Superior Semicircular Canal Dehiscence Syndrome

Superior canal dehiscence syndrome (SCDS) is a vestibular disorder caused by a pathologic third window into the labyrinth that can present with autophony, sound- or pressure-induced vertigo, and chronic disequilibrium among other vestibulocochlear symptoms. Careful history taking and examination in conjunction with appropriate diagnostic testing can accurately diagnose the syndrome. Key examination techniques include fixation-suppressed ocular motor examination investigating for sound- or pressure-induced eye movements in the plane of the semicircular canal. Audiometry, vestibular evoked myogenic potentials, and computed tomography confirm the diagnosis. Corrective surgical techniques can be curative, but many patients find their symptoms are not severe enough to undergo surgery. Although a primarily peripheral vestibular disorder, as first-line consultants for most dizziness complaints, neurologists will serve their patients well by understanding SCDS and its role in the differential diagnosis of vestibular disorders.

Healing the Professional Culture of Medicine

The past decade has been a time of great change for US physicians. Many physicians feel that the care delivery system has become a barrier to providing high-quality care rather than facilitating it. Although physician distress and some of the contributing factors are now widely recognized, much of the distress physicians are experiencing is related to insidious issues affecting the cultures of our profession, our health care organizations, and the health care delivery system. Culture refers to the shared and fundamental beliefs of a group that are so widely accepted that they are implicit and often no longer recognized. When challenges with culture arise, they almost always relate to a problem with a subcomponent of the culture even as the larger culture does many things well. In this perspective, we consider the role of culture in many of the problems facing our health care delivery system and contributing to the high prevalence of professional burnout plaguing US physicians. A framework, drawn from the field of organizational science, to address these issues and heal our professional culture is considered.

Surgical Complications from Superior Canal Dehiscence Syndrome Repair: Two Decades of Experience

Objective

To determine the incidence of surgical complications associated with superior canal dehiscence syndrome (SCDS) repair and identify the demographic, medical, and intraoperative risk factors that are associated with SCDS complications.

Study Design

Cases series with chart review, including patients who underwent SCDS repair between 1996 and 2015.

Setting

A tertiary care academic medical center.

Subjects and Methods

Data were collected from 220 patients, including demographic information, medical comorbidities, prior otologic surgical history, surgical approach, intraoperative findings, and postoperative complications. Relative risk analysis and multivariable logistic regression evaluated the associations between perioperative risk factors and SCDS complications.

Results

A total of 242 consecutive cases were performed: 95.5% middle fossa and 4.5% transmastoid approach (mean age: 47.8 ± 10.6 years; 54.5% female). Surgical complications were reported in 27 (11.2%) cases; 20 (8.3%) had Clavien-Dindo grade I complications, most commonly benign paroxysmal positional vertigo (n = 11, 4.5%) and profound sensorineural hearing loss (n = 6, 2.5%). Two cases (0.8%) had grade II; 4 cases (1.7%), grade III; and 1 case (0.4%), grade IV complications. In the analysis of comorbidities, only preoperative coagulopathy was significantly associated with increased risk of complications (relative risk = 6.4, P < .01). Following multivariate logistic regression adjusting for demographic covariates, coagulopathy was still associated with increased odds of complications (odds ratio = 15.7, P = .03). There were no significant associations between other risk factors and complications.

Conclusion

SCDS repair has low rates of adverse events. We observed an incidence of 11.2% complications, most commonly postoperative benign paroxysmal positional vertigo. The risk of nonotologic intracranial complications (1.7%) is low.

Superior Canal Dehiscence Syndrome: Lessons from the First 20 Years

Superior semicircular canal dehiscence syndrome was first reported by Lloyd Minor and colleagues in 1998. Patients with a dehiscence in the bone overlying the superior semicircular canal experience symptoms of pressure or sound-induced vertigo, bone conduction hyperacusis, and pulsatile tinnitus. The initial series of patients were diagnosed based on common symptoms, a physical examination finding of eye movements in the plane of the superior semicircular canal when ear canal pressure or loud tones were applied to the ear, and high-resolution computed tomography imaging demonstrating a dehiscence in the bone over the superior semicircular canal. Research productivity directed at understanding better methods for diagnosing and treating this condition has substantially increased over the last two decades. We now have a sound understanding of the pathophysiology of third mobile window syndromes, higher resolution imaging protocols, and several sensitive and specific diagnostic tests. Furthermore, we have a treatment (surgical occlusion of the superior semicircular canal) that has demonstrated efficacy. This review will highlight some of the fundamental insights gained in SCDS, propose diagnostic criteria, and discuss future research directions.

Variation in response dynamics of regular and irregular vestibular-nerve afferents during sinusoidal head rotations and currents in the chinchilla

In mammals, vestibular-nerve afferents that innervate only type I hair cells (calyx-only afferents) respond nearly in phase with head acceleration for high-frequency motion, whereas afferents that innervate both type I and type II (dimorphic) or only type II (bouton-only) hair cells respond more in phase with head velocity. Afferents that exhibit irregular background discharge rates have a larger phase lead re-head velocity than those that fire more regularly. The goal of this study was to investigate the cause of the variation in phase lead between regular and irregular afferents at high-frequency head rotations. Under the assumption that externally applied galvanic currents act directly on the nerve, we derived a transfer function describing the dynamics of a semicircular canal and its hair cells through comparison of responses to sinusoidally modulated head velocity and currents. Responses of all afferents were fit well with a transfer function with one zero (lead term). Best-fit lead terms describing responses to current for each group of afferents were similar to the lead term describing responses to head velocity for regular afferents (0.006 s + 1). This finding indicated that the pre-synaptic and synaptic inputs to regular afferents were likely to be pure velocity transducers. However, the variation in phase lead between regular and irregular afferents could not be explained solely by the ratio of type I to II hair cells (Baird et al 1988), suggesting that the variation was caused by a combination of pre- (type of hair cell) and post-synaptic properties.

