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Lucieer F, van der Lubbe M, van Stiphout L, Janssen M, Van Rompaey V, Devocht E, Perez-Fornos A, Guinand N, van de Berg R. Multi-frequency VEMPs improve detection of present otolith responses in bilateral vestibulopathy. Front Neurol 2024; 15:1336848. [PMID: 38450070 PMCID: PMC10915078 DOI: 10.3389/fneur.2024.1336848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 01/31/2024] [Indexed: 03/08/2024] Open
Abstract
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.
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Affiliation(s)
- F. Lucieer
- Division of Balance Disorders, Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - M. van der Lubbe
- Division of Balance Disorders, Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - L. van Stiphout
- Division of Balance Disorders, Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - M. Janssen
- Department of Methodology and Statistics, Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
| | - V. Van Rompaey
- Department of Otorhinolaryngology and Head and Neck Surgery, Antwerp University Hospital, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - E. Devocht
- Division of Balance Disorders, Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - A. Perez-Fornos
- Service of Otorhinolaryngology Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - N. Guinand
- Service of Otorhinolaryngology Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - R. van de Berg
- Division of Balance Disorders, Department of Otorhinolaryngology, Head and Neck Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
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Fattahi CB, Zaro C, Chung JJ, Lewis RF, Chari DA. Comparative utility of vestibular function tests in patients with peripheral and central vestibular dysfunction. J Otol 2024; 19:5-9. [PMID: 38313756 PMCID: PMC10837540 DOI: 10.1016/j.joto.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/31/2023] [Indexed: 02/06/2024] Open
Abstract
Background Bithermal caloric irrigation, video head impulse test (vHIT), and rotational testing are commonly used to assess peripheral vestibular function, but the relative clinical utility of each test in differentiating patients with peripheral vestibulopathy is debated. Objectives To determine whether (1) the combination of two or more vestibular tests enhances diagnostic utility over a single test; (2) abnormal test results on vestibular tests correlate with one another. Methods Retrospective analysis of data collected from multidisciplinary vestibular clinics at two academic medical centers from 2016 to 2022. Results 150 patients (54.10 ± 15.09 years, 88 females) were included. No individual test was significantly better at predicting the presence of peripheral vestibular damage (p > 0.05). vHIT test results improved significantly when combined with either the caloric test (p = 0.007) or rotary chair test (p = 0.039). Caloric and rotational testing had high sensitivity (74.65% and 76.06%, respectively) and specificity (83.54% and 78.48%, respectively). vHIT demonstrated excellent specificity (89.87%) but poor sensitivity (47.89%). Caloric, vHIT, and rotary chair tests results did not correlate with one another (p > 0.05). Conclusions Vestibular function tests have comparable diagnostic utility, yet each offers unique advantages. Caloric and rotational testing may be best suited for screening peripheral damage and vHIT may function ideally as a confirmatory test.
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Affiliation(s)
- Cameron B. Fattahi
- Department of Otolaryngology – Head and Neck Surgery, UMASS Memorial Medical Center, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Jenks Vestibular Physiology Laboratory, Massachusetts Eye and Ear, Boston, MA, USA
| | - Christopher Zaro
- Department of Otolaryngology – Head and Neck Surgery, UMASS Memorial Medical Center, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Janice J. Chung
- Department of Otolaryngology – Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Richard F. Lewis
- Jenks Vestibular Physiology Laboratory, Massachusetts Eye and Ear, Boston, MA, USA
- Department of Otolaryngology – Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Divya A. Chari
- Department of Otolaryngology – Head and Neck Surgery, UMASS Memorial Medical Center, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Jenks Vestibular Physiology Laboratory, Massachusetts Eye and Ear, Boston, MA, USA
- Department of Otolaryngology – Head and Neck Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
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3
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Padovan L, Becker-Bense S, Flanagin VL, Strobl R, Limburg K, Lahmann C, Decker J, Dieterich M. Anxiety and physical impairment in patients with central vestibular disorders. J Neurol 2023; 270:5589-5599. [PMID: 37550497 PMCID: PMC10576724 DOI: 10.1007/s00415-023-11871-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/10/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND There is increasing evidence for close interrelations between vestibular and emotional brain networks. A study in patients with bilateral peripheral vestibulopathy (BVP) showed relatively low vertigo-related anxiety (VRA), despite high physical impairment. The current working hypothesis proposes the integrity of the peripheral vestibular system as a prerequisite for development of VRA. Here we contribute by evaluating VRA and vestibular-related handicap in central vestibular disorders. METHODS Of 6396 patients presenting in a tertiary vertigo centre, 306 were identified with four clear central vestibular disorders: pure cerebellar ocular motor disorder (COD; 61), cerebellar ataxia (CA; 63), atypical parkinsonian syndromes (APS; 28), vestibular migraine (VM; 154). Their results of the Vertigo Handicap Questionnaire (VHQ), with its subscales for anxiety and handicapped activity, were compared to those of 65 BVP patients. Postural instability was measured on a force-plate. Multivariate linear regression was used to adjust for patient demographics. RESULTS Patients with chronic central vestibular disorders (COD, CA, APS) had relatively low VRA levels comparable to those in BVP, independent of increased handicapped activity or postural instability. Only VM patients showed significantly higher VRA, although their activity impairment and postural instability were lowest. No significant differences within chronic central vestibular disorders were found for VRA and subjective activity impairment. CONCLUSIONS Subjective and objective vestibular-related impairment are not necessarily correlated with vestibular-related anxiety in central vestibular disorders. Our findings rather support the hypothesis that, in addition to an intact peripheral, an intact central vestibular system could also serve as a prerequisite to develop specific VRA.
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Affiliation(s)
- Lena Padovan
- German Center for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, Munich, Germany.
- Department of Neurology, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.
