Vestibulo-ocular reflex tests may reflect unilateral Ménière disease progression: A cross-sectional study

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE: 1

Comparison between audio-vestibular findings and contrast-enhanced MRI of inner ear in patients with unilateral Ménière’s disease

Objective

The diagnosis of Ménière’s disease (MD), characterized by idiopathic endolymphatic hydrops (ELH), remains a clinical priority. Many ancillary methods, including the auditory and vestibular assessments, have been developed to identify ELH. The newly emerging delayed magnetic resonance imaging (MRI) of the inner ear after intratympanic gadolinium (Gd) has been used for identifying ELH in vivo. We aimed to investigate the concordance of audio-vestibular and radiological findings in patients with unilateral MD.

Methods

In this retrospective study, 70 patients with unilateral definite MD underwent three-dimensional fluid-attenuated inversion recovery (3D-FLAIR) sequences following intratympanic application of Gd. Audio-vestibular evaluations were performed, including pure tone audiometry, electrocochleogram (ECochG), glycerol test, caloric test, cervical and ocular vestibular evoked myogenic potentials (VEMPs), and video head impulse test (vHIT). The relationship between imaging signs of ELH and audio-vestibular results was investigated.

Results

The incidence of radiological ELH was higher than that of neurotological results, including the glycerol test, caloric test, VEMPs, and vHIT. Poor or slight agreement was observed between audio-vestibular findings and radiological ELH in cochlear and/or vestibular (kappa values <0.4). However, the pure tone average (PTA) in the affected side significantly correlated with the extent of both cochlear (r = 0.26795, p = 0.0249) and vestibular (r = 0.2728, p = 0.0223) hydrops. Furthermore, the degree of vestibular hydrops was also positively correlated with course duration (r = 0.2592, p = 0.0303) and glycerol test results (r = 0.3944, p = 0.0061) in the affected side.

Conclusion

In the diagnosis of MD, contrast-enhanced MRI of the inner ear is advantageous in detecting ELH over the conventional audio-vestibular evaluations, which estimates more than hydropic dilation of endolymphatic space.

Radiological presence of vascular loops in the cerebellopontine angle region in patients with unilateral Ménière's disease

OBJECTIVE

The relationship between vascular compression of the vestibulocochlear nerve and audio-vestibular symptoms remains controversial. We aimed to examine the radiological features of vascular loops signs in cerebellopontine angle (CPA) and internal auditory canal (IAC) in patients with unilateral Ménière's disease (MD).

METHODS

One hundred and thirty-seven patients with unilateral definite MD and 69 control subjects (138 ears) were enrolled. All subjects received magnetic resonance imaging of CPA-IAC. The configuration of vascular loops in CPA-IAC, based on the Kazawa classification system, from MD-affected, non-affected and control ears were compared. The associations between imaging findings and Ménière's stage, electrocochleogram (EcochG) and caloric test were analyzed.

RESULTS

(1) Among the MD-affected ears, 6 cases (4.4%) were classified as Kazawa type IA, 27 cases (19.7%) as IB, 60 cases (43.8%) as IIA, and 44 cases (32.1%) as IIB. No significant interaural difference in the distribution of Kazawa's types was found ([Formula: see text] = 4.737, p = 0.578) in unilateral MD patients. (2) The distribution of Kazawa's types were not significantly different between the MD-affected ears and the control subjects ([Formula: see text] = 2.876, p = 0.411). (3) No relationship was found between Kazawa staging of the MD-affected ear and Ménière's stage (H = 2.679, p = 0.444), EcochG ([Formula: see text] = 0.827, p = 0.867) and caloric test ([Formula: see text] = 4.116, p = 0.248).

CONCLUSIONS

In patients with unilateral MD, the configuration of vascular loops in CPA-IAC region, measured by Kazawa criteria, did not correlate with the laterality, clinical stage, the results of EcochG and caloric test, suggesting that vascular loops may be natural anatomical variations for patients with MD.

The Efficacy of Combined VHIT and VNG in the Diagnosis of Vertigo Caused by Meniere's Disease

This study aimed to evaluate the efficacy of video head impulse test (VHIT) and Videonystagmography (VNG) diagnostic tests in the diagnosis of vertigo caused by Meniere's disease. In this cross-sectional study 20 patients (10 in Meniere's group and 10 in control group) with vertigo attacks were involved. Patients were diagnosed with Meniere's disease (according to clinical criteria) or acute vertigo due to other causes after taking a history, complete examination, audiometry screening, and recording patient information in a pre-prepared checklist. Patients were referred to an audiology clinic for performing ECOG, VHIT, and VNG. All variables and sensitivity, specificity, positive predictive value, and negative predictive value were recorded and analyzed. There was no statistical difference between two groups regarding the mean age and gender of the patients (p > 0.05). The results showed no statistically significant difference between the study groups regarding the frequency distribution of ECOG, VNG, VHIT results. Also the results showed no statistically significant difference between the study groups regarding the frequency distribution of combined VNG and VHIT results. Combined VNG and VHIT had a relatively low sensitivity but high specificity in diagnosing Meniere's disease compared with the ECOG test, which had a sensitivity of 70% and a specificity of 90%. At the time of attack in this study, combined VNG and VHIT had a sensitivity of 50% and a specificity of 90%. According to the results of the current study, it can be concluded that patients in whom the result of combined VNG and VHIT was positive for Meniere's were more likely to have Meniere's disease based on clinical criteria.