Complementary gain modifications of the cervico-ocular (COR) and angular vestibulo-ocular (aVOR) reflexes after canal plugging

To determine whether the COR compensates for the loss of aVOR gain, independent of species, we studied cynomolgus and rhesus monkeys in which all six semicircular canals were plugged. Gains and phases of the aVOR and COR were determined at frequencies ranging from 0.02 to 6 Hz and fit with model-based transfer functions. Following canal plugging in a rhesus monkey, the acute stage aVOR gain was small and there were absent responses to thrusts of yaw rotation. In the chronic state, aVOR behavior was characterized by a cupula/endolymph time constant of ≈ 0.07 s, responding only to high frequencies of head rotation. COR gains were ≈ 0 before surgery but increased to ≈ 0.15 at low frequencies just after surgery; the COR gains increased to ≈ 0.4 over the next 12 weeks. Nine weeks after surgery, the summated aVOR + COR responses compensated for head velocity in space in the 0.5-3 Hz frequency range. The gains and phases continued to improve until the 35th week, where the combined aVOR + COR stabilized with gains of ≈ 0.5-0.6 and the phases were compensatory over all frequencies. Two cynomolgus monkeys operated 3-12 years earlier had similar frequency characteristics of the aVOR and COR. The combined aVOR + COR gains were ≈ 0.4-0.8 with compensatory phases. To achieve gains close to 1.0, other mechanisms may contribute to gaze compensation, especially with the head free. Thus, while there are individual variations in the time of adaptation of the gain and phase parameters, the essential functional organization of the adaption to vestibular lesions is uniform across these species.

Physiologic effects on the vestibular system in Meniere's disease

Ménière syndrome is an inner ear disorder characterized by spontaneous attacks of vertigo, fluctuating low-frequency sensorineural hearing loss, aural fullness and tinnitus. When the syndrome is idiopathic and cannot be attributed to any other cause (eg, syphilis, immune-mediated inner ear disease, surgical trauma), it is referred to as Ménière disease. This article reviews the physiologic effects of Ménière disease on vestibular function, as measured by caloric, head impulse, and vestibular-evoked myogenic potential testing.

Multimodal integration after unilateral labyrinthine lesion: single vestibular nuclei neuron responses and implications for postural compensation

Plasticity in neuronal responses is necessary for compensation following brain lesions and adaptation to new conditions and motor learning. In a previous study, we showed that compensatory changes in the vestibuloocular reflex (VOR) following unilateral vestibular loss were characterized by dynamic reweighting of inputs from vestibular and extravestibular modalities at the level of single neurons that constitute the first central stage of VOR signal processing. Here, we studied another class of neurons, i.e., the vestibular-only neurons, in the vestibular nuclei that mediate vestibulospinal reflexes and provide information for higher brain areas. We investigated changes in the relative contribution of vestibular, neck proprioceptive, and efference copy signals in the response of these neurons during compensation after contralateral vestibular loss in Macaca mulata monkeys. We show that the time course of recovery of vestibular sensitivity of neurons corresponds with that of lower extremity muscle and tendon reflexes reported in previous studies. More important, we found that information from neck proprioceptors, which did not influence neuronal responses before the lesion, were unmasked after lesion. Such inputs influenced the early stages of the compensation process evidenced by faster and more substantial recovery of the resting discharge in proprioceptive-sensitive neurons. Interestingly, unlike our previous study of VOR interneurons, the improvement in the sensitivity of the two groups of neurons did not show any difference in the early or late stages after lesion. Finally, neuronal responses during active head movements were not different before and after lesion and were attenuated relative to passive movements over the course of recovery, similar to that observed in control conditions. Comparison of compensatory changes observed in the vestibuloocular and vestibulospinal pathways provides evidence for similarities and differences between the two classes of neurons that mediate these pathways at the functional and cellular levels.

Current and future management of bilateral loss of vestibular sensation - an update on the Johns Hopkins Multichannel Vestibular Prosthesis Project

Bilateral loss of vestibular sensation can disable individuals whose vestibular hair cells are injured by ototoxic medications, infection, Ménière's disease or other insults to the labyrinth including surgical trauma during cochlear implantation. Without input to vestibulo-ocular and vestibulo-spinal reflexes that normally stabilize the eyes and body, affected patients suffer blurred vision during head movement, postural instability, and chronic disequilibrium. While individuals with some residual sensation often compensate for their loss through rehabilitation exercises, those who fail to do so are left with no adequate treatment options. An implantable neuroelectronic vestibular prosthesis that emulates the normal labyrinth by sensing head movement and modulating activity on appropriate branches of the vestibular nerve could significantly improve quality of life for these otherwise chronically dizzy patients. This brief review describes the impact and current management of bilateral loss of vestibular sensation, animal studies supporting the feasibility of prosthetic vestibular stimulation, and a vestibular prosthesis designed to restore sensation of head rotation in all directions. Similar to a cochlear implant in concept and size, the Johns Hopkins Multichannel Vestibular Prosthesis (MVP) includes miniature gyroscopes to sense head rotation, a microcontroller to process inputs and control stimulus timing, and current sources switched between pairs of electrodes implanted within the vestibular labyrinth. In rodents and rhesus monkeys rendered bilaterally vestibulardeficient via treatment with gentamicin and/or plugging of semicircular canals, the MVP partially restores the vestibulo-ocular reflex for head rotations about any axis of rotation in 3-dimensional space. Our efforts now focus on addressing issues prerequisite to human implantation, including refinement of electrode designs and surgical technique to enhance stimulus selectivity and preserve cochlear function, optimization of stimulus protocols, and reduction of device size and power consumption.

Neural substrates underlying vestibular compensation: contribution of peripheral versus central processing

The vestibulo-ocular reflex (VOR), which functions to stabilize gaze and ensure clear vision during everyday activities, shows impressive adaptation in response to environmental requirements. In particular, the VOR exhibits remarkable recovery following the loss of unilateral labyrinthine input as a result of injury or disease. The relative simplicity of the pathways that mediate the VOR, make it an excellent model system for understanding the changes (learning) that occur in the brain following peripheral vestibular loss to yield adaptive changes. This mini review considers the findings of behavioral, single unit recording and lesion studies of VOR compensation. Recent experiments have provided evidence that the brain makes use of multiple plasticity mechanisms (i.e., changes in peripheral as well as central processing) during the course of vestibular compensation to accomplish the sensory-motor transformations required to accurately guide behavior.