| | - Sandra Becker-Bense
- German Center for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, Munich, Germany
| | - Virginia L Flanagin
- German Center for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, Munich, Germany
| | - Ralf Strobl
- German Center for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, Munich, Germany
- Institute for Medical Information Processing Biometry and Epidemiology (IBE), Ludwig-Maximilians-Universität München, Munich, Germany
| | - Karina Limburg
- Clinic for Conservative Orthopaedics, Manual Medicine and Pain Medicine, Sana Klinik München, Munich, Germany
| | - Claas Lahmann
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Julian Decker
- German Center for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, Munich, Germany
- Department of Neurology, Schön Klinik Bad Aibling, Bad Aibling, Germany
| | - Marianne Dieterich
- German Center for Vertigo and Balance Disorders, University Hospital, Ludwig-Maximilians-Universität München, Marchioninistr. 15, 81377, Munich, Germany
- Department of Neurology, University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
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Hao W, Ye L, Yu H, Li H. Prognosis of vestibular dysfunction in idiopathic sudden sensorineural hearing loss with vertigo: a prospective cohort study. J Neurol 2023; 270:5516-5526. [PMID: 37517037 DOI: 10.1007/s00415-023-11894-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Approximately 28%-57% of patients with idiopathic sudden sensorineural hearing loss (ISSNHL) have an acute vertigo attack and probable vestibular dysfunction; however, the prognosis of vestibular function in these patients remains unclear. METHODS A prospective cohort study of patients with ISSNHL and vertigo was conducted to evaluate the prognosis of vestibular function, especially the roles of peripheral vestibular restoration and central compensation, in patients with ISSNHL and vertigo. Clinical data were recorded at baseline and at 60 days from onset in participants with unilateral ISSNHL with vertigo. Enrolment occurred from May 1, 2019 to May 1, 2022 in the outpatient clinics and inpatient departments of the Eye and ENT Hospital of Fudan University in Shanghai. The primary outcome measure was the recovery rate of vestibular function 60 days after onset as assessed by vestibular function tests, including caloric tests, cervical and ocular vestibular-evoked myogenic potential tests (cVEMP, oVEMP), video head impulse tests (vHIT), and sensory organization tests (SOT). The secondary outcome measure was the recovery of subjective evaluations in vestibular dysfunction (the dizziness handicap inventory [DHI], and the visual analogue scale for vertigo [VAS-V]) and hearing assessments (pure-tone audiometry [PTA]). RESULTS Overall, 86 patients were recruited, with an average duration of disease of 11.7 days and follow-up time of 60.7 days. Vestibular function was significantly improved (p < 0.05) after 60 days. The recovery rates were 100% for anterior semicircular canal (ASC), 56% for posterior semicircular canal (PSC), 41% for horizontal semicircular canal (HSC), 28% for saccule, and 23% for utricle. The recovery of vestibular function was not significantly related to changes in DHI (p = 0.245), VAS-V score (p = 0.509), or hearing outcome (p = 0.390). CONCLUSIONS Restoration of peripheral vestibular sensory input and central vestibular compensation can occur during the course of ISSNHL with vertigo. The otolith organs are at a higher risk of being affected and have worse recovery than the semicircular canals. Incomplete and in-process restoration of vestibular dysfunction may perturb and delay the establishment of central compensation for balance. Neither hearing outcomes nor subjective vestibular symptoms are related to recovery from vestibular dysfunction. TRIAL REGISTRATION ClinicalTrials.gov (identifier NCT03951584).
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Affiliation(s)
- Weiming Hao
- ENT Institute and Department of Otorhinolaryngology, Eye and ENT Hospital, Fudan University, Shanghai, 200031, People's Republic of China
| | - Lei Ye
- ENT Institute and Department of Otorhinolaryngology, Eye and ENT Hospital, Fudan University, Shanghai, 200031, People's Republic of China
| | - Huiqian Yu
- ENT Institute and Department of Otorhinolaryngology, Eye and ENT Hospital, Fudan University, Shanghai, 200031, People's Republic of China.
- NHC Key Laboratory of Hearing Medicine (Fudan University), Shanghai, 200031, People's Republic of China.
| | - Huawei Li
- ENT Institute and Department of Otorhinolaryngology, Eye and ENT Hospital, Fudan University, Shanghai, 200031, People's Republic of China.
- NHC Key Laboratory of Hearing Medicine (Fudan University), Shanghai, 200031, People's Republic of China.
- Institutes of Biomedical Sciences, Fudan University, Shanghai, 200032, People's Republic of China.
- The Institutes of Brain Science and the Collaborative Innovation Center for Brain Science, Fudan University, Shanghai, 200032, People's Republic of China.
- State Key Laboratory of Medical Neurobiology and MOE Frontiers Center for Brain Science, Fudan University, Shanghai, 200032, People's Republic of China.
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Hoppes CW, Anson ER, Carender WJ, Marchetti GF, Hall CD, Whitney SL, Keinath C, Herdman SJ. Type, dose, and outcomes of physical therapy interventions for unilateral peripheral vestibular hypofunction: protocol for a systematic review. Syst Rev 2023; 12:164. [PMID: 37710291 PMCID: PMC10503155 DOI: 10.1186/s13643-023-02328-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 08/18/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Unilateral peripheral vestibular hypofunction can result in symptoms of dizziness, gaze and gait instability, and impaired navigation and spatial orientation. These impairments and activity limitations may negatively impact an individual's quality of life, ability to perform activities of daily living, drive, and work. There is strong evidence supporting vestibular physical therapy for reducing symptoms, improving gaze and postural stability, and improving function in individuals with vestibular hypofunction. However, there is great variability in clinical practice with regard to the type of interventions and only weak evidence to guide optimal exercise dosage. It is important to identify the most appropriate interventions and exercise dosage to optimize and accelerate recovery of function and to decrease distress. The objective of this systematic review is to determine which interventions and which doses are most effective in decreasing dizziness or vertigo, improving postural control, and improving quality of life in adults with unilateral peripheral vestibular hypofunction. METHODS The literature will be systematically searched using the following online databases: PubMed/MEDLINE, EMBASE, Web of Science (Science and Social Science Citation Index), Cumulative Index for Nursing and Allied Health Literature (CINAHL), and The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials [CENTRAL], Cochrane Methodology Register). The review will include randomized controlled trials (RCTs), including cluster RCTs, to assess the beneficial effects of the interventions. Assessment of methodological quality and risk of bias will be performed by two independent, blinded reviewers using the PEDro scale and Cochrane Risk of Bias version 2, respectively. The primary outcome measure will be change in self-perceived handicap related to dizziness from baseline to the end of the study, measured using the Dizziness Handicap Inventory. Other relevant outcome measures will include self-reported change in symptoms (to include severity, frequency, and duration) such as verbal or visual analog scales for dizziness. Tertiary outcome measures will include questionnaires related to disability and/or quality of life. DISCUSSION This systematic review will identify, evaluate, and integrate the evidence on the effectiveness of physical therapy interventions for unilateral peripheral vestibular hypofunction in an adult population. We anticipate our findings may inform individualized treatment and future research. Clinical recommendations generated from this systematic review may inform vestibular physical therapy treatment of individuals with unilateral peripheral vestibular hypofunction. TRIAL REGISTRATION In accordance with the guidelines, our systematic review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on 06 August 2021 (registration number CRD42021266163 ). In the event of protocol amendments, the date of each amendment will be accompanied by a description of the change and the rationale.