Anatomical variation of inner ear may be a predisposing factor for unilateral Ménière's disease rather than for ipsilateral delayed endolymphatic hydrops

Objective

Radiological anatomical variations, measured by magnetic resonance imaging (MRI), were evaluated in patients with ipsilateral delayed endolymphatic hydrops (DEH) and unilateral Ménière’s disease (MD). The role of anatomical variations in different subtypes of hydropic ear disease was investigated.

Methods

Twenty-eight patients with ipsilateral DEH, 76 patients with unilateral MD, and 59 control subjects were enrolled. The radiological indices included the distance between the vertical part of the posterior semicircular canal and the posterior fossa (MRI-PP distance) and the visibility of vestibular aqueduct (MRI-VA). These variations among patients with DEH, MD, and control subjects were compared. The correlation between radiological anatomical variations and clinical features or audio-vestibular findings was also examined.

Results

(1) MRI-PP distance in the affected side of unilateral MD was shorter than that in ipsilateral DEH (Z =  − 2.481, p = 0.013) and control subjects (Z =  − 2.983, p = 0.003), while the difference of MRI-PP distance between the affected side of ipsilateral DEH and control subjects was not statistically significant (Z =  − 0.859, p = 0.391). (2) There was no significant interaural difference of MRI-PP distance in patients with unilateral MD (Z =  − 0.041, p = 0.968) and ipsilateral DEH (t =  − 0.107, p = 0.915) respectively. (3) No significant interaural difference of MRI-VA visibility was observed in patients with unilateral MD (χ² = 0.742, p = 0.389) and ipsilateral DEH (χ² = 0.327, p = 0.567) respectively. (4) No correlation was found between these anatomical variables and clinical features or audio-vestibular findings in patients with unilateral MD and ipsilateral DEH respectively (p > 0.05).

Conclusions

Anatomical variations of inner ear may be a predisposing factor in the pathogenesis of unilateral MD rather than ipsilateral DEH.

Key Points

• Patients with ipsilateral delayed endolymphatic hydrops showed normal distance between the vertical part of the posterior semicircular canal and the posterior fossa.

• Compared to patients with ipsilateral delayed endolymphatic hydrops and control subjects, patients with unilateral Ménière’s disease exhibited shorter distance between the vertical part of the posterior semicircular canal and the posterior fossa.

• Anatomical variations of inner ear may be a predisposing factor in the pathogenesis of unilateral Ménière’s disease rather than ipsilateral delayed endolymphatic hydrops.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-021-08430-7.

[Dissociation of the results of caloric and video head impulse tests as a marker of Meniere's disease]

The study of vestibular function in patients with Meniere's disease (MD) is an urgent task, since it influences the choice of treatment tactic. We evaluated the results of caloric and video head impulse (vHIT) tests in 76 patients who met the clinical criteria for significant Meniere's disease (AAO-HNS modified by the Barany Society, 2015). Dissociation of the results of caloric and vHIT tests is observed in the majority (74%) of patients with MD: at normal gain, according to vHIT data, hypofunction of peripheral vestibular structures is recorded according to the caloric test (KASL 47 ± 7.8%). In patients with MD, vestibular dysfunction is observed mainly at low frequencies (0.003 Hz), therefore vHIT, which allows assessing horizontal semicircular canal function at high frequencies (3-5 Hz), is not an optimal study for assessing the degree of vestibular dysfunction in patients with MD.

Clinical Implication of Caloric and Video Head Impulse Tests for Patients With Enlarged Vestibular Aqueduct Presenting With Vertigo

Background: By examining the clinical features and results of video head impulse test (vHIT) and caloric tests in patients with enlarged vestibular aqueduct (EVA) presenting with vertigo, we aimed to investigate the function of angular vestibulo-ocular reflex (VOR) and its clinical implications.

Methods: Nine patients with EVA manifesting with vertigo were enrolled. The medical history, audiological examination, imaging, and the results of the caloric test and the vHIT were analyzed.

Results: Of the nine patients with EVA (eight bilateral and one unilateral case), five were pediatric cases. All 17 ears exhibited sensorineural hearing loss (SNHL). Enlarged vestibular aqueduct patients can present with recurrent (seven cases) or single (two cases) vertigo attack, trauma-induced (two cases), or spontaneous (seven cases) vertigo. Diminished caloric responses were observed in 77.8% (7/9) of the patients (four cases unilaterally and three bilaterally), while unilateral abnormal vHIT results in 11.1% (1/9) patients. Abnormal caloric and normal horizontal vHIT responses were found in 66.7% (6/9) of EVA patients.

Conclusions: Vestibular manifestations in EVA are diverse. Enlarged vestibular aqueduct patients with vertigo can present with a reduced caloric response and normal horizontal vHIT, and this pattern of angular VOR impairment was also found in other hydropic ear diseases.