Adaptation of the vestibulo-ocular reflex for forward-eyed foveate vision

To maintain visual fixation on a distant target during head rotation, the angular vestibulo-ocular reflex (aVOR) should rotate the eyes at the same speed as the head and in exactly the opposite direction. However, in primates for which the 3-dimensional (3D) aVOR has been extensively characterised (humans and squirrel monkeys (Saimiri sciureus)), the aVOR response to roll head rotation about the naso-occipital axis is lower than that elicited by yaw and pitch, causing errors in aVOR magnitude and direction that vary with the axis of head rotation. In other words, primates keep the central part of the retinal image on the fovea (where photoreceptor density and visual acuity are greatest) but fail to keep that image from twisting about the eyes' resting optic axes. We tested the hypothesis that aVOR direction dependence is an adaptation related to primates' frontal-eyed, foveate status through comparison with the aVOR of a lateral-eyed, afoveate mammal (Chinchilla lanigera). As chinchillas' eyes are afoveate and never align with each other, we predicted that the chinchilla aVOR would be relatively low in gain and isotropic (equal in gain for every head rotation axis). In 11 normal chinchillas, we recorded binocular 3D eye movements in darkness during static tilts, 20-100 deg s(1) whole-body sinusoidal rotations (0.5-15 Hz), and 3000 deg s(2) acceleration steps. Although the chinchilla 3D aVOR gain changed with both frequency and peak velocity over the range we examined, we consistently found that it was more nearly isotropic than the primate aVOR. Our results suggest that primates' anisotropic aVOR represents an adaptation to their forward-eyed, foveate status. In primates, yaw and pitch aVOR must be compensatory to stabilise images on both foveae, whereas roll aVOR can be under-compensatory because the brain tolerates torsion of binocular images that remain on the foveae. In contrast, the lateral-eyed chinchilla faces different adaptive demands and thus enlists a different aVOR strategy.

Trends in the management of vestibular schwannomas at Johns Hopkins 1997-2007

OBJECTIVES/HYPOTHESIS

To assess trends in the management of unilateral vestibular schwannomas over an 11-year period and to identify disease- and provider-related influences.

STUDY DESIGN

Retrospective chart review.

METHODS

Subjects presented to the Department of Otolaryngology-Head and Neck Surgery and the Department of Neurosurgery for management of unilateral vestibular schwannoma from 1997 through 2007, with at least two visits within the first year of presentation. The proportion of patients for whom initial management consisted of observation, surgical resection, or radiation therapy was determined, and the relative influence of study year, patient age, hearing status, and tumor size was analyzed.

RESULTS

Over the study period there was an increase in the proportion of cases that were observed with follow-up scanning (10.5% to 28.0%) and recommended for radiation (0% to 4.0%), whereas the proportion of operated cases declined (89.5% to 68.0%). There were no changes in mean age or hearing status at diagnosis, but mean tumor size declined significantly. Compared to those undergoing surgery, patients choosing observation and radiation therapy were on average 11.7 and 4.5 years older, respectively. Tumors that were surgically removed were on average 11.6 mm larger than those that were observed. The increasing frequency over time of observation relative to surgery was significant even after controlling for age, hearing status, and tumor size.

CONCLUSIONS

Among patients managed by our center, there has been a significant shift in management of vestibular schwannomas over the last decade, with increasing tendency towards observation. This trend implies changing provider philosophy and patient expectations.

Vestibular function and vertigo control after intratympanic gentamicin for Ménière's disease

The aim of this study was to correlate long-term vertigo control with reduction in vestibular function after intratympanic (IT) gentamicin therapy for unilateral Ménière's disease. IT gentamicin injections were given as needed to control vertigo attacks. Vertigo frequency and changes in angular vestibulo-ocular reflex (AVOR) gain (measured using magnetic search coils and manual head thrusts) and caloric weakness were assessed before and after treatment. Better vertigo control after treatment was found with >or=60% reduction in quantitative ipsilateral horizontal semicircular canal AVOR gain from pre-treatment values and/or with caloric unilateral weakness (UW) >50%. However, no correlations were found between the continuous variables of vertigo control and either gain or gain recovery, nor between gain and UW because of the large variability in vertigo control in subjects with lesser reductions in these measures.

Effects of canal plugging on the vestibuloocular reflex and vestibular nerve discharge during passive and active head rotations

Mechanical occlusion (plugging) of the slender ducts of semicircular canals has been used in the clinic as well as in basic vestibular research. Here, we investigated the effect of canal plugging in two macaque monkeys on the horizontal vestibuloocular reflex (VOR) and the responses of vestibular-nerve afferents during passive head rotations. Afferent responses to active head movements were also studied. The horizontal VOR gain decreased after plugging to <0.1 for frequencies <2 Hz but rose to about 0.6 as frequency was increased to 15 Hz. Afferents innervating plugged horizontal canals had response sensitivities that increased with the frequency of passive rotations from <0.01 (spikes/s)/( degrees/s) at 0.5 Hz to values of about 0.2 and 0.5 (spikes/s)/( degrees/s) at 8 Hz for regular and irregular afferents, respectively (<50% of responses in controls). An increase in phase lead was also noted following plugging in afferent discharge, but not in the VOR. Because the phase discrepancy between the VOR and afferent discharge is much larger than that seen in control animals, this suggests that central adaptation shapes VOR dynamics following plugging. The effect of canal plugging on afferent responses can be modeled as an increase in stiffness and a reduction in the dominant time constant and gain in the transfer function describing canal dynamics. Responses were also evident during active head rotations, consistent with the frequency content of these movements. We conclude that canal plugging in macaques is effective only at frequencies <2 Hz. At higher frequencies, afferents show significant responses, with a nearly 90 degrees phase lead, such that they encode near-rotational acceleration. Our results demonstrate that afferents innervating plugged canals respond robustly during voluntary movements, a finding that has implications for understanding the effects of canal plugging in clinical practice.

Static and dynamic discharge properties of vestibular-nerve afferents in the mouse are affected by core body temperature

The goal of this study was to determine the effect of changes in core body temperature on the resting discharge rate and sensitivity of vestibular-nerve afferents. Extracellular recordings were made from vestibular-nerve afferents innervating the semicircular canals in anesthetized C57BL/6 mice maintained at a core body temperature of either 30-32 degrees C (T (31)) or 35-37 degrees C (T (36)). The resting rates of regular (CV* < 0.1) and irregular afferents (CV* > 0.1) were lower at T (31) than at T (36). Sensitivity and phase were compared for rotations ranging from 0.1 to 12 Hz by calculating coefficients of a transfer function, g . t(c)S . (t(z)S +1)/(t(c)S + 1), for each afferent. The sensitivity (g) increased with CV* and with higher core body temperature. The value of the coefficient representing the low-frequency dynamics (t (c)) varied inversely with CV* but did not change with core body temperature. The high-frequency dynamics represented by t (z) increased with CV* and decreased with higher core body temperature. These findings indicate that changes in temperature have effects on the static and dynamic properties of vestibular-nerve afferents.