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Affiliation(s)
- Carrie W Hoppes
- Army-Baylor University Doctoral Program in Physical Therapy, Joint Base San Antonio-Fort Sam Houston, TX, USA.
| | - Eric R Anson
- Department of Otolaryngology, University of Rochester, Rochester, NY, USA
| | - Wendy J Carender
- Department of Otolaryngology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Courtney D Hall
- Hearing and Balance Research Program, Mountain Home VAMC, Mountain Home, TN, USA
- Department of Rehabilitative Sciences, Physical Therapy Program, East Tennessee State University, Johnson City, TN, USA
| | - Susan L Whitney
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Christiana Keinath
- Library, Quillen College of Medicine, East Tennessee State University, Johnson City, TN, USA
| | - Susan J Herdman
- Department of Physical Medicine and Rehabilitation, School of Medicine (Emerita), Emory University, Atlanta, GA, USA
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Zhu M, van Stiphout L, Karabulut M, Pérez Fornos A, Guinand N, Meijer K, van de Berg R, McCrum C. Assessing balance in people with bilateral vestibulopathy using the Mini-Balance Evaluation Systems Test (Mini-BESTest): feasibility and comparison with healthy control data. J Neurol 2023; 270:4423-4433. [PMID: 37269353 PMCID: PMC10421784 DOI: 10.1007/s00415-023-11795-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/23/2023] [Accepted: 05/24/2023] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Bilateral vestibulopathy (BVP) leads to unsteadiness when walking, which worsens in darkness or on uneven ground, as well as falls. Since simple balance tests struggle to distinguish between BVP and healthy participants, we aimed (1) to test if the Mini-BESTest is feasible in BVP, (2) how people with BVP perform on the Mini-BESTest and (3) to compare these scores with healthy reference data. METHODS Fifty participants with BVP completed the Mini-BESTest. 12-month falls incidence was obtained by questionnaire. To compare the overall and sub-scores between our participants with BVP and those of healthy participants from the literature (n = 327; obtained via PubMed searches), Mann-Whitney U tests were used. Sub scores within the BVP group were also compared. Spearman correlations were used to investigate the relationships between Mini-BESTest score and age. RESULTS No floor or ceiling effects were observed. Participants with BVP had significantly lower Mini-BESTest total scores than the healthy group. Anticipatory, reactive postural control and sensory orientation sub scores of the Mini-BESTest were significantly lower in BVP, while dynamic gait sub scores were not significantly different. A stronger negative correlation between age and Mini-BESTest total score was found in BVP than in the healthy group. Scores did not differ between patients with different falls history. CONCLUSION The Mini-BESTest is feasible in BVP. Our results confirm the commonly reported balance deficits in BVP. The stronger negative association between age and balance in BVP might reflect the age-related decline in the remaining sensory systems with which people with BVP compensate.
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Affiliation(s)
- Meichan Zhu
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands.
- Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.
- Department of Otorhinolaryngology, Guangzhou Twelfth People's Hospital (Guangzhou Otolarynology-Head and Neck Surgery Hospital), No. 1 Tianqiang Road, Tianhe District, Guangzhou, 510620, Guangdong, China.
| | - Lisa van Stiphout
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Mustafa Karabulut
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Angélica Pérez Fornos
- Service of Otorhinolaryngology and Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Nils Guinand
- Service of Otorhinolaryngology and Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Kenneth Meijer
- Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
| | - Raymond van de Berg
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Christopher McCrum
- Department of Nutrition and Movement Sciences, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands.
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Dissociation between Caloric and Video Head Impulse Tests in Dizziness Clinics. Audiol Res 2022; 12:423-432. [PMID: 36004951 PMCID: PMC9404865 DOI: 10.3390/audiolres12040043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/31/2022] [Accepted: 08/05/2022] [Indexed: 11/17/2022] Open
Abstract
Vestibular assessment tests such as the video head impulse test (vHIT) for the horizontal semicircular canal, and caloric test (Cal), both evaluate horizontal canal function. One would assume that the outcomes for these tests should lead to concordant results, yet several studies have suggested that dissociation can occur in certain pathological conditions. As this topic remains inconclusive, this review aims to analyze the scientific evidence regarding the patterns of hypofunction observed in vHIT and Cal in different otoneurological diseases. A comprehensive review of the literature regarding dissociation between these tests in common neurotological diseases was carried out. Articles were analyzed when data for vHIT and Cal were described in a way that it was possible to calculate discordance rates; both retrospective and prospective studies were analyzed. In this review, the discordance rates were as follows: 56% in Ménière’s disease, 51.5% in vestibular migraine, 37.2% in vestibular schwannoma, and 20.8% in vestibular neuritis. These results highlight the benefit of using both Cal and vHIT, and that they are complementary tests.
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8
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van Dooren T, Starkov D, Lucieer F, Dobbels B, Janssen M, Guinand N, Pérez Fornos A, Kingma H, Van Rompaey V, van de Berg R. Suppression Head Impulse Test (SHIMP) versus Head Impulse Test (HIMP) When Diagnosing Bilateral Vestibulopathy. J Clin Med 2022; 11:jcm11092444. [PMID: 35566570 PMCID: PMC9102589 DOI: 10.3390/jcm11092444] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/20/2022] [Accepted: 04/21/2022] [Indexed: 02/05/2023] Open
Abstract
The Suppression Head Impulse (SHIMP) test was introduced as an alternative to the Head Impulse Paradigm (HIMP) to overcome challenges in VOR gain calculation due to the interference of covert saccades. The objectives of this study were (1) to determine if SHIMP, compared to HIMP, reduces covert saccades in BV patients and (2) to define the agreement on diagnosing BV between SHIMP and HIMP. First, the number of covert saccades was compared between SHIMP and HIMP. Secondly, VOR gain was compared between SHIMP and HIMP. Lastly, the agreement between SHIMP and HIMP on identifying BV (horizontal VOR gain <0.6) was evaluated. A total of 98 BV patients were included. To our knowledge, this is the largest study population on SHIMP testing in BV patients. Covert saccades were significantly reduced, and a lower VOR gain was found during SHIMP compared to HIMP (p < 0.001). However, the clinical relevance of these statistically significant differences is small. In 93% of the patients, an agreement was found between the two paradigms regarding the diagnosis of BV, and both paradigms detect BV in the vast majority of patients.
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Affiliation(s)
- Tessa van Dooren
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (F.L.); (N.G.); (H.K.); (R.v.d.B.)
- Correspondence:
| | - Dmitrii Starkov
- Faculty of Physics, Tomsk State Research University, 634050 Tomsk, Russia;
| | - Florence Lucieer
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (F.L.); (N.G.); (H.K.); (R.v.d.B.)
| | - Bieke Dobbels
- Faculty of Medicine and Health Sciences, University of Antwerp, 2000 Antwerp, Belgium; (B.D.); (V.V.R.)
- Department of Otorhinolaryngology and Head and Neck Surgery, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Miranda Janssen
- Department of ENT/Audiology, School for Mental Health and Neuroscience (MHENS), Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands;
- Department of Methodology and Statistics, Care and Public Health Research Institute (CAPHRI), Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Nils Guinand
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (F.L.); (N.G.); (H.K.); (R.v.d.B.)
- Service of Otorhinolaryngology Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, 1205 Geneva, Switzerland;
| | - Angelica Pérez Fornos
- Service of Otorhinolaryngology Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, 1205 Geneva, Switzerland;
| | - Herman Kingma
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (F.L.); (N.G.); (H.K.); (R.v.d.B.)
| | - Vincent Van Rompaey
- Faculty of Medicine and Health Sciences, University of Antwerp, 2000 Antwerp, Belgium; (B.D.); (V.V.R.)
