigation.

Association of cervical vestibular-evoked myogenic potential tuning property test results with MRI findings of endolymphatic hydrops in Meniere's disease

PURPOSE

To examine the concordance between cervical vestibular-evoked myogenic potential (cVEMP) tuning property test results and MRI findings of endolymphatic hydrops (EH).

METHODS

Fourteen subjects (age 24-76 years) that had been diagnosed with unilateral definite Meniere's disease (MD) (N = 8) or unilateral probable MD (N = 6) were enrolled. All of the subjects underwent cVEMP tests (using 500 Hz and 1000 Hz tone bursts), pure-tone audiometry, and gadolinium-enhanced 3 T-MRI. To examine tuning properties of cVEMP, the 500-1000 Hz amplitude ratio was calculated as the SLOPE. The results of the cVEMP tuning property test results were compared with EH-related MRI findings.

RESULTS

EH positivity in both the cochlea and vestibule on MRI was observed in 7 of the 8 affected ears of definite MD and 3 of the 6 affected ears of probable MD, although it was only in one of the 14 unaffected ears. EH(+) or no response (NR) in cVEMP tuning property test was significantly associated with EH positivity on MRI, while EH(-) in the cVEMP tuning property test was significantly associated with EH-negativity on MRI (p = 0.0016 Fisher's exact test test).

CONCLUSION

EH(+) or NR in the cVEMP tuning property test correspond well to EH positivity in the MRI findings. The cVEMP tuning property test is useful for screening and following up EH.

Transmastoid Labyrinthectomy for Menière's Disease: Experience and Outcomes

OBJECTIVE

To characterize presurgical symptoms and treatment history and postoperative course in patients with medically recalcitrant Menière's disease undergoing transmastoid labyrinthectomy in the post-intratympanic gentamicin era.

STUDY DESIGN

Retrospective case series.

SETTING

Tertiary academic medical center.

PATIENTS

All patients who underwent transmastoid labyrinthectomy for medically recalcitrant Menière's disease in 2003 to 2019 by the senior author.

INTERVENTIONS

Review of patients' medical records for: preoperative history of drop attacks, gentamicin injections, endolymphatic sac decompression or vestibular neurectomy, preoperative audiograms, length of hospital stay, postoperative complications, and persistent symptoms or challenging recovery.

MAIN OUTCOME MEASURES

Presurgical clinical history and proximal postoperative outcomes.

RESULTS

Seventy-two patients with a mean age of 56.7 (standard deviation [SD] 10.7) were included. All cases were unilateral. Forty-three patients (59.7%) suffered from drop attacks. Sixty-two (86.1%) had failed sufficient symptom control with gentamicin injections. The mean preoperative word recognition score was 36.4% (SD 23.7) versus 95.1% (SD 8.5) in the contralateral ear. The mean pure-tone average (PTA) of the ipsilateral ear before surgery was 65.5 dB (SD 18.0) versus 16.2 (SD 13.5) for the contralateral ear. Mean hospital stay was 2.0 days (SD 0.87 days, range of 1-5 d). Three patients (4.2%) had prolonged postoperative vertigo.

CONCLUSIONS

Transmastoid labyrinthectomy at our center is performed for unilateral Menière's disease, generally when intratympanic gentamicin has failed. A majority of surgical patients suffer from drop attacks preoperatively. Hospital stay is typically brief.

Cervical vestibular evoked myogenic potential with chirp sounds

BACKGROUND

There are only a few reports concerning cervical vestibular evoked myogenic potential (cVEMP) using chirp sound, and clinical indications/advantages of it are still unclear.

OBJECTIVE

To compare cVEMP using CE-chirp LS® with cVEMP using 500 Hz and 1000 Hz tone bursts (TB) and to investigate clinical indications/advantages of CE-chirp LS® for recording cVEMP.

METHODS

Sixteen patients with vestibular disorders (2men and 14 women) (18∼62, mean 42.9 years of age) were enrolled in this study. Participants underwent cVEMP testing using 500 Hz and 1000 Hz tone bursts (TB) and CE-chirp LS®. Response rate of P1-N1, corrected/normalized amplitude of P1-N1, latencies of P1 and N1, asymmetry ratio, and correlation of P1 latency to SLOPE in tuning property test (an index of endolymphatic hydrops) were compared.