Modification of the cervico-ocular reflex by canal plugging

The cervico-ocular reflex (COR) has a low gain in normal animals. In this study, we determined whether COR gain increases were specific to the low/midband frequency range, which is the range over which the angular vestibulo-ocular reflex (aVOR) is compromised by plugging. The gain and phase of the yaw and pitch COR and aVOR were compared in normal monkeys and those with all six semicircular canals or only the lateral canal plugged. During experiments animals sat with the body fixed to a chair and the head fixed in space. The body was oscillated about body-yaw and body-pitch axes over a frequency range of 0.05-6 Hz, with amplitude <10 degrees. For normal animals, both yaw and pitch eye velocities were compensatory to the relative velocity of the head with respect to the body. The gains were 0.1-0.2 at frequencies below 1 Hz and decreased to zero as stimulus frequency increased above 1 Hz. Canal-plugged animals had COR gains close to 1.0 at low frequencies, decreasing to approximately 0.6 at 0.5 Hz and to 0.2 for stimulus frequencies above 3 Hz. The phase of eye velocity was 180 degrees relative to head-re-body velocity at frequencies below 0.5 Hz and shifted toward 270 degrees as frequencies were increased to 4 Hz. This study demonstrates that adaptation of COR gain is tuned to a frequency range at which the aVOR is compromised by the canal plugging.

Time course of repeated intratympanic gentamicin for Ménière's disease

OBJECTIVES/HYPOTHESIS

With low-dose and titration protocols, subsequent intratympanic (IT) gentamicin injections are frequently necessary for vertigo control in Ménière's disease. To date, studies have not provided detailed descriptions of the time course of recurrent vertigo and repeated injections. Our objective is to provide such a description with a Kaplan-Meier survival analysis, which may enable accurate predictions of the probability of recurrent vertigo after a given time or number of injections.

STUDY DESIGN

Injections of IT gentamicin were administered for unilateral definite Ménière's disease. One injection (or rarely more) in a 6-week period constituted a "round." Repeat rounds were given when needed for control of recurrent vertigo.

METHODS

We used a Kaplan-Meier method to quantify percentages of patients with control of vertigo over an 8-year period. A separate curve was created for each number of rounds, and failure for each was defined as the need for an additional round.

RESULTS

Of 78 patients, 75 (96%) achieved sufficient vertigo control to avoid ablative surgery, and 42 (54%) required only one round. Thirty-six (46%) required multiple rounds. The probability of needing another round increased with each subsequent one, through four rounds. The median times to the next round after one, two, or three rounds were 148, 118, and 124 days, respectively.

CONCLUSIONS

More than half of patients need only one round of IT gentamicin injections. With each additional round through the fourth one, the probability of additional rounds increases. Nevertheless, the majority (96%) of patients do not need ablative surgery after IT gentamicin.

Tonic and phasic contributions to the pathways mediating compensation and adaptation of the vestibulo-ocular reflex

Processes of vestibular compensation mediate recovery of many aspects of vestibular dysfunction following unilateral vestibular injury. The VOR in response to high-frequency, high-acceleration head movements, however, retains an enduring asymmetry. Head movements that are inhibitory with respect to semicircular canals on the intact side lead to a diminished VOR whereas head movements that are excitatory for semicircular canals on the intact side lead to a VOR that returns close to normal. We review our work directed toward understanding the processes of VOR compensation to high-frequency, high-acceleration head movements and the related topic of adaptation to changes in the visual requirements for a compensatory VOR. Our work has shown that the processes of both compensation and adaptation to these stimuli can be described by a mathematical model with inputs from tonic and phasic components. We have further shown that the dynamics of regular afferents have close resemblance to the tonic pathway whereas the dynamics of irregular afferents match those of the phasic pathway.

Efferent-mediated responses in vestibular nerve afferents of the alert macaque

The peripheral vestibular organs have long been known to receive a bilateral efferent innervation from the brain stem. However, the functional role of the efferent vestibular system has remained elusive. In this study, we investigated efferent-mediated responses in vestibular afferents of alert behaving primates (macaque monkey). We found that efferent-mediated rotational responses could be obtained from vestibular nerve fibers innervating the semicircular canals after conventional afferent responses were nulled by placing the corresponding canal plane orthogonal to the plane of motion. Responses were type III, i.e., excitatory for rotational velocity trapezoids (peak velocity, 320 degrees/s) in both directions of rotation, consistent with those previously reported in the decerebrate chinchilla. Responses consisted of both fast and slow components and were larger in irregular (approximately 10 spikes/s) than in regular afferents (approximately 2 spikes/s). Following unilateral labyrinthectomy (UL) on the side opposite the recording site, similar responses were obtained. To confirm the vestibular source of the efferent-mediated responses, the ipsilateral horizontal and posterior canals were plugged following the UL. Responses to high-velocity rotations were drastically reduced when the superior canal (SC), the only intact canal, was in its null position, compared with when the SC was pitched 50 degrees upward from the null position. Our findings show that vestibular afferents in alert primates show efferent-mediated responses that are related to the discharge regularity of the afferent, are of vestibular origin, and can be the result of both afferent excitation and inhibition.

The human sound-evoked vestibulo-ocular reflex and its electromyographic correlate

OBJECTIVE

Sound and vibration evoke a short-latency eye movement or "sound-evoked vestibulo-ocular reflex" (VOR) and an infraorbital surface potential: the "ocular vestibular-evoked myogenic potential" (OVEMP). We examined their relationship by measuring the modulation of both responses by gaze and stimulus parameters.

METHODS

In seven subjects with superior semicircular-canal dehiscence (SCD) and six controls, the sound-evoked VOR was measured in 3D using scleral search coils. OVEMPs were recorded simultaneously, using surface electromyography.

RESULTS

Eye movement onset (11.6+/-0.8ms) coincided with the OVEMP peak (12.1+/-0.35ms). OVEMP and VOR magnitudes were 5-15 times larger in SCD compared with controls. OVEMP amplitudes were maximal on upgaze and abolished on downgaze; VOR magnitudes were unaffected. When stimulus type was changed from sound to vibration, OVEMP and VOR changed concordantly: increasing in controls and decreasing in SCD. OVEMP and VOR tuned to identical stimulus frequencies. OVEMP and VOR magnitudes on upgaze were significantly correlated (R=0.83-0.97).

CONCLUSION

Selective decrease of the OVEMP upon downgaze is consistent with relaxation or retraction of the inferior oblique muscles. The temporal relationship of OVEMP and VOR and their identical modulation by external factors confirms a common origin.

SIGNIFICANCE

Sound-evoked OVEMP and VOR represent the electrical and mechanical correlates of the same vestibulo-ocular response.