- Department of Otorhinolaryngology and Head and Neck Surgery, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Raymond van de Berg
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Centre, 6229 HX Maastricht, The Netherlands; (F.L.); (N.G.); (H.K.); (R.v.d.B.)
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9
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Pleshkov M, Rondas N, Lucieer F, van Stiphout L, Janssen M, Guinand N, Perez-Fornos A, Demkin V, van Rompaey V, Kingma H, van de Berg R. Reported thresholds of self-motion perception are influenced by testing paradigm. J Neurol 2022; 269:5755-5761. [PMID: 35294617 PMCID: PMC9553771 DOI: 10.1007/s00415-022-11032-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 04/01/2021] [Accepted: 02/15/2022] [Indexed: 11/27/2022]
Abstract
Background/objective Different testing paradigms have been proposed to investigate perceptual self-motion thresholds. They can differ regarding the amount of possible motions that patients have to choose from. Objective of this study was to compare the two-option paradigm and twelve-option paradigm, to investigate whether reducing the choice options significantly influences the reported thresholds of self-motion perception of healthy subjects. Methods Thirty-three volunteers with no prior vestibular complaints were included and sequentially tested with both paradigms at a random sequence. Perceptual self-motion thresholds were measured using a hydraulic motion platform in the absence of external visual and auditory cues. The platform delivered twelve different movements: six translations and six rotations. Each subject had to report the correct type and direction of movements. Thresholds were determined by a double confirmation of the lowest threshold, in combination with a double rejection of the one-step lower stimulus. Perceptual self-motion thresholds of both paradigms were compared using the mixed model analysis. Results The twelve-option paradigm showed significantly higher reported thresholds for yaw rotations and translations left, right and down (p < 0.001), compared to the two-option paradigm. No statistical difference was found for rolls and translations up. No significant gender effect, learning effect and carry-over effect were present in any of the applied motion directions. Conclusion Reported thresholds of self-motion perception of healthy subjects are influenced by the testing paradigm. The twelve-option paradigm showed significantly higher thresholds than the two-option paradigm. Results obtained with each testing paradigm should, therefore, be compared to paradigm-specific normative data. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-022-11032-y.
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Affiliation(s)
- M. Pleshkov
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Universiteitssingel 40, 6229 ET Maastricht, The Netherlands
- Faculty of Physics, Tomsk State University, Tomsk, Russia
| | - N. Rondas
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - F. Lucieer
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Universiteitssingel 40, 6229 ET Maastricht, The Netherlands
| | - L. van Stiphout
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Universiteitssingel 40, 6229 ET Maastricht, The Netherlands
| | - M. Janssen
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Universiteitssingel 40, 6229 ET Maastricht, The Netherlands
- School for Public Health and Primary Care (CAPHRI), Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
| | - N. Guinand
- Service of Otorhinolaryngology Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - A. Perez-Fornos
- Service of Otorhinolaryngology Head and Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - V. Demkin
- Faculty of Physics, Tomsk State University, Tomsk, Russia
| | - V. van Rompaey
- Department of Otorhinolaryngology and Head and Neck Surgery, Faculty of Medicine and Health Sciences, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - H. Kingma
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Universiteitssingel 40, 6229 ET Maastricht, The Netherlands
| | - R. van de Berg
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, School for Mental Health and Neuroscience, Maastricht University Medical Center, Universiteitssingel 40, 6229 ET Maastricht, The Netherlands
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10
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King S, Dahlem K, Karmali F, Stankovic KM, Welling DB, Lewis RF. Imbalance and dizziness caused by unilateral vestibular schwannomas correlate with vestibulo-ocular reflex precision and bias. J Neurophysiol 2022; 127:596-606. [PMID: 35080420 PMCID: PMC8858680 DOI: 10.1152/jn.00725.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Imbalance and dizziness are disabling symptoms for many patients with vestibular schwannomas (VS) but symptom severity typically does not correlate with the vestibulo-ocular reflex (VOR) amplitude-based metrics used to assess peripheral vestibular damage. In this study, we tested the hypothesis that imbalance and dizziness in patients with VS relate to VOR metrics that are not based on response amplitude. Twenty-four patients with unilateral, sporadic VS tumors were studied, and objective (balance) and subjective (dizziness) vestibular dysfunction was quantified. The VOR was tested using two yaw-axis motion stimuli, low-frequency en-bloc sinusoidal, and high-frequency head-on-body impulsive rotations. Imbalance correlated with VOR precision (the inverse of the trial-to-trial variability) and with low-frequency VOR dynamics (quantified with the time constant), and these two metrics were also strongly correlated. Dizziness correlated with the VOR bias caused by an imbalance in static central vestibular tone, but not with dynamic VOR metrics. VOR accuracy (mean response amplitude relative to the ideal response) was not correlated with the severity of imbalance or dizziness or with measures of VOR precision or time constant. Imbalance in patients with VS, therefore, scales with VOR precision and time constant, both of which appear to reflect the central vestibular signal-to-noise ratio, but not with VOR slow-phase accuracy, which is based on the magnitude of the central vestibular signals. Dizziness was related to the presence of a static central tone imbalance but not to any VOR metrics, suggesting that abnormal perception in VS may be affected by factors that are not captured by yaw-axis VOR measurements.NEW & NOTEWORTHY The severity of symptoms associated with unilateral vestibular schwannomas (VS) is poorly correlated with standard yaw-axis vestibulo-ocular reflex (VOR) metrics that are based on response amplitude. In this study, we show that the balance and perceptual dysfunction experienced by patients with VS scales with VOR metrics that capture information about the central signal-to-noise ratio (balance) and central static tone (dizziness), but are not correlated with the VOR gain, which reflects central signal amplitude.
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Affiliation(s)
- Susan King
- 1Jenks Vestibular Physiology Laboratory, Massachusetts Eye and Ear, Boston, Massachusetts
| | - Kilian Dahlem
- 1Jenks Vestibular Physiology Laboratory, Massachusetts Eye and Ear, Boston, Massachusetts
| | - Faisal Karmali
- 1Jenks Vestibular Physiology Laboratory, Massachusetts Eye and Ear, Boston, Massachusetts,2Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | | | - D. Bradley Welling
- 2Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts
| | - Richard F. Lewis
- 1Jenks Vestibular Physiology Laboratory, Massachusetts Eye and Ear, Boston, Massachusetts,2Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts,3Department of Neurology, Harvard Medical School, Boston, Massachusetts
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11
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Zhang Y, Cheng Y, Chen Z, Chen F, Zhang Q. Case Report: Preservation of Otolithic Function After Triple Semicircular Canal Occlusion in a Patient With Intractable Ménière Disease. Front Neurol 2022; 12:713275. [PMID: 35002908 PMCID: PMC8732767 DOI: 10.3389/fneur.2021.713275] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022] Open
Abstract
Operative measures are considered when medical treatment fails to control vertigo in patients with intractable Ménière disease. The present report discusses a case in which triple semicircular canal occlusion was performed in a 30-year-old female patient who responded poorly to previously performed endolymphatic sac surgery. Her vestibular and auditory functions were evaluated both before and after surgery. Class A control of vertigo was achieved during the 76-month postoperative follow-up period. Ocular and cervical vestibular evoked myogenic potentials could be elicited before and after surgery. This case suggests that relatively long-term preservation of otolithic function can be achieved following triple semicircular canal occlusion, highlighting its potential as an alternative treatment for patients with Ménière disease.