RESULTS

Corrected/normalized amplitude of P1-N1 to CE-chirp LS® was smaller than corrected/normalized amplitude of P1-N1 to 500 Hz TB. Peak latencies to CE-chirp LS® were the shortest among the 3 types of stimulation. EH-positive ears according to the tuning property test had tendency of prolonged P1 latencies to CE-chirp LS®.

CONCLUSION

CE-chirp LS® is applicable for recording cVEMP with a similar diagnostic accuracy to TB. Prolongation of P1 latency in CE-chirp LS® might be an indicator of endolymphatic hydrops in the saccule.

Predicting Development of Bilateral Menière's Disease Based on cVEMP Threshold and Tuning

OBJECTIVE

To investigate if the cervical vestibular evoked myogenic potential (cVEMP) is predictive for developing bilateral Menière's disease (MD).

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care center.

PATIENTS

Records of 71 patients previously diagnosed with unilateral MD at our institution who underwent cVEMP testing between 2002 and 2011 were screened.

INTERVENTION

Patients were contacted to answer a questionnaire to identify which patients had developed bilateral disease. Based on questionnaires and medical charts, 49 patients with a follow-up time of at least 5 years were included. The 49 originally asymptomatic ears are referred to as "study ears." Previously reported cVEMP criteria (original criteria) applied to study-ear cVEMPs separated them into Menière-like and normal-like groups.

MAIN OUTCOME MEASURE

The main purpose was to determine if previously obtained cVEMP thresholds and tuning ratios of unilateral MD patients could predict who develops bilateral disease.

RESULTS

From the 49 included patients, 12 developed bilateral disease (24.5%). The study ears characterized by original cVEMP criteria as Menière-like were significantly more likely to develop bilateral disease compared with the normal-like study ears. The original criteria predicted development of bilateral disease with a positive predictive value (PPV) and negative predictive value (NPV) of 58.3% and 86.5% respectively. ROC curves were used to revise cVEMP criteria for predicting the progression to bilateral disease. A revised criterion combining three cVEMP metrics, reached a PPV and NPV of 85.7% and 93.7%.

CONCLUSION

cVEMP threshold and tuning in unilateral MD patients are predictive of which patients will develop bilateral disease.

Audiometric and cVEMP Thresholds Show Little Correlation With Symptoms in Superior Semicircular Canal Dehiscence Syndrome

OBJECTIVE

Evaluate the relationship between objective audiometric and vestibular tests and patient symptoms in superior canal dehiscence (SCD) syndrome.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary care center.

PATIENTS

Ninety-eight patients with SCD, preoperative threshold audiograms, cervical vestibular evoked myogenic potential (cVEMP) thresholds, and computed tomography (CT) imaging were included. Clinical reports were reviewed for self-reported SCD symptoms. Twenty-five patients completed the Hearing Handicap Inventory (HHI), Dizziness Handicap Inventory (DHI), Autophony Index (AI), and the 36-item Short Form Survey (SF-36).

MAIN OUTCOME MEASURES

Correlations between preoperative low-frequency air-bone gap (ABG), cVEMP thresholds, and symptoms (including HHI, DHI, AI, and SF-36). Symptoms included hearing loss, aural fullness, autophony, hyperacusis, tinnitus, vertigo, imbalance and sound-, pressure and exercise provoked dizziness. Secondary outcome measure: Correlations between changes of objective and subjective measures before and after surgery.

RESULTS

Patients who reported hearing loss had larger ABGs at 250 Hz than patients without subjective hearing loss (p = 0.001). ABGs and cVEMP thresholds did not correlate with any other symptom. No significant correlation was found between ABG or cVEMP threshold and the HHI, DHI, AI or Health Utility Value (derived from the SF-36 quality of life score). Following SCD surgery, ABG decreased (p < 0.001), cVEMP thresholds increased (p < 0.001) and overall symptoms, handicap scores and quality-of-life improved; however, there was no significant relationship between these measures.

CONCLUSION

While threshold audiometry and cVEMP are important tools to diagnose SCD and monitor surgical outcomes, these measures showed no significant correlation with vestibular and most auditory symptoms or their severity.