Vestibular-evoked myogenic potential thresholds normalize on plugging superior canal dehiscence

BACKGROUND

Diagnosis of the superior canal dehiscence syndrome (SCDS) relies on symptoms such as sound- or pressure-induced vertigo or oscillopsia, demonstration of sound or pressure-evoked vertical/torsional eye movements, and the presence of a defect in the bony roof overlying the superior semicircular canal. Lowered thresholds for eliciting vestibular-evoked myogenic potentials (VEMPs) provide additional conformation.

OBJECTIVE

To examine VEMP characteristics before and after canal plugging for SCDS.

METHODS

VEMPs evoked by air- and bone-conducted tones were measured from the sternocleidomastoid muscles (cVEMP) and periocular sites (oVEMP) of 20 normal volunteers, 10 newly diagnosed subjects with SCDS, and 12 subjects who underwent successful superior canal plugging.

RESULTS

In all SCDS ears, thresholds for evoking VEMP using air-conducted tones were pathologically lowered, with average values of 83.85 +/- 1.40 dB sound pressure level (SPL) for cVEMP and 85.38 +/- 1.32 dB SPL for oVEMP, 20 to 30 dB below those of controls. Successful canal plugging resulted in normal reflex thresholds. For bone vibration, average thresholds in SCDS ears were 114.62 +/- 1.54 dB FL (force level) for cVEMP and 116.0 +/- 1.52 dB FL for oVEMP, 10 to 20 dB below controls, yet three SCDS ears had normal thresholds.

CONCLUSIONS

Ocular and cervical vestibular-evoked myogenic potentials evoked by air-conducted sound are equally useful in the diagnosis and follow-up of superior canal dehiscence syndrome. Stimulus thresholds are consistently lowered upon presentation and normalize after corrective surgery. Thresholds for bone vibration, in contrast, have a lower diagnostic yield.

Semicircular Canal Function Before and After Surgery for Superior Canal Dehiscence

OBJECTIVE

To characterize semicircular canal function before and after surgery for superior semicircular canal dehiscence (SCD) syndrome.

STUDY DESIGN

Prospective unblinded study of physiologic effect of intervention.

SETTING

Tertiary referral center.

PATIENTS

Patients with SCD syndrome documented by history, sound- or pressure-evoked eye movements, vestibular-evoked myogenic potential testing, and high-resolution multiplanar computed tomographic scans.

INTERVENTION

Nineteen subjects with SCD had quantitative measurements of their angular vestibulo-ocular reflexes (AVOR) in response to rapid rotary head thrusts measured by magnetic search coil technique before and after middle fossa approach and repair of the dehiscence. In 18 subjects, the dehiscence was plugged; and in 1, it was resurfaced.

MAIN OUTCOME MEASURES

The AVOR gains (eye velocity/head velocity) for excitation of each of the semicircular canals.

RESULTS

Vertigo resulting from pressure or loud sounds resolved in each case. Before surgery, mean AVOR gains were normal for the ipsilateral horizontal (0.94 +/- 0.07) and posterior (0.84 +/- 0.09) canals. For the superior canal to be operated on, AVOR gain was 0.75 +/- 0.13; but this was not significantly lower than the gain for the contralateral superior canal (0.82 +/- 0.11, p = 0.08). Mean AVOR gain decreased by 44% for the operated superior canals (to 0.42 +/- 0.11, p < 0.0001). There was a 13% decrease in gain for the ipsilateral posterior canal (p = 0.02), perhaps because plugging affected the common crus in some cases. There was a 10% decrease in gain for excitation of the contralateral posterior canal (p < 0.0001), which likely reflects the loss of the inhibitory contribution of the plugged superior canal during head thrusts exciting the contralateral posterior canal. Mean AVOR gain did not change for any of the other canals, but two subjects did develop hypofunction of all three ipsilateral canals postoperatively.

CONCLUSION

Middle fossa craniotomy and repair of SCD reduce the function of the operated superior canal but typically preserve the function of the other ipsilateral semicircular canals.

Response of vestibular-nerve afferents to active and passive rotations under normal conditions and after unilateral labyrinthectomy

We investigated the possible contribution of signals carried by vestibular-nerve afferents to long-term processes of vestibular compensation after unilateral labyrinthectomy. Semicircular canal afferents were recorded from the contralesional nerve in three macaque monkeys before [horizontal (HC) = 67, anterior (AC) = 66, posterior (PC) = 50] and 1-12 mo after (HC = 192, AC = 86, PC = 57) lesion. Vestibular responses were evaluated using passive sinusoidal rotations with frequencies of 0.5-15 Hz (20-80 degrees /s) and fast whole-body rotations reaching velocities of 500 degrees /s. Sensitivities to nonvestibular inputs were tested by: 1) comparing responses during active and passive head movements, 2) rotating the body with the head held stationary to activate neck proprioceptors, and 3) encouraging head-restrained animals to attempt to make head movements that resulted in the production of neck torques of < or =2 Nm. Mean resting discharge rate before and after the lesion did not differ for the regular, D (dimorphic)-irregular, or C (calyx)-irregular afferents. In response to passive rotations, afferents showed no change in sensitivity and phase, inhibitory cutoff, and excitatory saturation after unilateral labyrinthectomy. Moreover, head sensitivities were similar during voluntary and passive head rotations and responses were not altered by neck proprioceptive or efference copy signals before or after the lesion. The only significant change was an increase in the proportion of C-irregular units postlesion, accompanied by a decrease in the proportion of regular afferents. Taken together, our findings show that changes in response properties of the vestibular afferent population are not likely to play a major role in the long-term changes associated with compensation after unilateral labyrinthectomy.

Auditory Function in Patients with Surgically Treated Superior Semicircular Canal Dehiscence

OBJECTIVE

To characterize preoperative and postoperative audiologic findings in patients with superior semicircular canal dehiscence syndrome.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Patients with documented superior semicircular canal dehiscence syndrome (according to history, vestibular testing, and high-resolution computed tomography imaging) who underwent surgical repair of their dehiscence.

INTERVENTION

Middle fossa craniotomy for superior semicircular canal plugging and/or resurfacing.

MAIN OUTCOME MEASURES

Audiologic testing both before and after surgery with pure-tone threshold measurements of air and bone conduction.

RESULTS

Twenty-nine subjects underwent surgical repair of superior semicircular canal dehiscence. Overall, there were no statistically significant differences by paired t test in hearing before or after surgery, in either air-conduction or bone-conduction thresholds, for 19 patients that had no previous surgical history. At least partial closure of air-bone gap was achieved in five patients. One patient with previous stapes surgery had significantly worse hearing both before and after canal repair compared with those without previous surgery. Two patients who had undergone previous middle fossa surgery with incomplete resolution of symptoms developed sensorineural hearing loss after revision surgery. Previous middle-ear exploration and tympanostomy tube placement did not seem to affect audiologic outcomes. Surgical hearing results did not differ according to method of canal repair (plugging versus resurfacing).