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Affiliation(s)
- Yuzhong Zhang
- Department of Otorhinolaryngology-Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Ying Cheng
- Department of Otorhinolaryngology-Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zichen Chen
- Department of Otorhinolaryngology-Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Feiyun Chen
- Department of Otorhinolaryngology-Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Qing Zhang
- Department of Otorhinolaryngology-Head and Neck Surgery, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China.,Department of Otorhinolaryngology-Head and Neck Surgery, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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12
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The european particle therapy network (EPTN) consensus on the follow-up of adult patients with brain and skull base tumours treated with photon or proton irradiation. Radiother Oncol 2022; 168:241-249. [DOI: 10.1016/j.radonc.2022.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 01/19/2022] [Indexed: 12/25/2022]
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13
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Paplou V, Schubert NMA, Pyott SJ. Age-Related Changes in the Cochlea and Vestibule: Shared Patterns and Processes. Front Neurosci 2021; 15:680856. [PMID: 34539328 PMCID: PMC8446668 DOI: 10.3389/fnins.2021.680856] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/20/2021] [Indexed: 12/16/2022] Open
Abstract
Both age-related hearing loss (ARHL) and age-related loss in vestibular function (ARVL) are prevalent conditions with deleterious consequences on the health and quality of life. Age-related changes in the inner ear are key contributors to both conditions. The auditory and vestibular systems rely on a shared sensory organ - the inner ear - and, like other sensory organs, the inner ear is susceptible to the effects of aging. Despite involvement of the same sensory structure, ARHL and ARVL are often considered separately. Insight essential for the development of improved diagnostics and treatments for both ARHL and ARVL can be gained by careful examination of their shared and unique pathophysiology in the auditory and vestibular end organs of the inner ear. To this end, this review begins by comparing the prevalence patterns of ARHL and ARVL. Next, the normal and age-related changes in the structure and function of the auditory and vestibular end organs are compared. Then, the contributions of various molecular mechanisms, notably inflammaging, oxidative stress, and genetic factors, are evaluated as possible common culprits that interrelate pathophysiology in the cochlea and vestibular end organs as part of ARHL and ARVL. A careful comparison of these changes reveals that the patterns of pathophysiology show similarities but also differences both between the cochlea and vestibular end organs and among the vestibular end organs. Future progress will depend on the development and application of new research strategies and the integrated investigation of ARHL and ARVL using both clinical and animal models.
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Affiliation(s)
- Vasiliki Paplou
- Department of Otorhinolaryngology and Head/Neck Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Nick M A Schubert
- Department of Otorhinolaryngology and Head/Neck Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Research School of Behavioural and Cognitive Neurosciences, Graduate School of Medical Sciences, University of Groningen, Groningen, Netherlands
| | - Sonja J Pyott
- Department of Otorhinolaryngology and Head/Neck Surgery, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.,Research School of Behavioural and Cognitive Neurosciences, Graduate School of Medical Sciences, University of Groningen, Groningen, Netherlands
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14
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Curthoys IS, Grant JW, Pastras CJ, Fröhlich L, Brown DJ. Similarities and Differences Between Vestibular and Cochlear Systems - A Review of Clinical and Physiological Evidence. Front Neurosci 2021; 15:695179. [PMID: 34456671 PMCID: PMC8397526 DOI: 10.3389/fnins.2021.695179] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/12/2021] [Indexed: 12/04/2022] Open
Abstract
The evoked response to repeated brief stimuli, such as clicks or short tone bursts, is used for clinical evaluation of the function of both the auditory and vestibular systems. One auditory response is a neural potential - the Auditory Brainstem Response (ABR) - recorded by surface electrodes on the head. The clinical analogue for testing the otolithic response to abrupt sounds and vibration is the myogenic potential recorded from tensed muscles - the vestibular evoked myogenic potential (VEMP). VEMPs have provided clinicians with a long sought-after tool - a simple, clinically realistic indicator of the function of each of the 4 otolithic sensory regions. We review the basic neural evidence for VEMPs and discuss the similarities and differences between otolithic and cochlear receptors and afferents. VEMPs are probably initiated by sound or vibration selectively activating afferent neurons with irregular resting discharge originating from the unique type I receptors at a specialized region of the otolithic maculae (the striola). We review how changes in VEMP responses indicate the functional state of peripheral vestibular function and the likely transduction mechanisms allowing otolithic receptors and afferents to trigger such very short latency responses. In section "ELECTROPHYSIOLOGY" we show how cochlear and vestibular receptors and afferents have many similar electrophysiological characteristics [e.g., both generate microphonics, summating potentials, and compound action potentials (the vestibular evoked potential, VsEP)]. Recent electrophysiological evidence shows that the hydrodynamic changes in the labyrinth caused by increased fluid volume (endolymphatic hydrops), change the responses of utricular receptors and afferents in a way which mimics the changes in vestibular function attributed to endolymphatic hydrops in human patients. In section "MECHANICS OF OTOLITHS IN VEMPS TESTING" we show how the major VEMP results (latency and frequency response) follow from modeling the physical characteristics of the macula (dimensions, stiffness etc.). In particular, the structure and mechanical operation of the utricular macula explains the very fast response of the type I receptors and irregular afferents which is the very basis of VEMPs and these structural changes of the macula in Menière's Disease (MD) predict the upward shift of VEMP tuning in these patients.
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Affiliation(s)
- Ian S. Curthoys
- Vestibular Research Laboratory, School of Psychology, The University of Sydney, Sydney, NSW, Australia
| | - John Wally Grant
- Department of Biomedical Engineering and Mechanics, Virginia Tech, Blacksburg, VA, United States
| | - Christopher J. Pastras
- The Menière’s Research Laboratory, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Laura Fröhlich
- Department of Otorhinolaryngology, Head and Neck Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Daniel J. Brown
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, WA, Australia
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15
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Rogers C. Perspectives: Evaluation of Older Adult Cochlear Implant Candidates for Fall Risk in a Developing Country Setting. Front Neurol 2021; 12:678773. [PMID: 34122319 PMCID: PMC8187949 DOI: 10.3389/fneur.2021.678773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/14/2021] [Indexed: 11/13/2022] Open
Abstract
Dizziness, vertigo, and falls are common in older adults. Data suggest that cochlear implant candidates are no different and could be argued to be at elevated risk due to the presence of hearing loss and likely vestibular involvement. Perspectives contextualizes current testing and screening paradigms for vestibular deficits and fall risk and suggests a protocol suitable for use in developing country settings.