Cervical VEMP tuning changes by Meniere's disease stages

Objective

To determine if changes in cervical vestibular-evoked myogenic potential (cVEMP) testing reflect the different stages of cochlea-saccular hydrops in Meniere's disease (MD).

Methods

This is a case-control retrospective series. Forty-seven patients with unilateral MD by American Academy of Otolaryngology-Head and Neck Surgery diagnostic and staging criteria, and 30 with non-MD vertigo as control. Meniere patients were further classified based on symptoms at the time of testing as active or stable. Subsequently, patients underwent cVEMP testing by tone-burst stimuli at 500 and 1,000 Hz. The main outcome measure was to compare the cVEMP 1,000 and 500 Hz amplitude ratio in ears with MD and non-MD vertigo, and in active versus stable MD.

Results

The cVEMP 1,000/500 Hz amplitude ratio was higher in Meniere's ears (mean = 1.14 μV, SD = 0.25) than in non-Meniere's ears (mean = 0.96 μV, SD = 0.2) (Student's t test, P = .001), and higher in active (mean = 1.22 μV, SD = 0.25) than in stable MD (mean = 1.00 μV, SD = 0.18) (P = .0035). The diagnostic value of cVEMP 1,000/500 Hz amplitude ratio to differentiate MD versus non-MD vertigo was evaluated with a receiver-operating characteristics (ROC) curve and the area under the curve (AUC) was 0.716 (95% confidence interval [CI] [0.591, 0.829]). The ideal cutoff point was 0.9435 with sensitivity and specificity values of 83% and 53%, respectively. The sensitivity and specificity values for this test to differentiate active versus stable MD were 68% and 81%, respectively, with AUC 0.746 (95% CI [0.607, 0.885]) and cutoff value of 1.048. In all ears, the 1,000/500 Hz amplitude ratio increased by a decrease of the 500 Hz amplitude with increasing age.

Conclusion

The cVEMP 1,000/500 Hz amplitude ratio is elevated in ears with MD but not in those with non-MD vertigo. After corrected by age, this ratio is higher in active but not in stable MD, probably reflecting dynamic changes in saccular membrane motion mechanics in hydrops, and may be a useful marker of disease progression and the effect of therapy.

Level of Evidence

IV.

Air-Conducted Vestibular Evoked Myogenic Potential Testing in Children, Adolescents, and Young Adults: Thresholds, Frequency Tuning, and Effects of Sound Exposure

OBJECTIVES

Pediatric vestibular evaluations incorporate cervical and ocular vestibular evoked myogenic potential (c- and oVEMP, respectively) testing; however, in children, c- and oVEMP thresholds have been minimally investigated and frequency tuning is unknown. Children are also at risk for unsafe sound exposure secondary to VEMP. While it is unknown if VEMP threshold testing leads to cochlear changes, it is possible that this risk increases due to the increased number of trials needed to obtain a threshold. Obtaining VEMP thresholds at various frequencies in children provides further information for pediatric normative VEMP data. Assessing for cochlear changes after VEMP threshold testing would provide information on the safety of threshold VEMP testing in children. The objectives of this study were to (1) characterize c- and oVEMP thresholds in children, adolescents, and young adults with normal hearing using 500 and 750 Hz tone burst (TB) stimuli, (2) compare frequency tuning of 500 and 750 Hz TB, and (3) assess whether cochlear changes exist after VEMP threshold testing. It is hypothesized that children, adolescents, and young adults would not show age-related changes to the vestibular system. Therefore, reliable VEMP thresholds would be seen below maximum acoustical stimulation levels (e.g., <125 dB SPL) and frequency tuning will be similar for 500 and 750 Hz TB stimuli.

DESIGN

Ten children (age 4-9), 10 adolescents (age 10-19), and 10 young adults (age 20-29) with normal hearing and tympanometry participated. All subjects received c- and oVEMP testing at maximum stimulation and threshold. To address frequency tuning, but not exceed recommended sound exposure allowance, subjects received a 500 Hz TB stimulus in one ear and a 750 Hz TB stimulus in the other ear. Subjects completed tympanometry pre-VEMP, and audiometric threshold testing, distortion product otoacoustic emission testing, and subjective questionnaire pre- and post-VEMP to study the effect of VEMP exposure on cochlear function for each stimulus frequency.