CONCLUSION

Primary middle fossa repair of superior semicircular canal dehiscence is not associated with sensorineural hearing loss and, in some cases, can lead to normalization of conductive hearing loss. Revision middle fossa repair or previous stapes surgery may be associated with postoperative sensorineural hearing loss.

Dynamics of the horizontal vestibuloocular reflex after unilateral labyrinthectomy: response to high frequency, high acceleration, and high velocity rotations

Loss of vestibular information from one labyrinth results in a marked asymmetry in the horizontal vestibuloocular reflex (VOR). The results of prior studies suggest that long-term deficits in VOR are more severe in response to rapid impulses than to sinusoidal head movements. The goal of the present study was to investigate the VOR following unilateral labyrinthectomy in response to different stimuli covering the full range of physiologically relevant head movements in macaque monkeys. The VOR was studied 1-39 days post-lesion using transient head perturbations (up to 12,000 degrees/s(2)), rapid rotations (up to 500 degrees/s), and sinusoidal rotations (up to 15 Hz). In response to rotations with high acceleration or velocity, both contra- and ipsilesional gains remained subnormal. VOR gains decreased as a function of increasing stimulus acceleration or velocity, reaching minimal values of 0.7-0.8 and 0.3-0.4 for contra and ipsilesional rotations, respectively. For sinusoidal rotations with low frequencies and velocities, responses to contralesional stimulation recovered within approximately 4 days. With increasing velocities and frequencies of rotation, however, the gains of contra- and ipsilesional responses remained subnormal. For each of the most challenging stimuli tested (i.e., 12,000 degrees/s(2 )transient head perturbations, 500 degrees/s fast whole-body rotations and 15 Hz stimulation) no significant compensation was observed in contra- or ipsilesional responses over time. Moreover, we found that gain of the cervico-ocular reflex (COR) remained negligible following unilateral loss indicating that neck reflexes did not contribute to the observed compensation. VOR responses elicited by both sinusoidal and transient rotations following unilateral labyrinthectomy could be described by the same mathematical model. We conclude that the compensated VOR has comparable response dynamics for impulses and sinusoidal head movements.

Axis of eye rotation changes with head-pitch orientation during head impulses about earth-vertical

The goal of this study was to assess how the axis of head rotation, Listing's law, and eye position influence the axis of eye rotation during brief, rapid head rotations. We specifically asked how the axis of eye rotation during the initial angular vestibuloocular reflex (VOR) changed when the pitch orientation of the head relative to Earth-vertical was varied, but the initial position of the eye in the orbit and the orientation of Listing's plane with respect to the head were fixed. We measured three-dimensional eye and head rotation axes in eight normal humans using the search coil technique during head-and-trunk (whole-body) and head-on-trunk (head-only) "impulses" about an Earth-vertical axis. The head was initially oriented at one of five pitch angles (30 degrees nose down, 15 degrees nose down, 0 degrees, 15 degrees nose up, 30 degrees nose up). The fixation target was always aligned with the nasooccipital axis. Whole-body impulses were passive, unpredictable, manual, rotations with peak-amplitude of approximately 20 degrees , peak-velocity of approximately 80 degrees /s, and peak-acceleration of approximately 1000 degrees /s2. Head-only impulses were also passive, unpredictable, manual, rotations with peak-amplitude of approximately 20 degrees , peak-velocity of approximately 150 degrees /s, and peak-acceleration of approximately 3000 degrees /s2. During whole-body impulses, the axis of eye rotation tilted in the same direction, and by an amount proportional (0.51 +/- 0.09), to the starting pitch head orientation (P < 0.05). This proportionality constant decreased slightly to 0.39 +/- 0.08 (P < 0.05) during head-only impulses. Using the head-only impulse data, with the head pitched up, we showed that only 50% of the tilt in the axis of eye rotation could be predicted from vectorial summation of the gains (eye velocity/head velocity) obtained for rotations about the pure yaw and roll head axes. Thus, even when the orientation of Listing's plane and eye position in the orbit are fixed, the axis of eye rotation during the VOR reflects a compromise between the requirements of Listing's law and a perfectly compensatory VOR.

The effect of binocular eye position and head rotation plane on the human torsional vestibuloocular reflex

We examined how the gain of the torsional vestibulo-ocular reflex (VOR) (defined as the instantaneous eye velocity divided by inverted head velocity) in normal humans is affected by eye position, target distance, and the plane of head rotation. In six normal subjects we measured three-dimensional (3D) eye and head rotation axes using scleral search coils, and 6D head position using a magnetic angular and linear position measurement device, during low-amplitude (approximately 20 degrees ), high-velocity (approximately 200 degrees/s), high-acceleration (approximately 4000 degrees /s2) rapid head rotations or 'impulses.' Head impulses were imposed manually and delivered in five planes: yaw (horizontal canal plane), pitch, roll, left anterior-right posterior canal plane (LARP), and right anterior-left posterior canal plane (RALP). Subjects were instructed to fix on one of six targets at eye level. Targets were either straight-ahead, 20 degrees left or 20 degrees right from midline, at distance 15 or 124 cm from the subject. Two subjects also looked at more eccentric targets, 30 degrees left or 30 degrees right from midline. We found that the vertical and horizontal VOR gains increased with the proximity of the target to the subject. Previous studies suggest that the torsional VOR gain should decrease with target proximity. We found, however, that the torsional VOR gain did not change for all planes of head rotation and for both target distances. We also found a dynamic misalignment of the vertical positions of the eyes during the torsional VOR, which was greatest during near viewing with symmetric convergence. This dynamic vertical skew during the torsional VOR arises, in part, because when the eyes are converged, the optical axes are not parallel to the naso-occipital axes around which the eyes are rotating. In five of six subjects, the average skew ranged 0.9 degrees -2.9 degrees and was reduced to <0.4 degrees by a 'torsional' quick-phase (around the naso-occipital axis) occurring <110 ms after the onset of the impulse. We propose that the torsional quick-phase mechanism during the torsional VOR could serve at least three functions: (1) resetting the retinal meridians closer to their usual orientation in the head, (2) correcting for the 'skew' deviation created by misalignment between the axes around which the eyes are rotating and the line of sight, and (3) taking the eyes back toward Listing's plane.