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Affiliation(s)
- Christine Rogers
- Department of Health and Rehabilitation Sciences, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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16
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Cohen HS, Plankey MW, Sangi-Haghpeykar H. Vestibular Impairments on Objective Diagnostic Tests in HIV+ Women and Control Men and Women. Laryngoscope 2021; 131:E2318-E2322. [PMID: 33645629 DOI: 10.1002/lary.29466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 01/29/2021] [Accepted: 02/05/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To describe the value of two vestibular test batteries across ages in healthy men and women for detecting vestibular disorders and to compare the occurrence of vestibular disorders in the healthy adult population and women with human immunodeficiency virus (HIV) disease. STUDY DESIGN Two groups were tested on the battery of objective diagnostic tests of the vestibular system. SETTING Two tertiary care centers. SUBJECTS Healthy controls (284 women and 105 men) and women (63) with HIV/AIDS (HIV+) who are being followed up in a longitudinal study of HIV. They were tested on objective diagnostic tests of the vestibular system. RESULTS In all age decades, healthy controls had evidence of vestibular impairment, significantly more in older adults. HIV+ subjects, all females, did not differ from healthy control females. CONCLUSION These data suggest that at all ages, people do have decreased vestibular function, even young, asymptomatic, and apparently healthy adults. HIV disease, itself, does not cause an increased prevalence of peripheral vestibular disorders when HIV is controlled on antiretroviral medication. LEVEL OF EVIDENCE 2 Laryngoscope, 131:E2318-E2322, 2021.
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Affiliation(s)
- Helen S Cohen
- Bobby R Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Michael W Plankey
- Division of General Internal Medicine, Department of Medicine, Georgetown University Medical Center, Washington, District of Columbia, U.S.A
| | - Haleh Sangi-Haghpeykar
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, U.S.A
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17
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Jensen MK, Hougaard DD. Suppression head impulse testing is recommended for vestibular testing of patients with untreated unilateral vestibular schwannoma. Eur Arch Otorhinolaryngol 2021; 279:91-99. [PMID: 33502546 DOI: 10.1007/s00405-021-06621-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 01/11/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE Suppression head impulse testing (SHIMP) is a new vestibular method capable of quantifying vestibular function. The aim of this study was to evaluate the feasibility of this test in patients with existing or newly diagnosed vestibular schwannoma (VS) patients by comparing the results with the traditionally used video head impulse test (vHIT or HIMP). METHODS Fifty-five patients with unilateral VS underwent a wide battery of audiological and vestibular tests. HIMP results were evaluated using newly introduced objective guidelines based on the trace evaluation of pathological saccades. The sensitivity and specificity of HIMP and SHIMP were evaluated and compared. A new SHIMP parameter is presented; the anticompensatory saccade amplitude ratio (ASAR). RESULTS We found a marked increase in specificity in HIMP testing using the objective guidelines. SHIMP testing revealed a gain threshold of 0.7 to be optimal in terms of achieving high specificity and sensitivity in relation to HIMP testing. Significant correlations were found between a low ASAR and a high degree of vestibular pathology. CONCLUSION The SHIMP test is a viable addition to the standard HIMP test in patients with VS, especially with the addition of the ASAR, which could prove useful in monitoring the residual vestibular function. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION N/A.
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Affiliation(s)
- Morten Klitskov Jensen
- Department of Otolaryngology, Head and Neck Surgery and Audiology, Aalborg University Hospital, Aalborg, Denmark. .,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark. .,Audiological Department, Balance and Dizziness Centre, Havrevangen 1, 9000, Aalborg, Denmark.
| | - Dan Dupont Hougaard
- Department of Otolaryngology, Head and Neck Surgery and Audiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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18
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Starkov D, Strupp M, Pleshkov M, Kingma H, van de Berg R. Diagnosing vestibular hypofunction: an update. J Neurol 2021; 268:377-385. [PMID: 32767115 PMCID: PMC7815536 DOI: 10.1007/s00415-020-10139-4] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 07/31/2020] [Accepted: 08/01/2020] [Indexed: 12/13/2022]
Abstract
Unilateral or bilateral vestibular hypofunction presents most commonly with symptoms of dizziness or postural imbalance and affects a large population. However, it is often missed because no quantitative testing of vestibular function is performed, or misdiagnosed due to a lack of standardization of vestibular testing. Therefore, this article reviews the current status of the most frequently used vestibular tests for canal and otolith function. This information can also be used to reach a consensus about the systematic diagnosis of vestibular hypofunction.
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Affiliation(s)
- Dmitrii Starkov
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.
- Faculty of Physics, Tomsk State Research University, Tomsk, Russia.
- Maastricht University ENT Department, P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands.
| | - Michael Strupp
- German Center for Vertigo and Balance Disorders, Ludwig Maximilians University, Munich, Germany
- Department of Neurology, Ludwig Maximilians University, Munich, Germany
| | - Maksim Pleshkov
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Faculty of Physics, Tomsk State Research University, Tomsk, Russia
| | - Herman Kingma
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Faculty of Physics, Tomsk State Research University, Tomsk, Russia
| | - Raymond van de Berg
- Division of Balance Disorders, Department of Otorhinolaryngology and Head and Neck Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
- Faculty of Physics, Tomsk State Research University, Tomsk, Russia
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19
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Huang S, Zhou H, Zhou E, Zhang J, Feng Y, Yu D, Shi H, Wang J, Wang H, Yin S. A New Proposal for Severity Evaluation of Menière's Disease by Using the Evidence From a Comprehensive Battery of Auditory and Vestibular Tests. Front Neurol 2020; 11:785. [PMID: 33013611 PMCID: PMC7461919 DOI: 10.3389/fneur.2020.00785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/25/2020] [Indexed: 12/18/2022] Open
Abstract
To date, no widely accepted criteria exist to quantify the severity of Menière's disease (MD) by using vestibular tests. This study aimed to compare association of hearing loss and vertigo severity with association of accurate assessments of vestibular function and the vertigo severity. The severity of vertigo was documented by a comprehensive medical history with number of vertigo attacks in the past 6 months and a Dizziness Handicap Inventory (DHI) questionnaire. The involvement of vestibular organs was verified by audio-vestibular tests in 80 definite MD patients. Correlations between DHI scores, number of vertigo attacks in the past 6 months, audio-vestibular function, and the number of involved vestibular end organs were evaluated. We show that there are no significant differences in either severity of vertigo or laboratory results across the degree of hearing loss. Furthermore, the number of involved vestibular end organs was significantly correlated with vestibulo-ocular reflex gain in anterior and posterior canal video head impulse test (vHIT), interaural asymmetry ratio in vestibular-evoked myogenic potentials (VEMPs), and number of vertigo attacks in the past 6 months and DHI score. The vestibulo-ocular reflex gain in the rotatory chair test (RCT) was significantly correlated with the DHI Physical scores and number of involved vestibular end organs at 0.08 Hz. These results indicate that hearing loss is a poor indicator of vertigo severity in MD whereas the number of involved vestibular end organs may serve as an objective measure for MD progress. A battery of vestibular tests targeting different sensor organs is a complementary method for evaluating inner ear deficits and may aid in "grading" the severity of MD.