RESULTS

(1) cVEMP thresholds were determined for both stimulus frequencies for children (500 Hz = 106 dB SPL; 750 Hz = 106 dB SPL), adolescents (500 Hz = 107.5 dB SPL; 750 Hz = 109.5 dB SPL), and young adults (500 Hz = 111.5 dB SPL; 750 Hz = 112 dB SPL). oVEMP thresholds were also obtained in response to both stimulus frequencies for children (500 Hz = 111.1 dB SPL; 750 Hz = 112.2 dB SPL), adolescents (500 Hz = 112.5 dB SPL; 750 Hz = 114.5 dB SPL), and young adults (500 Hz = 116 dB SPL; 750 Hz = 117 dB SPL). Similar thresholds were found between groups except for children who had significantly lower thresholds compared with adults for cVEMP (500 Hz: p = 0.002; 750 Hz: p = 0.004) and oVEMP (500 Hz: p = 0.01; 750 Hz: p = 0.02). In addition, equivalent ear-canal volume and VEMP thresholds were linearly correlated. (2) There was no significant effect of stimulus frequency on VEMP response rates, latencies, peak to peak amplitudes, or thresholds, suggesting similar frequency tuning for 500 and 750 Hz. (3) There were no significant effects of VEMP threshold testing on cochlear function for either stimulus frequency.

CONCLUSIONS

Children, adolescents, and young adults show VEMP thresholds below high stimulation levels and had similar frequency tuning between 500 and 750 Hz. Use of 750 Hz could be regarded as the safer stimuli due to its shorter duration and thus reduced sound exposure. Children with smaller ear-canal volume had present responses at maximum stimulation and lower thresholds, suggesting that VEMP testing could be initiated at lower acoustic levels to minimize sound exposure and optimize testing.

Toward Optimizing VEMP: Calculating VEMP Inhibition Depth With a Generic Template

OBJECTIVES

Cervical vestibular evoked myogenic potentials (cVEMP) indirectly reveal the response of the saccule to acoustic stimuli through the inhibition of sternocleidomastoid muscle electromyographic response. VEMP inhibition depth (VEMPid) is a recently developed metric that estimates the percentage of saccular inhibition. VEMPid provides both normalization and better accuracy at low response levels than amplitude-normalized cVEMPs. Hopefully, VEMPid will aid in the clinical assessment of patients with vestibulopatholgy. To calculate VEMPid a template is needed. In the original method, a subject's own cVEMP was used as the template, but this method can be problematic in patients who do not have robust cVEMP responses. We hypothesize that a "generic" template, created by assembling cVEMPs from healthy subjects, can be used to compute VEMPid, which would facilitate the use of VEMPid in subjects with pathological conditions.

DESIGN

A generic template was created by averaging cVEMP responses from 6 normal subjects. To compare VEMPid calculations using a generic versus a subject-specific template, cVEMPs were obtained in 40 healthy subjects using 500, 750, and 1000 Hz tonebursts at sound levels ranging from 98 to 123 dB peSPL. VEMPids were calculated both with the generic template and with the subject's own template. The ability of both templates to determine whether a cVEMP was present or not was compared with receiver operating characteristic curves.

RESULTS

No significant differences were found between VEMPid calculations using a generic template versus using a subject-specific template for all frequencies and sound levels. Based on the receiver operating characteristic curves, the subject-specific and generic template did an equally good job at determining threshold. Within limits, the shape of the generic template did not affect these results.

CONCLUSIONS

A generic template can be used instead of a subject-specific template to calculate VEMPid. Compared with cVEMP normalized by electromyographic amplitudes, VEMPid is advantageous because it averages zero when there is no sound stimulus and it allows the accumulating VEMPid value to be shown during data acquisition as a guide to deciding when enough data has been collected.

Cervical Vestibular Evoked Myogenic Potentials in Menière's Disease: A Comparison of Response Metrics

OBJECTIVE

The cervical vestibular evoked myogenic potential (cVEMP) has been used to evaluate patients with Menière's disease (MD). Studied cVEMP metrics include: amplitude, threshold, frequency tuning, and interaural asymmetry ratio (IAR). However, few studies compared these metrics in the same set of MD patients, and methodological differences prevent such a comparison across studies. This study investigates the value of different cVEMP metrics in distinguishing one set of MD patients from age-matched controls.