Orientation of human semicircular canals measured by three-dimensional multiplanar CT reconstruction

Analysis of vestibulo-ocular reflex experiments requires knowledge of the absolute orientations (with respect to skull landmarks) of semicircular canals (SCC). Data relating SCC orientations to accessible skull landmarks in humans are sparse, apart from a classic study of 10 skulls, which concluded that the horizontal and anterior SCC are not mutually orthogonal (111 +/- 7.6 degrees). Multiple studies of isolated labyrinths have shown the inter-SCC angles are close to 90 degrees. We hypothesized that a larger sample would yield mean absolute SCC orientations closer to the mutual orthogonality demonstrated for isolated labyrinths. We measured canal orientations with respect to accessible skull landmarks using 3-D multiplanar reconstructions of computerized tomography scans of the temporal bones of 22 human subjects. Images were acquired with 0.5-mm thickness and reconstructed with in-plane resolution of 234 microm. There was no significant difference between the left and a mirror image of the right (p > 0.57 on multiway ANOVA of orientation vector coefficients), so data were pooled for the 44 labyrinths. The angle between the anterior and posterior SCC was 94.0 +/- 4.0 degrees (mean +/- SD). The angle between the anterior and horizontal SCC was 90.6 +/- 6.2 degrees. The angle between the horizontal and posterior SCC was 90.4 +/- 4.9 degrees. The direction angles between a vector normal to the left horizontal SCC and the positive Reid's stereotaxic X (+nasal), Y (+left), and Z (+superior) axes were 108.7 +/- 7.5 degrees, 92.2 +/- 5.7 degrees, and 19.9 +/- 7.0 degrees, respectively. The angles between a vector normal to the left anterior SCC and the positive Reid's stereotaxic X, Y, and Z axes were 125.9 +/- 5.2 degrees, 38.4 +/- 5.1 degrees, and 100.1 +/- 6.2 degrees, respectively. The angles between a vector normal to the left posterior SCC and the positive Reid's stereotaxic X, Y, and Z axes were 133.6 +/- 5.3 degrees, 131.5 +/- 5.1 degrees, and 105.6 +/- 6.6 degrees, respectively. The mean anterior SCC-contralateral posterior SCC angle was 15.3 +/- 7.2 degrees. The absolute orientations of human SCC are more nearly orthogonal than previously reported.

Superior Canal Dehiscence Is Not Due to Cephalic Displacement of the Labyrinth

Superior semicircular canal dehiscence syndrome may have a congenital basis. CT scans of 44 control and 21 dehiscent superior canals were examined to determine if dehiscent canals were more cephalically placed or vertically oriented than control canals. Results showed that neither was the case. Instead, the defect may be in the process of ossification above the superior canal.

Gaze Position Corrective Eye Movements in Normal Subjects and in Patients with Vestibular Deficits

Eye movements in response to high-acceleration head rotations (thrusts) in the horizontal plane from patients with unilateral (UVD) or bilateral vestibular loss (BVD) were recorded. The rapid, gaze-position corrections (GPCs) that appeared when vestibulo-ocular reflex (VOR) slow phases were undercompensatory were characterized. For comparison, eye movements from normal subjects who were asked to generate saccades in the direction opposite head rotation (in the same direction as slow phases) were recorded. This normal-subject model produced responses with spatial and temporal characteristics similar to those from GPCs in patients as follows: When head rotations were generated actively, compared with passively, gaze-position errors and corresponding GPCs were smaller and occurred earlier. During passively generated head thrusts, GPCs still occurred when head rotations were made in total darkness, though their accuracy decreased as the requirement for maintaining gaze on a specific location in space was relaxed. Time of onset of GPCs was not rigidly tied to head kinematics (peak velocity or peak acceleration). Speeds of GPCs, however, were lower than speeds of similar-sized, head-fixed saccades. Finally, during passive and active head thrusts in patients, sustained, high-frequency (20 to 30 Hz) oscillations that appeared as tiny saccades were occasionally observed, one immediately following the other, resembling a compensatory slow-phase response. Taken together, the results suggest that one strategy for overcoming a VOR deficit is to enlist the saccadic system to produce an oculomotor response that is required to compensate for head rotation. This response may come in the form of high-velocity GPCs or smaller-amplitude oscillations.

Angular vestibulo-ocular reflex gains correlate with vertigo control after intratympanic gentamicin treatment for Meniere's disease

OBJECTIVES

The objective of our study was to determine whether angular vestibulo-ocular reflex (aVOR) gains correlated with vertigo control after intratympanic gentamicin treatment for Meniere's disease.

METHODS

We conducted a prospective study of 18 subjects with unilateral Meniere's disease treated with intratympanic gentamicin injection and followed all subjects for 1 year. We measured the gain of the aVOR elicited by rapid rotary head thrusts in each of the canal planes for each subject before and after treatment with intratympanic gentamicin by using magnetic search coils to record eye movements.

RESULTS

During the follow-up period, 11 subjects ("single-treatment group"; 61%) had control of their vertigo with a single gentamicin injection. The remaining 7 subjects ("multiple-treatment group"; 39%) experienced recurrent vertigo that required a second injection of gentamicin at a mean of 6 months after the first treatment. The 11 subjects in the single-treatment group had significantly greater reduction of labyrinthine function after the first treatment, as measured by change in ipsilateral horizontal canal gain, than did the 7 subjects with vertigo recurrence. Changes in caloric asymmetry did not correlate with vertigo control.

CONCLUSIONS

Our results suggest that successful treatment of Meniere's disease is closely related to attenuation of semicircular canal function as measured by horizontal canal aVOR gains.

Clinical Manifestations of Superior Semicircular Canal Dehiscence

OBJECTIVES/HYPOTHESES

To determine the symptoms, signs, and findings on diagnostic tests in patients with clinical manifestations of superior canal dehiscence. To investigate hypotheses about the effects of superior canal dehiscence. To analyze the outcomes in patients who underwent surgical repair of the dehiscence.

STUDY DESIGN

Review and analysis of clinical data obtained as a part of the diagnosis and treatment of patients with superior canal dehiscence at a tertiary care referral center.

METHODS

Clinical manifestations of superior semicircular canal dehiscence were studied in patients identified with this abnormality over the time period of May 1995 to July 2004. Criteria for inclusion in this series were identification of the dehiscence of bone overlying the superior canal confirmed with a high-resolution temporal bone computed tomography and the presence of at least one sign on physiologic testing indicative of superior canal dehiscence. There were 65 patients who qualified for inclusion in this study on the basis of these criteria. Vestibular manifestations were present in 60 and exclusively auditory manifestations without vestibular symptoms or signs were noted in 5 patients.