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Affiliation(s)
- Shujian Huang
- Department of Otorhinolaryngology-Head and Neck Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China.,Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Huiqun Zhou
- Department of Otorhinolaryngology-Head and Neck Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China.,Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Enhui Zhou
- Department of Otolaryngology-Head and Neck Surgery, Shanghai Gongli Hospital, The Second Military Medical University, Shanghai, China
| | - Jiajia Zhang
- Department of Otorhinolaryngology-Head and Neck Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China.,Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Yanmei Feng
- Department of Otorhinolaryngology-Head and Neck Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China.,Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Dongzhen Yu
- Department of Otorhinolaryngology-Head and Neck Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China.,Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Haibo Shi
- Department of Otorhinolaryngology-Head and Neck Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China.,Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Jian Wang
- School of Communication Science and Disorders, Dalhousie University, Halifax, NS, Canada
| | - Hui Wang
- Department of Otorhinolaryngology-Head and Neck Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China.,Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
| | - Shankai Yin
- Department of Otorhinolaryngology-Head and Neck Surgery, Shanghai Jiaotong University Affiliated Sixth People's Hospital, Shanghai, China.,Otolaryngology Institute of Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Sleep Disordered Breathing, Shanghai, China
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20
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Adamec I, Juren Meaški S, Krbot Skorić M, Jažić K, Crnošija L, Milivojević I, Habek M. Persistent postural-perceptual dizziness: Clinical and neurophysiological study. J Clin Neurosci 2020; 72:26-30. [PMID: 31948878 DOI: 10.1016/j.jocn.2020.01.043] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/08/2019] [Accepted: 01/04/2020] [Indexed: 12/17/2022]
Abstract
The aim of this study was to evaluate clinical and neurophysiological characteristics of Persistent postural-perceptual dizziness (PPPD) in a tertiary vertigo clinic. This was a cross-sectional study that included consecutive patients examined in the Vertigo clinic of the University Hospital Center Zagreb, Croatia. The following data were extracted from the electronic hospital records: age, sex, the duration of symptoms, initial trigger event, results of the caloric testing, video head impulse test (vHIT) for all six semicircular canals and ocular and cervical vestibular evoked myogenic potentials (oVEMP and cVEMP). During the study period 147 consecutive patients with dizziness were examined and 28 (19%) were diagnosed with PPPD, 68% of them were women and the mean age was 59.5 ± 15 years. The median duration of symptoms was 23 months. The most common initial event was vestibular neuritis in 39.3% of patients, followed by benign paroxysmal positional vertigo in 10.7% of patients. Caloric testing was performed in 25 patients. It revealed six cases of unilateral canal paresis. vHIT was performed in 24 patients. There were 13 pathological responses with three cases of lateral canal dysfunction, two cases of posterior, one case of anterior and seven cases of multiple canals affection. VEMP was performed in 23 patients. There were five isolated oVEMP pathologies, one isolated cVEMP pathology and 11 findings of a combined oVEMP and cVEMP pathology. This study provides clinical and neurophysiological data on PPPD and indicates the utility of complete neurophysiological assessment of vestibular function in this group of patients.
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Affiliation(s)
- Ivan Adamec
- University Hospital Center Zagreb, Department of Neurology, Zagreb, Croatia.
| | | | - Magdalena Krbot Skorić
- University Hospital Center Zagreb, Department of Neurology, Zagreb, Croatia; University of Zagreb, Faculty of Electrical Engineering and Computing, Zagreb, Croatia
| | | | - Luka Crnošija
- University Hospital Center Zagreb, Department of Neurology, Zagreb, Croatia
| | - Iva Milivojević
- Special Hospital for Medical Rehabilitation Krapinske Toplice, Department of Physical Medicine and Rehabilitation, Krapinske Toplice, Croatia
| | - Mario Habek
- University Hospital Center Zagreb, Department of Neurology, Zagreb, Croatia; School of Medicine, University of Zagreb, Zagreb, Croatia
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Lee JY, Kwon E, Kim HJ, Choi JY, Oh HJ, Koo JW, Kim JS. Dissociated Results between Caloric and Video Head Impulse Tests in Dizziness: Prevalence, Pattern, Lesion Location, and Etiology. J Clin Neurol 2020; 16:277-284. [PMID: 32319245 PMCID: PMC7174114 DOI: 10.3988/jcn.2020.16.2.277] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 01/23/2023] Open
Abstract
Background and Purpose This study was designed to determine the prevalence, pattern, lesion location, and etiology of dissociation in the results of the bithermal caloric test and the horizontal video head impulse test (vHIT) in dizzy patients with various etiologies and disease durations. Methods We analyzed the results of bithermal caloric tests and vHITs performed over 26 months in 893 consecutive patients who underwent both tests within a 10-day period. Results Dissociation in the results of the two tests was found in 162 (18.1%) patients. Among them, 123 (75.9%) had abnormal caloric tests (unilateral paresis in 118 and bilateral paresis in 5) but normal vHITs. Peripheral lesions were identified in 105 (85.4%) of these patients, with the main underlying diseases being Meniere's disease (62/105, 59%) and vestibular neuritis/labyrinthitis (29/105, 27.6%). In contrast, central pathologies of diverse etiologies were found only in 18 (14.6%) patients. Abnormal vHIT (bilaterally positive in 18, unilaterally positive in 19, and hyperactive in 2) and normal caloric responses were found in 39 patients, with an equal prevalence of central (n=19) and peripheral (n=20) lesions. The peripheral lesions included vestibular neuritis/labyrinthitis in seven patients and Meniere's disease in another seven. The central lesions had diverse etiologies. Conclusions Dissociation in the results between caloric tests and horizontal vHITs is not uncommon. The present patients with abnormal caloric tests and normal vHITs mostly had peripheral lesions, while central lesions were likely to underlie those with abnormal vHITs and normal caloric tests.