STUDY DESIGN

Prospective study.

SETTING

Tertiary care center.

PATIENTS

Thirty patients with definite unilateral MD and 23 age-matched controls were prospectively included. All underwent cVEMP testing at 500, 750, 1000, and 2000 Hz on each side. Ears were separated into three groups: affected MD, unaffected MD, and control.

MAIN OUTCOME MEASURES

Sound level functions were obtained at each frequency, and normalized peak-to-peak amplitude (VEMPn), VEMP inhibition depth (VEMPid), threshold, frequency-tuning ratio, and IAR were calculated. For all metrics, the differentiation between MD and control ears was compared using receiver operating characteristic (ROC) curves.

RESULTS

500 Hz cVEMP threshold, VEMPn, and VEMPid were similarly good at distinguishing affected MD ears from healthy ears, with ROC area under the curves (AUCs) of more than 0.828 and optimal sensitivities and specificities of at least 80 and 70%. Combinations of these three metrics yielded slightly larger AUCs (>0.880). Tuning ratios and IAR were less effective in separating healthy from affected ears with AUCs ranging from 0.529 to 0.720.

CONCLUSION

The cVEMP metrics most useful in distinguishing MD patients from healthy controls are threshold, VEMPn, and VEMPid, using 500 Hz stimuli.

Vestibular evoked myogenic potentials in practice: Methods, pitfalls and clinical applications

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Vestibular evoked myogenic potentials (VEMPs) are used to test the otolith organs in patients with vertigo and imbalance.

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This review discusses the optimal procedures for recording VEMPs and the pitfalls commonly encountered by clinicians.

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Better understanding of VEMP methodology should lead to improved quality of recordings.

Vestibular evoked myogenic potentials (VEMPs) are a useful and increasingly popular component of the neuro-otology test battery. These otolith-dependent reflexes are produced by stimulating the ears with air-conducted sound or skull vibration and recorded from surface electrodes placed over the neck (cervical VEMPs) and eye muscles (ocular VEMPs). VEMP abnormalities have been reported in various diseases of the ear and vestibular system, and VEMPs have a clear role in the diagnosis of superior semicircular canal dehiscence. However there is significant variability in the methods used to stimulate the otoliths and record the reflexes. This review discusses VEMP methodology and provides a detailed theoretical background for the techniques that are typically used. The review also outlines the common pitfalls in VEMP recording and the clinical applications of VEMPs.

Toward Optimizing cVEMP: 2,000-Hz Tone Bursts Improve the Detection of Superior Canal Dehiscence

BACKGROUND

The cervical vestibular evoked myogenic potential (cVEMP) test measures saccular and inferior vestibular nerve function. The cVEMP can be elicited with different frequency stimuli and interpreted using a variety of metrics. Patients with superior semicircular canal dehiscence (SCD) syndrome generally have lower cVEMP thresholds and larger amplitudes, although there is overlap with healthy subjects. The aim of this study was to evaluate which metric and frequency best differentiate healthy ears from SCD ears using cVEMP.

METHODS

Twenty-one patients with SCD and 23 age-matched controls were prospectively included and underwent cVEMP testing at 500, 750, 1,000 and 2,000 Hz. Sound level functions were obtained at all frequencies to acquire threshold and to calculate normalized peak-to-peak amplitude (VEMPn) and VEMP inhibition depth (VEMPid). Third window indicator (TWI) metrics were calculated by subtracting the 250-Hz air-bone gap from the ipsilateral cVEMP threshold at each frequency. Ears of SCD patients were divided into three groups based on CT imaging: dehiscent, thin or unaffected. The ears of healthy age-matched control subjects constituted a fourth group.

RESULTS

Comparing metrics at all frequencies revealed that 2,000-Hz stimuli were most effective in differentiating SCD from normal ears. ROC analysis indicated that for both 2,000-Hz cVEMP threshold and for 2,000-Hz TWI, 100% specificity could be achieved with a sensitivity of 92.0%. With 2,000-Hz VEMPn and VEMPid at the highest sound level, 100% specificity could be achieved with a sensitivity of 96.0%.

CONCLUSION

The best diagnostic accuracy of cVEMP in SCD patients can be achieved with 2,000-Hz tone burst stimuli, regardless of which metric is used.