RESULTS

For the 60 patients with vestibular manifestations, symptoms induced by loud sounds were noted in 54 patients and pressure-induced symptoms (coughing, sneezing, straining) were present in 44. An air-bone on audiometry in these patients with vestibular manifestations measured (mean +/- SD) 19 +/- 14 dB at 250 Hz; 15 +/- 11 dB at 500 Hz; 11 +/- 9 dB at 1,000 Hz; and 4 +/- 6 dB at 2,000 Hz. An air-bone gap 10 dB or greater was present in 70% of ears with superior canal dehiscence tested at 250 Hz, 68% at 500 Hz, 64% at 1,000 Hz, and 21% at 2,000 Hz. Similar audiometric findings were noted in the five patients with exclusively auditory manifestations of dehiscence. The threshold for eliciting vestibular-evoked myogenic potentials from affected ears was (mean +/- SD) 81 +/- 9 dB normal hearing level. The threshold for unaffected ears was 99 +/- 7 dB, and the threshold for control ears was 98 +/- 4 dB. The thresholds in the affected ear were significantly different from both the unaffected ear and normal control thresholds (P < .001 for both comparisons). There was no difference between thresholds in the unaffected ear and normal control (P = .2). There were 20 patients who were debilitated by their symptoms and underwent surgical repair of superior canal dehiscence through a middle cranial fossa approach. Canal plugging was performed in 9 and resurfacing of the canal without plugging of the lumen in 11 patients. Complete resolution of vestibular symptoms and signs was achieved in 8 of the 9 patients after canal plugging and in 7 of the 11 patients after resurfacing.

CONCLUSIONS

Superior canal dehiscence causes vestibular and auditory symptoms and signs as a consequence of the third mobile window in the inner ear created by the dehiscence. Surgical repair of the dehiscence can achieve control of the symptoms and signs. Canal plugging achieves long-term control more often than does resurfacing.

Search-coil head-thrust and caloric tests in Ménière's disease

CONCLUSIONS

Our findings suggest that canal function is substantially preserved in subjects with active vertigo attacks as a result of Ménière's disease (MD). In these subjects, the head-thrust test (HTT) may not be as sensitive to canal dysfunction as traditional caloric testing. MD may differentially affect the low-frequency sensitivity of the canals.

OBJECTIVE

Caloric tests have traditionally been used to characterize semicircular canal function in vestibular disorders, including MD. The quantitative HTT provides an objective measurement of semicircular canal function in the frequency and velocity ranges of normal head movements. The aim of this study was to compare the findings of caloric and HTTs in subjects with unilateral MD.

MATERIAL AND METHODS

The study population consisted of 38 candidates for gentamicin treatment due to a high frequency of vertiginous attacks (25 males, 13 females; mean age 52.9 years; range 30-70 years). The duration of symptoms was 1-30 years (mean 5.3 years). Horizontal canal function was characterized with bithermal aqueous caloric tests and recordings of the angular vestibulo-ocular reflexes (aVORs) using the scleral search-coil technique during HTTs. The main outcomes were unilateral weakness (UW) on caloric testing and aVOR gain asymmetry (GA) during HTTs. A caloric response asymmetry of >20% was considered to be indicative of pathologic UW. A difference in GA during HTTs of >5.8% was considered significant.

RESULTS

Twenty subjects (52.6%) showed abnormal results on one or both tests. Pathologic UW was present in 16 subjects (42.1%). During HTTs, 11 subjects (28.9%) showed pathologic GA. Seven subjects (18.4%) showed abnormal results on both tests. A significant correlation was found between UW and GA. However, pathologic GA during HTTs in subjects with unilateral MD was less frequent and the values smaller than those published for vestibular neuritis patients. Two subjects with unilateral MD had 100% UW, but none had >30% asymmetry on HTTs.

The Vestibulo-Ocular Reflex Response to Head Impulses Rarely Decreases after Cochlear Implantation

OBJECTIVE

Measure vestibular function using the head impulse test and assess the change in function due to unilateral cochlear implantation.

BACKGROUND

Cochlear implantation entails risks to vestibular function in the implanted ear. However, the nature and extent of this risk is not known. The head impulse test uses physiologically relevant stimuli that allow detection of subtle changes in vestibular function of individual semicircular canals.

SUBJECTS

Sixteen adults (age, 28-65 years) were recruited for prospective study from the Listening Center at Johns Hopkins. Eleven of these subjects were tested 4 to 6 weeks after cochlear implantation.

METHODS

Three-dimensional eye movement recordings were made using the scleral search coil technique. Stimuli were rapid, passive, transient, head-on-body rotations (acceleration approximately 3000 degrees /s) in the direction excitatory for each of the six semicircular canals.

RESULTS

Of the 16 subjects measured preoperatively, 6 (36%) had low (< 0.74) VOR gains in one or both of the horizontal canals and 8 (50%) had low (< 0.64) vestibulo-ocular reflex (VOR) gains in one or more of the vertical canals. These preoperative gain deficits were bilateral in six subjects. The VOR gain did not significantly change after implantation in 10 out of the 11 subjects tested postoperatively. The remaining subject suffered a partial loss of function in the implanted ear and was the only subject who experienced transient vertigo and oscillopsia after implantation.

CONCLUSIONS

Preoperative vestibular deficits were common among this group of candidates for cochlear implantation; however, significant loss of vestibular function due to cochlear implantation was uncommon.

Inexpensive system for real-time 3-dimensional video-oculography using a fluorescent marker array

We describe a novel, inexpensive method for real-time measurement of binocular three-dimensional eye position. The method employs consumer-grade digital video cameras ("webcams") to track an array of three fluorescent non-collinear markers affixed to each eye. The instantaneous position of the marker array relative to a reference position is used to construct a rotation matrix describing the eye rotation. The mathematical computation used to determine the rotation matrix is conceptually simpler and computationally more efficient than methods previously described, allowing generation of binocular three-dimensional eye position in real-time during image acquisition. The fluorescent marker is illuminated using a UV-A light source. The light source and reflective artifacts are filtered out to improve the signal to noise ratio. In addition, we present a method to align the camera with the center of eye rotation. When tested in vitro, the video-oculography (VOG) method had a <2.9% positional error (in each component of 3-D eye position) for eye positions within 20 degrees of center. We directly compared this method of VOG to the search coil technique by measuring three-dimensional eye position simultaneously using search coils and VOG in a chinchilla (C. laniger). The in vivo positional difference between the two methods was <3.1% for each component of 3-D eye position.