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Affiliation(s)
- Ju Young Lee
- Department of Neurology, Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Eunjin Kwon
- Dizziness Center, Clinical Neuroscience Center, and Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hyo Jung Kim
- Research Administration Team, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jeong Yoon Choi
- Dizziness Center, Clinical Neuroscience Center, and Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea.
| | - Hui Jong Oh
- The MTV (Migraine, Tinnitus, and Vertigo) Clinic, Oh Neurology Center, Daegu, Korea
| | - Ja Won Koo
- Dizziness Center and Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Ji Soo Kim
- Dizziness Center, Clinical Neuroscience Center, and Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea
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Visscher RMS, Feddermann-Demont N, Romano F, Straumann D, Bertolini G. Artificial intelligence for understanding concussion: Retrospective cluster analysis on the balance and vestibular diagnostic data of concussion patients. PLoS One 2019; 14:e0214525. [PMID: 30939164 PMCID: PMC6445465 DOI: 10.1371/journal.pone.0214525] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 03/14/2019] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVES We propose a bottom-up, machine-learning approach, for the objective vestibular and balance diagnostic data of concussion patients, to provide insight into the differences in patients' phenotypes, independent of existing diagnoses (unsupervised learning). METHODS Diagnostic data from a battery of validated balance and vestibular assessments were extracted from the database of the Swiss Concussion Center. The desired number of clusters within the patient database was estimated using Calinski-Harabasz criteria. Complex (self-organizing map, SOM) and standard (k-means) clustering tools were used, and the formed clusters were compared. RESULTS A total of 96 patients (81.3% male, age (median [IQR]): 25.0[10.8]) who were expected to suffer from sports-related concussion or post-concussive syndrome (52[140] days between diagnostic testing and the concussive episode) were included. The cluster evaluation indicated dividing the data into two groups. Only the SOM gave a stable clustering outcome, dividing the patients in group-1 (n = 38) and group-2 (n = 58). A large significant difference was found for the caloric summary score for the maximal speed of the slow phase, where group-1 scored 30.7% lower than group-2 (27.6[18.2] vs. 51.0[31.0]). Group-1 also scored significantly lower on the sensory organisation test composite score (69.0[22.3] vs. 79.0[10.5]) and higher on the visual acuity (-0.03[0.33] vs. -0.14[0.12]) and dynamic visual acuity (0.38[0.84] vs. 0.20[0.20]) tests. The importance of caloric, SOT and DVA, was supported by the PCA outcomes. Group-1 tended to report headaches, blurred vision and balance problems more frequently than group-2 (>10% difference). CONCLUSION The SOM divided the data into one group with prominent vestibular disorders and another with no clear vestibular or balance problems, suggesting that artificial intelligence might help improve the diagnostic process.
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Affiliation(s)
- Rosa M. S. Visscher
- Institute for Biomechanics, ETH Zurich, Zurich, Switzerland
- Department of Neurology, Interdisciplinary Center for Vertigo and Neurological Visual Disorders, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Nina Feddermann-Demont
- Department of Neurology, Interdisciplinary Center for Vertigo and Neurological Visual Disorders, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Swiss Concussion Center, Schulthess Clinic, Zurich, Switzerland
| | - Fausto Romano
- Department of Neurology, Interdisciplinary Center for Vertigo and Neurological Visual Disorders, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Swiss Concussion Center, Schulthess Clinic, Zurich, Switzerland
| | - Dominik Straumann
- Department of Neurology, Interdisciplinary Center for Vertigo and Neurological Visual Disorders, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Swiss Concussion Center, Schulthess Clinic, Zurich, Switzerland
| | - Giovanni Bertolini
- Department of Neurology, Interdisciplinary Center for Vertigo and Neurological Visual Disorders, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Swiss Concussion Center, Schulthess Clinic, Zurich, Switzerland
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Devantier L, Hoskison E, Ovesen T, Henriksen JJMØ. Suppression head impulse paradigm in healthy adolescents - A novel variant of the head impulse test. J Vestib Res 2018; 28:311-317. [PMID: 30373968 DOI: 10.3233/ves-180643] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Suppression Head Impulse Paradigm (SHIMP), a novel variant of the Head Impulse Test has been introduced. At the same time, the Head Impulse Test was renamed to the Head Impulse Paradigm (HIMP). Contrary to HIMP saccades, SHIMP saccades are a sign of vestibular function. OBJECTIVE 1) To compare SHIMP and HIMP feasibility, vestibular-ocular reflex (VOR) gain value and the saccadic pattern in healthy adolescents. 2) To compare SHIMP and HIMP feasibility in the hands of an experienced and an inexperienced HIMP examiner. METHOD A total of 29 adolescents from Skåde Municipal School, Denmark were tested with HIMP and then with SHIMP. RESULTS Neither covert nor overt saccades were observed in the HIMP, whereas SHIMP saccades were observed in all SHIMP reports. SHIMP gain values were statistically lower than HIMP gain values. A statistically significant difference was observed between the two examiners' right SHIMP gain values, but not for the left SHIMP gain values or the HIMP gain values. CONCLUSIONS We found that HIMP and SHIMP tests are feasible in healthy adolescents for experienced as well as inexperienced examiners. However, one must be aware of potential pitfalls in the execution and interpretation of both tests. This is a well-known fact for the HIMP test, but additional considerations are needed to obtain reliable results from the SHIMP test.
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Affiliation(s)
- Louise Devantier
- Department of Clinical Medicine, Aarhus University, Denmark.,Department of Oto-rhino-laryngology, Regional Hospital West Jutland, Denmark
| | - Emma Hoskison
- Department of Oto-rhino-laryngology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Therese Ovesen
- Department of Clinical Medicine, Aarhus University, Denmark.,Department of Oto-rhino-laryngology, Regional Hospital West Jutland, Denmark
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Corneil BD, Camp AJ. Animal Models of Vestibular Evoked Myogenic Potentials: The Past, Present, and Future. Front Neurol 2018; 9:489. [PMID: 29988517 PMCID: PMC6026641 DOI: 10.3389/fneur.2018.00489] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 06/05/2018] [Indexed: 11/13/2022] Open
Abstract
Vestibular-evoked myogenic potentials (VEMPs) provide a simple and cost-effective means to assess the patency of vestibular reflexes. VEMP testing constitutes a core screening method in a clinical battery that probes vestibular function. The confidence one has in interpreting the results arising from VEMP testing is linked to a fundamental understanding of the underlying functional anatomy and physiology. In this review, we will summarize the key role that studies across a range of animal models have fulfilled in contributing to this understanding, covering key findings regarding the mechanisms of excitation in the sensory periphery, the processing of sensory information in central networks, and the distribution of reflexive output to the motor periphery. Although VEMPs are often touted for their simplicity, work in animals models have emphasized how vestibular reflexes operate within a broader behavioral and functional context, and as such vestibular reflexes are influenced by multisensory integration, governed by task demands, and follow principles of muscle recruitment. We will conclude with considerations of future questions, and the ways in which studies in current and emerging animal models can contribute to further use and refinement of this test for both basic and clinical research purposes.
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Affiliation(s)
- Brian D. Corneil
- Department of Physiology and Pharmacology, University of Western Ontario, London, ON, Canada
- Department of Psychology, University of Western Ontario, London, ON, Canada
- Robarts Research Institute, University of Western Ontario, London, ON, Canada
| | - Aaron J. Camp
- Discipline of Biomedical Science, Sydney Medical School, University of Sydney, Sydney, NSW, Australia
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